| 020000087 |
Crown Bay Nursing & Rehabilitation Center |
020009162 |
B |
20-Mar-12 |
IPEX11 |
4603 |
483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALSThe facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility violated the aforementioned regulation by failing to report immediately, to the California Department of Public Health (Department), an allegation of physical abuse of a resident (Resident 1) by a certified nursing assistant (CNA 1). By not reporting all allegations of abuse, the facility did not afford the Department the possibility to conduct an independent investigation into the incident. This placed other residents at risk for possible abuse/harm by the alleged assailant. The Department received a written anonymous complaint by mail on 10/14/10 which alleged a CNA (1) had "slapped" a resident (Resident 1) during the provision of personal care. The letter indicated the incident occurred on 10/6/10. An onsite investigation conducted on 10/15/10, at 7:30 a.m. confirmed Resident 1 was a resident at the facility, and occupied the room identified in the complaint letter. Review of the personnel staffing list and resident care assignment for 10/6/10, confirmed CNA 1, the alleged assailant, was assigned to provide personal care to Resident 1 on the day of the alleged incident. Review on 10/15/10 of the facility Abuse Prevention and Reporting training outline, indicated employees were instructed to report all allegations of suspected abuse (verbal, physical, mental, sexual, neglect, involuntary seclusion, and misappropriation of resident property, immediately to the charge nurse or supervisor, director of nurses or administrator. During an interview on 10/15/10 at 10:16 a.m., when asked if she had received a report which alleged CNA 1 had slapped Resident 1, the Director of Nurses (DON) stated that at the time of the alleged incident, she was not in the facility but had been informed by the Director of Staff Development (DSD) of the alleged incident. The DON stated she instructed the DSD to inform the physician, notify Resident 1's responsible party, interview CNA 1, and assess Resident 1 for possible injury.During the same interview, the DON stated that she did not report the incident to the Department because she had taken care of the situation when she terminated CNA 1 on 10/11/10. Review of the facility policy and procedure titled, 'The Reporting of Unusual Incidents, Falls, Accidents, Abuse, and Neglect, undated, indicated the following:1) All unusual incidents, falls, accidents, cases of abuse and neglect will be reported and communicated to the Director of Nurses, the Administrator and the Quality Assurance Nurse as soon as possible. 2) The Administrator will determine if the unusual incident, falls, accident, or case of abuse and neglect are reportable to proper authorities. The facility policy did not meet the requirement of the regulation in respect to reporting allegations of abuse to the State Agency (Department). By not reporting all allegations of abuse, the facility did not afford the Department the possibility to conduct an independent investigation into the incident. This placed other residents at risk for possible abuse/harm by the alleged assailant. The violation had a direct relationship to the health, safety, and security of residents. |
| 020000053 |
Crestwood Manor - Fremont |
020010747 |
A |
06-Jun-14 |
DLZS11 |
10012 |
F 323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility is in violation of the above regulations by its failure to: Maintain supervision and provide a safe environment according to Resident 1's care needs. The patient was left unattended during snack time, which resulted in her choking on a sandwich.Resident 1's physician orders were to have all of her foods pureed (blended to the consistency of apple sauce). Resident 2 gave Resident 1 part of her sandwich, which was not pureed. This resulted in Resident 1 choking and sustaining a cardiac arrest (heart stops beating). She remained in the intensive care unit at the hospital, on life support (techniques used to maintain life after the failure of one or more vital organs) for 20 days, before life support was discontinued and she passed away. Definitions: Choking is a form of asphyxia (insufficient intake of oxygen) caused by an obstruction within the air passages. A cardiac arrest is a sudden collapse in an individual who is non-responsive, who has abnormal breathing, or not breathing at all. A heart attack is quite different from a cardiac arrest which is when the arteries supplying the heart get blocked up. [What Is the Difference between a Cardiac Arrest and a Heart Attack? 11/7/08; Gordon Ewy, Medical Doctor (MD), Professor and Chief of Cardiology and Director, University of Arizona Sarver Heart] Findings: A review of the clinical record on 2/7/14 showed that the patient was an 83 year old woman, and was admitted to the facility on 12/22/09. She had multiple diagnoses, which included one that impaired her decision-making ability. The physician orders dated 11/23/13 directed staff to transfer the resident to the emergency department (ED) for her unresponsiveness related to choking. The facility's investigative reports dated 11/25/13 reflected CNA A handed out evening snacks and gave Resident 1 her applesauce and everyone had finished their snacks.During interviews on 2/7/14, at 3:30 p.m., and 3/14/14, at 3:37 p.m., CNA A stated she handed out snacks around 7:00 p.m., and confirmed she did feed Resident 1 all of her applesauce. She was unable to explain how the resident choked on food after she gave her the applesauce. When asked if it was possible that not everyone had finished eating, she stated, "Yes." She stated she never returned to the TV room after answering a call light. CNA A failed to maintain supervision and left the resident unattended which resulted in her choking on a sandwich. During an interview, on 3/5/14, at 8:30 a.m., certified nursing assistant (CNA B) stated that on 11/23/13, he was standing outside of the television (TV) room concentrating on watching his one assigned resident. When CNA A left the room to answer a call light, he entered the room to sit down and he noticed Resident 1 "Lying" in her wheelchair; her color was bluish and had food particles by her mouth. "I pumped her chest (CPR) for two or three minutes, and no response, then wheeled her to the nurse's station, and saw the charge nurse remove something from her mouth." He stated the "nourishment person (CNA A), is supposed to watch the residents because some are prone to choking, and should stay until everyone is done eating." CNA B confirmed that residents were still eating in the TV room. He also stated he did not check Resident 1 for a pulse or do rescue breathing. The P&P dated 9/1/13, "Accidents and Incidents," instructed staff that if assistance is needed, summon help. If you cannot leave the victim, ask someone to report to the licensed nurse that help is needed. If possible, use the call system located in the resident's room to summon help. In an interview on 3/5/14 at 8:30 a.m., CNA B stated he did not press the TV room's emergency button. In an interview, on 2/10/14, at 4:51 p.m., RN 1 stated Resident 1 was unresponsive, and already lacking of oxygen, had ground food particles on the side of her mouth and cleared the airway of this. In an interview, on 2/7/14, at 2:40 p.m., Resident 3 stated he observed Resident 2 give a piece of sandwich to Resident 1 in the TV room. Review of Resident 3's MDS dated 10/22/13, indicated he had dementia (memory problems), cognitive impairment, and was able to understand and be understood.In an interview, on 2/7/14, at 5:05 p.m., the Director of Nurses (DON) stated she thinks Resident 3 is credible in his statement to staff.During an interview, on 2/11/14, at 4:48 p.m., licensed vocational nurse (LVN 2) stated that Resident 3 approached her to say that Resident 2 gave a piece of sandwich to Resident 1. LVN 2 stated, "I would say he is a reliable person when he told me about this." In an interview, on 2/7/14, at 3:10 p.m., Resident 2 stated, "I gave her some of my sandwich and she ate it and got sick. You should have seen what they were giving her...baby food!"Review of the undated "Snacks at HS (hour of sleep)," verified applesauce and egg sandwich snacks on the menu. Review of Resident 2's MDS dated 10/2/13 indicated she had dementia, cognitive impairment and was able to understand and be understood.Review of Resident 1's minimum data set (MDS) assessment dated 10/15/13 reflected she received a therapeutic diet.In an interview, on 3/26/13, at 2:34 p.m., the MDS coordinator (MDS) stated the resident did not have teeth and received a pureed diet for this. MDS coordinator stated CNA's supervise all residents in the dining area and for no one in particular." She stated the resident had behaviors of grabbing or taking things.Resident 1's physician orders dated 10/13 and 11/27/13, prescribed a pureed low fat, low cholesterol and small portion diet. Resident 1's care plan dated 10/15/13 identified problems of aspiration/choking during meals, swallowing and eating too fast, grabbing peer's food and quickly eating. The following approaches for having no choking episodes when eating included: a. all staff to be informed of resident's special dietary and safety needs. b. eat in small dining room for close supervision. c. monitor for choking. d. monitor/document/report as needed any symptoms of choking, coughing, pocketing, holding food in mouth, several attempts at swallowing or appears concerned during meals. The facility failed to maintain close supervision and monitor for choking according to the plan of care. On 2/7/14, at 2:30 p.m., when asked for the policy and procedure (P&P) for snacks, the Administrator (ADM) provided a document dated, "prior to 12/1/13," titled, "Nourishments and Snacks," to be distributed by CNA's to residents in the dining room or community living rooms. There was no information on how to distribute and supervise residents during snacks. Review of the emergency department (ED) report dated 11/23/13, at 8:15 p.m., indicated Resident 1's heart had pulseless electrical activity (PEA). PEA is characterized by unresponsiveness and lack of palpable (to feel) pulse in the presence of organized heart electrical activity [www.heartorg]. The resident was a full code, and emergency measures taken resulted in a return of the resident's heart rhythm. She remained unconscious and then transferred to the critical care unit. In an interview, on 3/11/14, at 5:42 p.m., the ED physician stated it was reported that the resident choked on food and that choking can result in cardiac arrest.In an interview, on 3/26/14, at 2:16 p.m., a first responder stated the crew arrived at 7:13 p.m., and Resident 1 was in full cardiac arrest. He stated when a person is initially found blue, it is a late sign of hypoxia (insufficient levels of oxygen in blood or tissue) and that brain damage/loss can occur in four to six minutes without oxygen.In an interview, on 4/1/14, at 10:58 p.m., Paramedic 1 stated staff reported that the resident had no chest pain, and was not complaining of anything prior to her choking. Furthermore, he said an overly upset nurse told him the resident was just talking to her when she began choking and went into cardiac arrest.Physician critical care notes dated 11/23/13 reflected Resident 1 had a "Recent normal heart stress test" which is the amount of stress that your heart can manage before developing either an abnormal rhythm or evidence of not enough blood flow to the heart muscle. The heart rhythm showed "no acute changes," and that the "Resident certainly had an aspiration event" (occurs when an object (food) or liquid, is inhaled into the respiratory tract, either the windpipe or the lungs).A second critical care physician note dated 11/24/13, reflected the "Chest x-ray showed no evidence of congestive heart failure (heart's function as a pump is inadequate to deliver oxygen rich blood to the body)...PEA arrest after choking on food; suspect respiratory cause of condition." The hospital's Bioethics Committee (consultants on medical decision making) met on 12/5/13, and agreed that life support measures should be withdrawn, and shift to comfort care because the resident sustained a severe anoxic (without oxygen) brain injury that would leave her permanently disabled, if not in a persistent vegetative state (complete unawareness of the self and the environment). The hospital nurse's notes dated 12/13/13 indicated Resident 1 was pronounced dead at 9:12 p.m. Review of the cardiologist's (heart doctor) Death Summary dated 12/15/13, listed previous medical conditions, and identified death due to PEA, anoxic brain injury and respiratory failure.Therefore the facility failed to: Maintain supervision and provide a safe environment according to Resident 1's care needs. The patient was left unattended during snack time, which resulted in her choking on a sandwich.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. |
| 020000053 |
Crestwood Manor - Fremont |
020011617 |
AA |
13-Jul-15 |
HLUU11 |
12591 |
F309 Title 42, Code of Federal Regulations, ? 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 facility violated the aforementioned regulation when it failed to follow their policy and procedure to provide a safe dining experience, and failed to implement their care plan to consistently assist and assure that safe eating occurred for Resident 1. Resident 1 complained of difficulty swallowing and was known to eat quickly and not chew adequately. Licensed staff wrote a care plan instructing staff to, "Assist and monitor during meals; alternate between bites of food and sips of fluids". As a result of these failures, Resident 1 choked on food and died. Review, on 9/10/14, of the facility's policy and procedure, titled, "Dysphagia and Swallowing Risks," no revision date, showed, "If a resident appears to be exhibiting signs of Dysphagia (difficulty with swallowing or moving food or liquid safely from the mouth to the stomach) or has a swallowing risk (physiological, neurological, structural, behavioral or other issues) which increase the likelihood of a hazardous event (i.e. aspiration, food goes down the wrong pipe), choking, reflux stomach acids go back up the esophagus), a referral to a Speech Pathologist should be initiated, physician/ physician's assistant and conservator should be notified." The policy and procedure, titled, "Group Dining," revised 5/7/14, reflected, "Residents who attend group meals or group snack times are provided a supportive and safe dining experience. Upon admission and with each comprehensive MDS (complete resident assessment), resident's dining skill level will be evaluated and care plans developed and updated to reflect current individual needs." According to the medical record, reviewed on 9/10/14, Resident 1 was admitted to the facility on 11/9/12. Her diagnostic list, dated 5/28/14, included head injury from a motor vehicle accident, and dysphagia (abnormal or difficulty with swallowing). Resident 1 was sent to the emergency room emergently after choking on food and having a cardiac arrest, on 7/26/14, in the dining room.Review of nursing care plans, dated 10/23/13, showed: 1. "Focus: Impaired cognitive function or impaired thought processes related to short term memory loss, impaired decision making.2. "Focus: Variable appetite/ weight variance" with the intervention, "Encourage resident's socialization and interaction with table mates during meals.3. "Focus; Resistive to care related to diagnosis..., history of head trauma, refusing recommended consultations/ appointments/ medical interventions...being resistive when staff attempts redirection or instruction..."A nurse's note, dated 1/15/14, showed, "During breakfast, resident was noted to be eating faster than usual. Kept putting food fast in her mouth. Staff intervened always whenever resident was eating fast. Resident had food in her mouth when she exited the dining room. Staff intervened and let her swallow first before leaving. No difficulty swallowing noted." A "Nursing to Therapy Referral," dated 1/15/14, showed, "Please route to speech therapy. Resident has shown recent changes in the following areas: Safety- coughing; choking. Complained of difficulty swallowing on 1/14/14." The physician's assistants notes, dated 1/15/14, showed, "Informed by nursing yesterday evening by phone that patient complained of difficulty swallowing a vegetable in the dining room. Did not have a choke, was able to cough." A physician's order, dated 1/15/14, showed, "Clinical swallowing evaluation for dysphagia; Change diet to no added salt with chopped vegetables." A physician's order, dated 1/19/14, showed, "Discontinue speech therapy evaluation order, evaluation only, as patient is performing at her highest level of functioning Rx (Prescription) - Continue her current regular diet with chopped vegetables with strict swallow precautions. Re-consult speech therapy if any signs or symptoms of aspiration/ penetration or change in swallow status occurs."Review of care plans, dated 1/19/14, showed, "Concern: Potential for aspiration due to poor dentition, edentulous (lack of teeth), history of poor eating habits; resident gobbles food quickly. Refused swallowing evaluation on 1/17/14 but observed by speech therapist on 1/19/14. Strict swallow precautions." The heading titled "Concern" showed, 'Resident will have no choking/ aspiration episode to 3/19/14." The heading titled, "Approach" showed, "Monitor for signs and symptoms of choking/ aspiration; Staff assistance and monitoring; Encourage to take small bites, eat slowly and not talk while food in mouth; Alternate between bites of food and sips of liquids; Speech/ swallowing evaluation as needed, ordered 1/15/14; Notify physician and conservator of any change as needed." There was no revision date.A care plan, dated 6/9/14, titled, "Potential for aspiration", showed the goal, "Resident will follow diet as ordered (regular, no added salt with chopped vegetables) x 90 days." The Interventions included, "Encourage to take small bites, eat slowly and not talk while food in mouth, alternate between bites of food and sips of liquids, staff assistance and monitoring." The MDS (minimum data set, a complete resident assessment), dated 6/19/14, reflected Resident 1 was independent in eating and only needed 'set-up.' Under the heading, "Swallowing/ Nutritional Status," showed "Loss of liquids/solids from mouth when eating or drinking." It reflected that Resident 1 was on a therapeutic diet, no added salt, and the space next to, "Mechanically altered- required change in texture of food or liquids," was blank. Review of the written report sent to the Department by the facility administrator (ADM) on 7/26/14, showed, "The following incident happened today at noon meal. RN 1 verified all the diets and CNA's passed the trays in the assisted dining area....LVN 1 heard, 'That resident needs help.' She was assisting another resident about ten feet away at another table. LVN 1 saw that Resident 1 was bluish, called for help, and began the Heimlich maneuver...LVN 1 swept a small piece of meat from her mouth... No pulse was detected so CPR was started until emergency responders arrived." During an interview on 9/10/14 at 11:30 a.m., the MDS coordinator was asked about the assistance Resident 1 required during meals. She stated, "We have CNAs (certified nursing assistants) going around looking at the residents. Resident 1 was independent in spite of having dysphagia. If a resident needed one to one assistant, it would be called 'supervision'. Resident 1's assessment showed zeros for 'self- performance,' meaning she needed no help. 'Set-up' is giving the tray, opening containers and cutting the meat if requested. I took this information from the CNA's ADL flow sheet."The activities of daily living (ADL) flow sheet, documented daily by the CNAs, reflected Resident 1 received 'set-up' and ate independently every day in 7/2014. During an interview on 9/10/14 at 12:30 p.m., the Director of Nurses (DON) stated, "Monitoring is when CNAs are going around in meal area and looking at residents while they eat. They will tell them to slow down, take small bites." During an interview on 9/10/14 at 12:35 p.m., the director of staff development (DSD) stated, "I saw staff stopping her (Resident 1) when she left the dining room with food still in her mouth. There were days when she wouldn't reality orient (having delusional thoughts)." During an interview on 9/10/14 at 12:50 p.m., registered nurse 1 (RN) stated, "I supervised the dining room on 7/26/14 when she (Resident 1) choked. I checked to be sure the diets were correct and delegated the CNAs to pass the trays. I walked around and observed and instructed to not talk while eating and chew properly, slowly and alternate with fluids. When Resident 1 choked, there was no coughing. LVN 1 heard someone say, 'This lady needs help.' We were in the community dining room. LVN 1 got to her first and called for help. Resident 1 was still sitting in the chair and her face was blue. LVN 1 gave her the Heimlich in the chair from behind and nothing came out. More staff came and we put her on the floor and tried thrusts. Her meat was not chopped." When asked how staff ensured alternating food and fluids, RN 1 stated, We reminded her. She was very independent and would reject our recommendations." During an interview on 9/10/14 at 1:30 p.m., the physician (MD 1) stated, "I feel they followed the speech therapist (ST) referral and I did, too. You should talk to the ST."During an interview on 9/10/14 at 1:45 p.m., licensed vocational nurse (LVN) 4 stated, "I was the one who called 911. She (Resident 1) was in the community center dining room which is for residents who need assistance like encouraging, cutting food if they want and feeding them if they are too delusional to focus." During a phone interview on 9/11/14 at 10:30 a.m., speech therapist (ST) stated, "I did observation on 1/19/14. She was uncooperative. I made a recommendation if they saw any problem with her forming a bolus (a pill shaped mass) to get a new ST referral to assess her swallow. I recommended chopped vegetables as the only change in texture because it was her preference. I saw her once, on 1/19/14, six months before the choking incident on 7/26/14." Review of the assessment by the emergency medical technicians who arrived on 7/26/14 showed, "Arrived at nursing home to find ...female patient lying on the dining room floor...There was report that this patient may have been choking when the (cardiac) arrest took place... When airway was assessed there was a lot of secretions with food content. Special instruments used to remove contents. While visualizing airway, a large piece of meat was removed from her airway." Review of the hospital emergency department records, dated 7/26/14, showed, "Chief complaint: CPR (cardiopulmonary resuscitation). Patient coming from assisted living facility. Was eating, began to choke, CPR initiated. Down for 5 minutes prior to EMS arrival, on scene patient in asystole (no heartbeat)...Airway cleared of food...History: Patient choked on turkey...EMS pulled three chunks from mouth..."The hospital's discharge summary, dated 8/1/14, reflected, "....resident who was rushed to ER via emergency medical system (EMS) after she choked on a piece of chicken meat during lunch time. CPR was initiated in the facility. In ER she was intubated (a tube inserted into the trachea to maintain an open airway) and placed on a mechanical ventilator. She had a seizure in the ER...Bronchoscopy (examination of the deeper parts of the lungs with a scope) was done...removed a piece of chicken meat completely obstructing the left main stem bronchus.....She was transferred to intensive care unit (ICU). Her mental status remained poor the next day, concerning her anoxic encephalopathy (lack of oxygen to the brain)...Comfort care initiated on 8/1/14. She expired at 3:30 p.m. Disposition: Deceased" During a phone interview on 9/11/14 at 2:15 p.m., the assistant director of nurses (ADON) stated, "Care plans are reviewed and revised every three months. There was no review of Resident 1's care plan to prevent aspiration between 1/19/14 and 6/9/14." During a phone interview on 9/18/14 at 1:45 p.m., the dietary manager (DM) was asked about the change in vegetable texture (chopped) but not the texture of the meat. DM Stated, "She was on soft-cooked vegetables and chopped to be soft. If it wasn't soft, she wouldn't be able to tolerate it. I just follow the diet orders." During a phone interview on 9/19/14 at 2:15 p.m., the director of staff development (DSD) stated, "I haven't given an inservice on dysphagia; I just tie it into what to do after someone chokes." Review, on 10/17/14, of Resident 1's death certificate, dated 8/7/14, showed the immediate cause of death as, "Anoxic encephalopathy", and the underlying cause as, "Aspiration of food". There was a space for the coroner to fill in, "How injury occurred, (events which resulted in injury)". The deputy coroner documented, "Choked on food". Therefore, the failure of the facility to follow Resident 1's care plan, and the physician's order for strict swallow precautions presented an imminent danger of death or serious harm to the patient, and was a direct proximate cause of the patient's death due to aspiration of food. |
| 020000048 |
Chaparral House |
020012919 |
B |
2-Feb-17 |
RVP911 |
8095 |
483.12 FREE FROM ABUSE/INVOLUNTARY SECLUSION 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.
The facility violated the aforementioned regulation by failing to protect one Resident (1) from physical and verbal abuse when:
1. Certified Nursing Assistant (CNA) 1 slapped Resident 1 in the back of the head, held her down, covered her face with a towel, and called her a "nasty b*#ch";
2. CNA 2 held down Resident 1 and covered her face with a towel; and
3. CNAs 1 and 2 were not removed from resident care during the facility's investigation.
Record review on 12/1/16 of the document titled, "Admission Record," showed the facility admitted Resident 1 on XXXXXXX11 with a diagnosis of Alzheimer's (a common form of dementia characterized by memory lapses, confusion, emotional instability, and progressive loss of mental ability).
Record review of the document titled "Minimum Data Set, Resident Assessment and Care Screening," (MDS), dated 9/27/16, showed Resident 1 was severely impaired (never or rarely made decisions) for daily activities. Resident 1's MDS also showed she had a short-term and long-term memory problem was sometimes able to understand others, and sometimes able to make herself understood. The MDS also showed Resident 1 had behaviors that included feeling or appearing down, depressed, or hopeless and being short-tempered or easily annoyed. Resident 1's MDS also showed she required the extensive assistance (resident involved in activity, staff provided weight-bearing support) of two staff persons for transfers and was totally dependent (staff performed entire activity) on two staff persons for personal hygiene.
Review of Resident 1's undated care plan showed:
a. She had an impaired cognitive (reasoning, memory, attention, and language) function and depression. The care plan showed instructions to staff to "...provide the resident with necessary cues - stop and return if agitated...introduce yourself and let her know what you are about to do and what you expect her to do...offer opportunities for choice, simplify instruction; be flexible and patient and encourage involvement in daily life...."
b. She "...may have difficulty communicating and will say loudly 'go away or go to hell or mind your own business' if she was getting too much stimulation, or too many questions too fast, or was not understanding...." The care plan showed instructions to staff to "...explain to her what you are doing and why...."
c. She had a self-care problem with activities of daily living (ADL - routine activities that people tend do every day without needing assistance such as eating, bathing, dressing, toileting, transferring, and continence). The care plan showed instructions to staff to "...segment (break up) the bathing process so it is not overwhelming for her and to explain what you are doing and what you expect her to do...."
In an interview on 12/1/16 at 2 p.m., Student 1 stated that on 11/28/16 at 1:15 p.m. she was working in the facility with CNA 2 to provide hygiene care for Resident 1 in her room. CNA 1 came into Resident 1's room and sat down while CNA 2 began to change Resident 1's wet undergarment. CNA 2 did not tell Resident 1 what she was doing and Resident 1 became combative. CNA 2 grabbed Resident 1's arm and held it down. Student 1 stated that CNA 1 got up, took hold of Resident 1's other arm and then held her down. Resident 1 became increasingly combative and started to "spit." Student 1 stated CNA 1 and 2 then rolled Resident 1 over and put a towel over her nose and mouth. Student 1 stated she heard Resident 1 say "I can't breathe," and they took the towel off and rolled her to the other side. Student 1 stated, Resident 1 yelled "Let go of me you b*#ches," and "CNA 1 got mad and called her a Nasty B*#ch." Student 1 stated that CNAs 1 and 2 moved Resident 1 from her bed to the wheelchair, and then CNA 1 hit Resident 1 on the head five times, and Resident 1 said, "Stop hitting me in the head," and CNA 2 was laughing.
In an interview on 12/9/16 at 3:07 p.m., Student 2 stated that on 11/28/16 she was assigned to work with CNA 2 and their assignment included caring for Resident 1. At approximately 1:00 p.m., (on 11/28/16) CNA 2 began to change Resident 1's undergarment while she was in her bed. Student 2 stated CNA 1 came into Resident 1's room and sat in a chair. Resident 1 became agitated and told CNA 2 she did not want her (CNA 2) to change her undergarment. Student 2 stated CNA 2 continued to try to change the undergarment and Resident 1 then began to spit at her (CNA 2). Student 2 stated CNA 1 then came over to the bed and held Resident 1's arms down while CNA 2 worked on changing the undergarment. Resident 1 then started to spit at both CNA 1 and CNA 2 and she told them to stop (changing her undergarment). Student 2 stated CNA 1 and CNA 2 continued to try and change the undergarment. Student 2 stated Resident 1 was screaming and yelling and said, "Don't hit me in the head again." Student 2 stated CNA 1 and CNA 2 then transferred Resident 1 into her wheel chair and both CNA1 and CNA 2 tried to tie a towel around Resident 1's mouth, but it fell off. Student 2 stated CNA 1 then started to hit the top of Resident 1's head with both of her hands and said "Nasty b*#ch." Student 2 stated CNA 2 witnessed CNA 1 hitting the top of Resident 1's head and did not say or do anything.
In an interview on 12/1/16 at 2:15 p.m., CNA 2 stated, when working with Resident 1 she needed extra help. CNA 2 stated that on 11/28/16 when they changed and dressed Resident 1 she "Spit."
In an interview on 12/1/16 at 2:40 p.m., CNA 1 stated, on 11/28/16, went into Resident 1's room to help CNA 2 put Resident 1 into the wheelchair. CNA 1 stated Resident 1 "fusses," and gets a little "Combative." CNA 1 stated Resident 1 spits so, "We put a towel on her mouth."
In an interview on 12/1/16 at 3:20 p.m., (fifty minutes after being notified of the IJ) the DON stated she needed to ask CNA 1 to leave because she was still in the in the facility.
In an interview on 12/13/16 at 9:10 a.m., the Administrator (ADM) stated CNA 1 and CNA 2 had returned to work providing resident care at the facility. The ADM stated she was still working on the facility's investigation. The ADM stated she could not believe CNA 1 or CNA 2 would do this (abuse Resident 1) or lie about it. The ADM stated she had known them forever and would "trust them with her life."
Review of the facility document titled, "Archived Time Card Report," dated 12/2/16 through 12/13/16 showed CNA 1 worked on 12/8/16, 12/9/16, 12/10/16, and 12/11/16 and CNA 2 worked on 12/6/16, 12/7/16, 12/10/16, 12/11/16, 12/12/16, and 12/13/16.
Record review of the facility's policy and procedure titled, "Abuse Prevention and Reporting," dated 11/2008, specified "Policy: (the facility) is dedicated to providing quality care, which enhances quality of life for the frail elderly residents served. (The facility) strives to maintain compliance with applicable Federal State and Local laws, regulations and requirements. Additionally, (the facility) places value on best practices among community standards for care. Abuse, in all forms, including, physical, emotional / mental, and fiduciary is strictly prohibited."
Therefore, the facility failed to protect one Resident (1) from physical and verbal abuse when:
1. Certified Nursing Assistant (CNA) 1 slapped Resident 1 in the back of the head, held her down, covered her face with a towel, and called her a "nasty b*#ch";
2. CNA 2 held down Resident 1 and covered her face with a towel; and
3. CNAs 1 and 2 were not removed from resident care during the facility's investigation.
These violations had a direct relationship to the health, safety or security of patients. |
| 020000048 |
Chaparral House |
020012920 |
B |
2-Feb-17 |
RVP911 |
7250 |
F 226
483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES 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 facility violated the aforementioned regulation by failing to protect one Resident (1) from abuse by not implementing their abuse prevention and reporting policy and procedure when Licensed Vocational Nurse (LVN 1), an employee of a contracted Certified Nurse Aid (CNA) training program, did not report to the facility the allegation of abuse made by Student Nurse 1 and 2.
In an interview on 12/1/16 at 12:30 p.m., Registered Nurse (RN 1) stated Students 1 and 2 were in a training program not affiliated with the facility, but did their clinical practice training at the facility. RN 1 stated that while the students are at the facility, they were supervised by a Licensed Vocational Nurse (LVN 1) who worked for a Certified Nurse Aid training program that had a contract with the facility to use its facilities for clinical rotation/training of its Certified Nursing Assistant and Home Health Aide Students.
In an interview on 12/1/16 at 2 p.m., Student 1 stated that on 11/28/16 at 1:15 p.m. she was working in the facility with CNA 2 to provide hygiene care for Resident 1 in her room. CNA 1 came into Resident 1's room and sat down while CNA 2 began to change Resident 1's wet undergarment. CNA 2 did not tell Resident 1 what she was doing and Resident 1 became combative. CNA 2 grabbed Resident 1's arm and held it down. Student 1 stated that CNA 1 got up, took hold of Resident 1's other arm and then held her down. Resident 1 became increasingly combative and started to "spit." Student 1 stated CNA 1 and 2 then rolled Resident 1 over and put a towel over her nose and mouth. Student 1 stated she heard Resident 1 say "I can't breathe," and they took the towel off and rolled her to the other side. Student 1 stated, Resident 1 yelled "Let go of me you b*#ches," and "CNA 1 got mad and called her a Nasty B*#ch." Student 1 stated that CNAs 1 and 2 moved Resident 1 from her bed to the wheelchair, and then CNA 1 hit Resident 1 on the head five times, and Resident 1 said, "Stop hitting me in the head," and CNA 2 was laughing. Student 1 stated that she thought that was abuse and she told her instructor (LVN 1) who told Student 1 to "ignore it and then she brushed it off." Student 1 stated she called her instructor at the training program (RN 1) and reported the incident.
In an interview on 12/9/16 at 3:07 p.m., Student 2 stated that on 11/28/16 she was assigned to work with CNA 2 and their assignment included caring for Resident 1. At approximately 1:00 p.m., (on 11/28/16) CNA 2 began to change Resident 1's brief while she was in her bed. Student 2 stated CNA 1 came into Resident 1's room and sat in a chair. Resident 1 became agitated and told CNA 2 she did not want her (CNA 2) to change her brief. Student 2 stated CNA 2 continued to try to change the brief and Resident 1 then began to spit at her (CNA 2). Student 2 stated CNA 1 then came over to the bed and held Resident 1's arms down while CNA 2 worked on changing the brief. Resident 1 then started to spit at both CNA 1 and CNA 2 and she told them to stop (changing her brief). Student 2 stated CNA 1 and CNA 2 continued to try and change the brief. Student 2 stated Resident 1 was screaming and yelling and said, "Don't hit me in the head again." Student 2 stated CNA 1 and CNA 2 then transferred Resident 1 into her wheel chair and both CNA1 and CNA 2 tried to tie a towel around Resident 1's mouth, but it fell off. Student 2 stated CNA 1 then started to hit the top of Resident 1's head with both of her hands and said Resident 1 was a "Nasty b*#ch." Student 2 stated CNA 2 witnessed CNA 1 hitting the top of Resident 1's head and did not say or do anything.
In an interview on 12/9/16 at 3:49 p.m. Student 2 stated she reported what she witnessed to LVN 1 and LVN 1 said she did not want to get involved.
In an interview on 12/9/16 at 2:59 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she recalled Students 1 and 2 reported to her that CNAs 1 and 2 had been verbally rough with Resident 1. LVN 1 stated she told the students to report the incident if they believed they had witnessed an intent to harm Resident 1.
During an interview on 12/12/16 at 4:15 p.m. the Administrator (ADM) stated the facility ensures CNA students are trained in abuse when the facility sets up the contract with the CNA schools - students were to watch two Department of Justice (DOJ) videos on elder abuse. The ADM also stated the teacher (LVN) onsite was responsible for the students - the LVN prepared with the students and worked closely with the students.
In an interview on 12/13/16 at 9:10 a.m., the Administrator (ADM) stated she just could not believe CNA 1 or CNA 2 would do this or lie about it. The ADM stated she had known them "forever and would trust them with her life." The ADM stated she was still working on the facility's investigation.
Review of the contract between the facility and the training program showed:
"...2. Responsibilities of School...(the School), its students, and faculty will adhere to all policies and procedures set forth by (the facility)...2(B)(10) (the School) and Clinical site (facility) will enforce rules and regulations governing the workers that are mutually agreed upon by the School and the Clinical site (facility)...2(B)(A) the "...School will notify the students that they are responsible for: 1. Following the administrative policies of the clinical site...."
Record review of the facility's policy and procedure titled, "Abuse Prevention and Reporting," dated 11/2008, indicated "Policy...All employees of (the facility) are considered 'mandated reporters' relative to Elder Abuse or Neglect...10. Any staff member who identifies a suspicious event that may be evidence of abuse is responsible to report their concerns...10(a). An internal event report is filled out, documenting the time, place and situation of concern...10(b). The Administrator or On-Call Administrative staff is notified...."
Therefore, the facility failed to protect one Resident (1) from abuse by not implementing their abuse prevention and reporting policy and procedure when Licensed Vocational Nurse (LVN 1), an employee of a contracted CNA training program, did not report to the facility the allegation of abuse made by Student Nurse 1 and 2. |
| 030001815 |
Courtyard Health Care Center |
030009414 |
B |
26-Jul-12 |
XJ5111 |
5097 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. 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 Unannounced visits were made to the facility on 9/15/09 and 9/17/09 to investigate a facility reported incident CA00194821 received on 7/13/09 at 3:32 p.m. regarding an incident of alleged patient to patient abuse which occurred on 7/10/09 at 5:00 p.m.The Department determined the facility failed to: 1. Follow state law related to reporting allegations of abuse. 2. Implement facility policies and procedures related to abuse reporting. Patient A, an 80 year old female was admitted to the facility on 4/18/09 with diagnoses of Alzheimer's disease, dementia with psychotic condition, and unspecified personality disorder. The Minimum Data Set, (MDS- a standardized assessment tool) dated 4/18/09, indicated Patient A was cognitively impaired with varied mental function and short and long term memory problems. Physician's Orders dated 4/18/2009 (in part) directed to staff to monitor Patient A for episodes of "explosive/aggressive behavior, restlessness, sleeplessness or striking out." Patient B, a 62 year old female was admitted to the facility on 3/18/08 with diagnoses of senile dementia, unspecified psychosis and psychomotor retardation. The MDS dated 6/30/09, indicated Patient B was cognitively impaired with short and long term memory problems, periods of restlessness, and easily altered indicators of depressed, sad or anxious mood.On 7/10/09 at 5:00 p.m., Resident B was seated in the dining room when Resident A walked up to her and struck her twice, with a closed fist, on the left shoulder and middle of her back. A CNA (Certified Nursing Assistant) who observed the incident immediately separated the patients and reported the incident to Registered Nurse 2 (RN 2).A review of Patient A's clinical record reflected that RN 2 notified the Patient A's physician, responsible party (RP), and the Director Of Nursing (DON) of the incident on 7/10/09. Patient B's clinical record reflected that RN 2 assessed Patient B and noted no physical injuries on 7/10/09.In an interview with RN 2 on 9/17/09 at 4:30 p.m., she stated the policy on abuse that was in use on 7/10/09 when the incident occurred, required the charge nurse to notify the physician, RP and DON. In a telephone interview on 9/23/09 at 10:45 a.m., RN 2 stated she notified the physician and RP for both residents but failed to document that notification in Patient B's clinical record.In an interview on 9/15/09 at 11:45 a.m., the DON confirmed RN 2 informed her of the incident on 7/10/09. The DON stated she notified the Social Service Director (SSD) on 7/13/09. In a subsequent telephone interview with the DON on 7/21/09 at 11:00 a.m., she stated at the time of the incident, she was under the impression that abuse must be reported to the Department within 72 hours. The DON also stated the facility adopted a new policy subsequent to the incident.On 9/15/09 at 12:00 p.m., in an interview with the SSD, she confirmed the DON informed her of the incident on 9/13/09. At that time the SSD completed a "Report of Suspected Dependent and Elder Abuse" form (SOC 341) and a "Self Report "and notified the Ombudsman and the Department.The facility policy and procedure entitled Suspected/Alleged Abuse Management Process dated 9/09, which was in use when the incident occurred on 7/10/09, was reviewed with sections summarized, in part. Under the section entitled "Communication", when an incident of suspected abuse occurs, the employee making the discovery is required to report the facts of known or suspected instances of abuse to the Administrator or Director of Nursing and/or the person acting as the abuse coordinator so that fulfillment of reporting responsibilities under local, state and federal agencies are met. Under the subsection entitled "*California Requirement" regulations require employees that provide services to the elderly or dependent adults ("mandated reporters") and other employees ( as required by state law) to report instances of abuse, neglect, or misappropriation of resident property to the local ombudsman or local law enforcement agency immediately or as soon as practically possible within 24 hours of detection.The Department determined the facility failed to follow state law and implement their facility policy related to abuse reporting requirements when they failed to: 1. Report the allegation of abuse to the Department immediately or within 24 hours of the event.2. Notify the local Ombudsman of the event as soon as practically possible within 24 hours of detection. Violation of this section of the California Health and Safety Code shall be a Class B Citation. |
| 030001815 |
Courtyard Health Care Center |
030009462 |
B |
30-Aug-12 |
60X311 |
10436 |
Patients' Rights - 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (4) To consent to or to refuse any treatment or procedure or participation in experimental research. Nursing Service -- General - 72311 (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. (C ) Reviewing and evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the at least quarterly and more often if there is a change in the patient's condition.The Department determined the facility failed to: 1. Ensure Patient A's Responsible Party consented to the extraction of 11 teeth, 2. Adequately plan for Patient A's care following the extraction of 11 teeth. These failures contributed to weight loss and dehydration which were further compounded by Patient A's medical condition and medications.An unannounced visit was made to the facility on 3/21/11 to investigate complaint number: CA00262231.Patient A was an 88 year old who had lived at the facility since 8/13/07. Her diagnoses included Alzheimer's dementia, depression, chronic kidney disease, neuropathy (pain) in the legs, diabetes, arthritis, gout, heart failure, and high blood pressure.Patient A's clinical record contained a document labeled: LA/ac/AdmAgrmtProvision.doc dated 8/13/07. Patient A's Responsible Party (RP) signed this document which contained the following information: "I [RP] am the niece of [Patient A]. I have acted as the representative/agent for [Patient A] in matters related to healthcare and related decision making matters. I agree to continue in my role [Patient A] as representative/agent for healthcare decisions, and related decisions, and wish to be notified as to all matters requiring medical decisions or consents." A document labeled ADMISSION AND DISCHARGE SUMMARY (also known as a "face sheet") listed the niece as Patient A's responsible party. A document in Patient A's clinical record labeled DENTAL NOTES dated 3/17/10, indicated Patient A had nine teeth extracted by the facility's contracted dentist. The extractions were needed due to severe tooth decay and preparation for full upper dentures. Dental Notes dated 4/9/10 indicated two more teeth were extracted on that date. On the Dental Notes form, under the section labeled Tx (treatment) Recommendation, the following appeared: "All Tx recommendations are subject to insurance and/or Responsible Party's authorization."In a document provided by the facility's contracted dental provider labeled GENERAL CONSENT FORM, signed and dated by Patient A on 3/12/10, the following appears: "If the patient is not able to give consent due to functional or mental limitations and you are the responsible party/personal representative on behalf of the patient, please complete the following: [space for name, address, phone number and signature]. In an interview with Patient A's RP on 3/21/11 at 12:35 p.m., she stated Patient A "went downhill" after an "unauthorized" tooth extraction. She stated they called her for everything, but for some reason they [the facility] did not call her for consent for the extraction(s) until after it was done.In an interview with Licensed Nurse (LN) 1 on 8/4/11 at 8:34 a.m., she stated Patient A's RP "definitely didn't know about the extractions." In an interview with the contracted dental service Director on 3/28/11 at 2:15 p.m., he stated the treating dentist would need consent for procedures such as extractions.In an interview with the treating dentist on 10/27/11 at 2:26 p.m., he stated Patient A was her own responsible party and had signed a consent form. He stated he did not get further consent from Patient A at the time of the extraction because she had "signs of dementia and confusion."Review of Patient A's clinical record revealed a WEIGHT RECORD which documented Patient A's weight went from 185.5 pounds (lb) to 156.5 lb (29 lb loss) between 3/10/10 and 4/15/10 (approximately one month after the teeth were extracted). [Some of the weight loss can possibly be accounted for as water loss because Patient A was taking medication to promote extra fluid loss each day. There is no documentation in the narrative Nurse's Notes that refer to Patient A's fluid status (for example swelling of the limbs or a reduction of swelling) during that time. The Nursing Weekly Summary Reviews covering the same time period had a check box indicating no edema (swelling) was identified.A Nurse's Note dated 3/22/10 indicated: [Patient A] "eating only food brought from niece." This information did not appear on any Care Plan.A Nurse's Note dated 3/24/10 documented: "[Patient A] has no appetite to eat because all her upper teeth were pulled." A Nurse's Note dated 3/25/10 documented "[Patient A has] little appetite for meals when [Patient A's] upper teeth were all pulled out."A Nurse's Note dated 4/12/10 documented: "[Patient A] unable to eat properly d/t [due to] s/p [status post] tooth extraction." Nurse's Notes from 3/17/10 through 4/15/10 contained 32 references to Patient A's declining appetite.Review of Patient A's clinical record revealed a NUTRITION CARE PLAN, dated originally 8/22/07 and last updated 2/2010. There was no mention of the tooth extractions or how Patient A's nutritional needs might change on a Care Plan until 4/13/10 (27 days after the first extractions). On that date, a Short Term Patient Care Plan was initiated and listed "Loss of appetite d/t [due to] s/p [status post] tooth extraction; Difficulty to bite" was listed as a Problem/Concern. The interventions for this problem were: 1) Inform MD, RP, DON [director of nursing], 2) Start a pureed diet with hot soup every meal, and 3) Refer for any untoward complaints. Other risk factors for Patient A losing weight included infection and antibiotic therapy. Lexicomp Online, a recognized drug reference website, indicated both Flagyl and tetracycline had anorexia (a marked reduction in appetite) listed as side effects. Patient A was taking 500 milligrams (mg) of Flagyl three times daily and tetracycline 500 mg three times daily, from 3/16/10 through 3/26/10. Patient A's antibiotic therapy was for an H. pylori infection (a stomach infection that can cause ulcers). The American Medical Director's Association Clinical Practice Guideline on Gastrointestinal (GI) Disorders in the Long-Term Care Setting list H. pylori infection as a risk factor for GI disorders.A Short Term Patient Care Plan dated 3/16/10 listed H. pylori infection as a Problem/Concern. Action approaches for this problem included: MD aware, RP will be notified, Monitor and Add new order: Flagyl, Tetracycline, Prilosec (a stomach ulcer medication). The care plan did not contain any reference to the possibility of changes in Patient A's food intake.A DISCHARGE SUMMARY from the General Acute Care Hospital (GACH) indicated Patient A was admitted to the GACH on 4/15/10 and discharged back to the facility on 4/19/10. Patient A's diagnoses included acute kidney failure secondary to dehydration.Facility Nurse's Notes between 3/17/10 and 4/15/10 indicated Patient A had a decrease in oral intake (see above). On 3/19/10, 3/23/10 and 4/12/10, there was documentation in the Nurse's Notes that Patient A vomited. There were no specific references to Patient A's hydration status except notations which indicated "fluids encouraged" on 3/23/10, 4/12/10 and 4/14/10.Intake and output records for March and April 2010 indicate that from 3/1/10 through 3/16/10 Patient A drank an average of 1359 milliliters (ml) each day. From 3/17/11 through 4/15/11 Patient A drank an average of 977 ml per day (a difference of 382 ml per day). Five days did not have a total intake recorded for the day.Other risk factors for Patient A developing dehydration included use of two diuretics (water pills), furosemide 20 mg once daily and spironolactone 12.5 mg once daily. The American Medical Director's Association, in the Clinical Practice Guideline Dehydration and Fluid Maintenance in the Long-Term Care Setting lists diuretics as medication that can increase the risk of dehydration. Other factors listed that relate to Patient A's risk for dehydration were lowered thirst impulse due to ageing, dementia, and depression. As noted above, a nursing care plan for risk of dehydration was not initiated until 4/23/10 (upon Patient A's return from the GACH).In an interview with LN 1 on 8/4/11 at 8:34 a.m., she stated Patient A was doing well and participating in activities before the dental extractions. She stated after Patient A's teeth were pulled she noticed Patient A started to decline and seemed to give up.Patient A had 11 teeth extracted without permission from the Responsible Party. After the extraction, the facility failed to plan for changes in Patient A's care concerning the possible effects of the extraction. Patient A was at risk for weight loss and dehydration not only because of the tooth extractions, but for other factors as well. The risks associated with Patient A should have caused nursing to carefully plan interventions to prevent or to lessen the weight loss and dehydration Patient A experienced one month after the surgery.Therefore the Department determined the facility failed to: 1. Ensure Patient A's Responsible Party consented to the extraction of 11 teeth. 2. Adequately plan for Patient A's care following the extraction of 11 teeth. These failures contributed to weight loss and dehydration which were further compounded by Patient A's medical condition.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents.. |
| 030001815 |
Courtyard Health Care Center |
030009544 |
B |
12-Oct-12 |
PA6N11 |
2600 |
1418.91 Health & Safety Code (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of an unannounced visit to the facility on 8/19/09 at 1:30 p.m. to investigate Entity Reported Incidents CA00184726 and CA00182759. As a result of the investigation, the Department determined the facility failed to report alleged or suspected abuse to the Department within 24 hours as required by law. Patient 1 was an 87 year old male admitted on 1/5/08 with diagnoses of dementia and failure to thrive. He was wheelchair bound and had a gastric tube for feeding. He was able to take some food and fluids by mouth.A review of the Minimum Data Set (MDS), an assessment tool) dated 10/10/2008, showed Patient 1 as having long and short term memory problems, moderately impaired cognitive skills for daily decision making, and expressive communication problems (he was non-verbal). He required total assistance with all Activities of Daily Living. MDS assessments dated 4/15/09 and 7/15/09 were the same for long and short term memory problems and daily decision making.Review of Social Services notes dated 1/5/09 indicated that nursing reported to Social Services that a staff member had observed Patient A's wife punching Patient A in the stomach on 1/4/09. Further review of the Social Services Designee (SSD) notes indicated "I do not feel it necessary to fill out an SOC 341, but I will continue to monitor..." There was no documented evidence the facility notified the Department of this allegation of abuse. In an interview with the SSD on 11/12/09 at 2:35 p.m. she stated that staff witnessed Patient A's wife hit him in the stomach, and the incident was related to her the next day. The SSD and the administrator decided not to report the incident to the Department. The SSD further stated that it "probably should have been reported."On 4/13/2009 the Facility reported to the Department that on 04/11/09 that Patient 1's wife was observed telling him he was a "son of a bitch" and punching him in the chest area and in the left side of his face or jaw.Therefore, the Department determined the facility failed to report allegation(s) of abuse to the Department immediately or within 24 hours as required by law. A failure to comply with the requirements of the California Health & Safety code Section 1418.91 shall be a class "B" violation. |
| 030001815 |
Courtyard Health Care Center |
030009545 |
B |
12-Oct-12 |
PA6N11 |
11320 |
72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 72527 Patient's Rights (a) Patients shall have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and any representative of the patient. The policies shall accessible to the public upon request. Patients have the right to: (10) To be free from mental and physical abuse.The following citation was written as a result of an unannounced visit to the facility on 8/19/09 for the initiation of the investigation of Entity Reported Incident CA00184726. As a result of the investigation, the Department determined the facility failed to ensure the patient was treated with dignity and respect and not subjected verbal or physical abuse of any kind. Patient 1 was an 87 year old male admitted on 1/5/08 with diagnoses of dementia and failure to thrive. He was wheelchair bound and had a gastric tube for feeding. He was able to take some food and fluids by mouth.A review of the Minimum Data Set (MDS, an assessment tool) dated 10/10/08, showed Patient 1 as having long and short term memory problems, severely impaired cognitive skills for daily decision making, and expressive communication problems (he was non-verbal). He required total assistance with all Activities of Daily Living. MDS assessments dated 4/15/09 and 7/15/09 were the same for long and short term memory problems and daily decision making.On 04/13/09, the facility reported incidents of alleged/suspected abuse to Patient 1 by his wife on 3/25/09 and 4/11/09. On 3/25/09, facility staff observed the wife hit him in the face and slap his legs. On 4/11/09, facility staff observed the wife call him "a son of a bitch" and hit him in the chest and jaw with a closed fist.Review of the facility policy from the Operational Policy and Procedure Manual, Resident Rights, Appendix B, Abuse Policies and Procedures revealed (in part)...The Abuse Policy, revised 1/1/08, "Every resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends or other individuals." The Abuse Policy, under the heading "Abuse, Neglect and Misappropriation of Property Guidelines "[the Facility] will...provide notification of information to the proper authorities according to state and federal regulations." The Abuse Policy, Section on Abuse, Neglect and Misappropriation of Property Guidelines, page 8, Number 12 states," If the family member or other visitor is suspected of violation of these policies, they may be prohibited from visiting the resident or in any other way have access to the facility pending investigation. Social Service notes dated 1/5/09 indicated nursing reported to Social Services that a staff member had observed the wife punching the resident in the stomach on 1/4/09. Investigation by Social Services determined that the wife was attempting to push the resident up in his wheelchair. Social Services Designee (SSD) documented in the clinical record "I do not feel it necessary to fill out an SOC 341, but I will continue to monitor" Resident 1 and his wife. A review of the Social Service notes for 3/25/09 revealed that "three different staff members observed the resident's wife slapping his legs and forcing his chin up with a closed fist." His wife stated that she did these things, but not to harm the resident, but to move his leg and to keep him from slouching in his wheelchair. She was counseled by Social Services staff that these behaviors were not acceptable. She was advised to get help from a Certified Nurses Assistant (CNA) or a (licensed) nurse if she needed help. Plans were made to monitor the resident for 3 days for injuries and psychosocial changes.In a review of Nurses Notes dated 3/16/09 through 3/30/09, there was no documentation of a conflict between Resident 1 and his wife or of any monitoring by the direct care staff. A review of the Resident Care plans from the current and thinned medical record documented a care plan dated 4/11/09 titled "Risk for Potential Harm", and on 4/13/09 a care plan titled "Wife angry, yelling and hitting resident". There were no care plans noted in the record addressing alleged abuse concerns prior to these dates.An Investigative Report dated 3/25/09 at 11 a.m. revealed the following: 1. Employee 1 walked by the resident's room and observed his wife with a closed fist between the resident's chin and neck. 2. Employee 2 walked by the resident's room from the opposite direction and observed his wife slapping his legs, and the resident was moaning.3. Employee 3 was in a nearby office and heard Employees 1 and 2 saying "she's hitting him".Employee 3 asked who they (Employees 1 and 2) were referring to and they indicated "Resident 1 and his wife". Employee 3 went into the room and asked if there was a problem. His wife removed her hand from the resident's neck and told Employee 3 that she was frustrated with the resident because he was sitting in the chair wrong. In an interview with Employee 1 on 8/19/09 at 12:15 p.m., she stated that she saw Resident 1's wife with her fist to the resident's neck. Employee 1 stated that the resident's wife had not asked for help in moving the resident in his wheelchair. She stated that she had never seen the resident's wife being rough with the resident before. In an interview with the SSD on 11/12/09 at 2:35 p.m., she was asked about the report filed with the Department on 3/26/09. She stated that a staff member heard the Resident's wife yelling and saw her strike the Resident. The SSD stated that she was responsible for the investigative report and typing the findings. She stated prior to June of 2009 Administrative staff found out about the incident the next day in the management meeting. She was then asked about the documentation from 1/5/09. She was aware of the incident. She stated that the Activities Assistant saw the resident's wife hit him in the stomach. When the SSD interviewed the wife she stated that she was trying to push the resident back up into the wheelchair. She reported the situation to Administrator 1. When asked who made the decision regarding reporting the incident she stated that "The Administrator 1 and I decided not to report it because others had seen him slipping and her trying to push him up." The SSD then stated that "it probably should have been reported." She was then asked for Interdisciplinary (IDT) notes documenting the implementation of protective measures surrounding the 3/25/09 incident, and she stated "as far as I can see, there is none." In an interview with the Director of Nurses (DON) on 11/12/09, she was asked about the abuse report. She stated "We followed Administrator 1's protocol and self reported. We care planned and observed behavior. We didn't move him then, which was bad, we should have done that." When asked for documentation of Care Planning and Observation for the March incident, she stated that "it should be in the chart."On 4/13/2009 the Facility reported that Patient 1's wife was observed telling him he was a "son of a bitch" and punching him in the chest area and in the left side of his face or jaw. The charge nurse came into the room and the wife exited the room and told the charge nurse that Resident 1 tried to pull out his gastric feeding tube. The charge nurse evaluated the resident and noted redness to his lower lip. A picture enclosed with report showed blood to the left side of the resident's mouth.Patient 1's wife was counseled by Social Services staff that these behaviors were not acceptable. She was advised to get help from a CNA or a nurse if she needed help. Plans were made to monitor the resident for 3 days for injuries and psychosocial changes. A report was made to the Ombudsman and the Department. A review of nurse's notes dated 4/11/09 reveal that Employee 4 and another Employee witnessed Resident 1's wife hitting him in the face and in the stomach. His wife reported that he had tried to pull out his gastric feeding tube. The nurse's notes reveal that the weekend supervisor was notified as well as the Administrator on call for the weekend. The Administrator instructed the staff to "not allows the wife alone in the room with resident. Must be in hallway or in front of dining room while together". Nurse's notes reveal that the doctor was notified of the incident. A review of Social Service notes for 4/13/09 reveal that the incident was reported to social services, and an investigation was conducted. The Resident was found to have a bloody lip on the lower left side. On 4/14/09 Social Services reported the suspected abuse to the Davis Police Department. The Officer determined at the scene that "although she was too aggressive, she still was not trying to abuse him intentionally" and the report was closed.On 4/17/09 Social Services conducted an Interdisciplinary Team meeting with the resident's wife and their daughter, the Director of Nursing and Administration. It was explained to the family that suspected abuse will always be reported. They also emphasized that if the family needs any help, ask anyone or just yell "Help" and someone will assist them. It was also explained why the resident was being moved closer to the nurses station. He was being moved so that staff could keep a closer watch on the resident to keep him from pulling out his feeding tube and it would be easier to get help when they need it. A review of the medical chart revealed a "Short Term Resident Care Plan" dated 4/13/09 addressing the wife's behaviors and how the facility adjusted the resident's cared and monitored the wife. The interventions were as follows: 1. Monitor resident every one hour for 72 hours 2. Social Services to visit and assess resident daily for 3 days 3. Will monitor wife's visits with resident very closely 4. Ongoing counseling of wife re: seriousness of possible resident abuse 5. Assess resident for injury every shift. The resident was moved from room B20 to room B3 which was closer to the nurses' station.In a review of Nurses Notes dated 3/16/09 through 3/30/09, there was no documentation of a conflict between Resident 1 and his wife or of any monitoring by the direct care staff. The facility failed to protect the resident from abuse and potential abuse from his family member. There were several documented episodes of suspected abuse by the resident's wife. Plans to monitor for behaviors were put into place, but formal care planning to monitor and intervene in these behaviors was not documented on the medical chart.The facility failed to protect Resident 1 from harm when they knew he was at risk of being struck by his wife due to her behavior on previous occasions and they did not take steps to prevent further occurrences.These violations had a direct relationship to the health, safety or security of long-term care facility patients or residents. |
| 100000036 |
CRESTWOOD MANOR |
030009568 |
B |
08-Nov-12 |
LT3Q11 |
9008 |
Title 22 72315 - Nursing Services - Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. The following citation was written as a result of an unannounced visit to the facility on 1/22/10 to investigate complaint number CA00214434, a facility reported incident. The Department determined the facility failed to ensure Patient A received the Registered Dietician's recommended amount of fluids daily. Patient 1 was at risk for fluid volume overload or deficit due to diagnoses of congestive heart failure (CHF), chronic renal failure, intermittent edema (swelling of the lower extremities) and being prescribed two different diuretics (medications which increase urination). Patient A was admitted to the facility on 6/17/05 with diagnoses that included congestive heart failure (a condition in which the heart can't pump enough blood to the body's other organs which can result in pooling of fluids in dependent extremities, i.e., edema) and chronic renal failure (slow loss of kidney function over time). Patient A had a Physician order, dated 4/15/08, for Lasix 40 milligrams (mg) twice daily for edema and Spironolactone 25 mg once daily for congestive heart failure. Both medications increase fluid loss. A Registered Dietitian Nutrition Assessment, dated 6/29/05, identified Patient A's daily fluid needs as 2280 cubic centimeters (cc).Per the assessment the "fluid factors" for "normal elderly = 30 cc per kilogram (kg)" of weight. For this calculation, Patient A weighed 76 kg. Subsequent Dietary Progress Notes, dated 3/31/08, 5/23/08, and 9/11/09, contained no mention of Patient A's required fluid intake.A Dietary Progress Notes, dated 11/10/09, by the Registered Dietician (RD) indicated Patient A's oral intake was approximately 75%, and "[Patient] with [history] of renal insufficiency and with elevated creatinine." Creatinine is a blood test and is an indicator of kidney function. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance by the kidneys. A Dietary Progress Notes, dated 11/30/09, by the Dietary Services Supervisor (DSS) identified Patient A had "...some refusals [of meals] and lower intake this last month, needs encouragement...no change at this time." Patient A was seen every three months by a Nephrologist (kidney specialist). Patient A was seen by the Nephrologist on 9/17/09. In preparation for the Nephrology visit, Patient A had blood tests done on 9/1/09 to monitor his fluid and kidney status. The blood tests consisted of, in part, Blood Urea Nitrogen (BUN - a kidney function test which is also an indicator of fluid status), a creatinine level, and electrolyte panel. Results of the tests from 9/1/09 were as follows: BUN 19 (normal is 5-26). This result showed Patient A's hydration was in the normal range. Creatinine 1.56 (normal is 0.61-1.24 - this high result would be expected as Patient A had a diagnosis of chronic renal failure. BUN/Creatinine Ratio 12 (normal is 7-25). Sodium (salt level) 137 (normal is 135-145). The Nephrologist documented Patient A was "stable" and based upon his blood tests, did not have to return to the Nephrologist for one year (9/16/10). Blood tests on 12/07/09 revealed Patient A's BUN had increased to 29, Creatinine had increased to 1.81, and Sodium had increased to 145. A physician response documented on the lab slip read, "Offer [by mouth] fluids" and to recheck the lab tests "in 1 week." Blood tests on 12/15/09 revealed Patient A's BUN had increased to 33, Creatinine had increased to 1.82, and Sodium had increased to 147. A Physician's Progress Note, dated 12/17/09, indicated Patient A's weight as 151.3 pounds. He had "no edema," and his CHF was stable. Patient A had a current plan of care in place for Alteration in Gastrointestinal Tract, which included a goal that the Patient would "maintain fluid intake." The Medication Administration Record (MAR) revealed Patient A received Lasix 40mg twice daily and Spironolactone 25mg once daily from 12/1/09 - 12/24/09. Both medications increase urine/fluid output. Patient A's MAR had an entry, dated 12/8/09, to "encourage fluids." Nursing Assistant Daily Flow Sheet records indicated "yes" regarding "fluids offered." Patient A's weight of 151.3 pounds equaled 68.77 kilograms (2.2 kg = 1 pound). Using the RD's formula of 30 cc of fluids required per kilogram of weight, Patient A should have received approximately 2065 cc of fluid per day. A ten day record of Patient A's fluid intake documented on a Point System for Calculating % Meal Intake form was analyzed and revealed the following: 12/14/09 Patient A received 1480 cc which indicated a 583 cc fluid deficit in 24 hours. 12/15/09 Patient A received 1370 cc which indicated a 693 cc fluid deficit in 24 hours. 12/16/09 Patient A received 810 cc which indicated a 1253 cc fluid deficit in 24 hours. 12/17/09 Patient A received 1140 cc which indicated a 923 cc fluid deficit in 24 hours. 12/18/09 Patient A received 760 cc which indicated a 1303 cc fluid deficit in 24 hours. 12/19/09 Patient A received 620 cc which indicated a 1443 cc fluid deficit in 24 hours. 12/20/09 Patient A received 720 cc which indicated a 1343 cc fluid deficit in 24 hours. 12/21/09 Patient A received 1480 cc which indicated a 583 cc fluid deficit in 24 hours. 12/22/09 Patient A received 540 cc which indicated a 1523 cc fluid deficit in 24 hours. 12/23/09 Patient A received 360 cc which indicated a 1703 cc fluid deficit in 24 hours. 12/24/09 Patient A received 480 cc which indicated a 1083 cc fluid deficit in 24 hours. During this 10 day period, Patient A was in a fluid intake deficit for ten out of ten days and received less than half of his fluid needs. (For comparison, one gallon of water equals 3,785 cc.) Fluid Restriction and Intake and Output Policy, dated 11/2007, directed "Intake and output records will be kept on...dehydration...upon nursing discretion." There was no documented evidence in the clinical record of a formal intake and output form. The information on the form would have been monitored by the licensed nursing staff secondary to nursing discretion in correlation to Patient A's rising blood test results. A Cumulative Progress Notes, dated 12/24/09 at 6:20 p.m., disclosed Patient A "...wasn't real responsive - took meds but not responding as usual...food coming out of mouth - VS (vital signs) - 100.7 [temperature - normal is 98.6], 134 [heart rate - normal is 80 beats per minute], 20 [breathing rate - normal is 16 - 20 breaths per minute], 78/42 [blood pressure - normal is 120/80] ...obtained order to send to [emergency room] for [evaluation]." A General Acute Care Hospital History and Physical, dated 12/24/09, disclosed in part, "...The patient was found to be markedly dehydrated..." Patient A's initial blood tests in the ER showed an elevated BUN of 78, elevated Creatinine of 4.0, and elevated Sodium of 156. These blood tests results had increased since 9/1/09. An interview was conducted with Patient A's primary physician on 1/25/10 at 12:50 p.m. The physician stated the uremic state (worsening kidney function) could have been "Iatrogenic inducted" (induced inadvertently by medical treatment). When asked why the two diuretics were continued when there was no evidence of edema and Patient A's worsening blood tests, the physician stated, "I don't know why I didn't decrease the diuretics..." An interview was conducted with Licensed Nurse 1 on 1/25/10 at 2:45 p.m. When asked if she notified the primary physician of Patient A's dual diuretic therapy on the faxed lab results, she stated, "I'm surprised; I usually do write them on there." She further stated, "We probably should have had better [fluid] monitoring." A follow up interview was conducted with Patient A's primary physician on 4/2/10 at 10 a.m. The physician stated he "was aware of the lab values" [and] "I didn't want to decrease the diuretics secondary to [Patient A's] history of congestive heart failure." The physician stated, "We continued to monitor fluid and food intake and continued to follow the labs." An interview was conducted with the Director of Nursing on 1/25/09 at 3:15 p.m. She stated she would "expect the charge nurse would communicate with the Certified Nurse's Assistants [for fluid monitoring to] become part of the care plan and initiate 1&O (intake and output). She further stated, "In hindsight we should have been monitoring his intake and output."The Department determined the facility failed to ensure Patient A received the Registered Dietician's recommended amount of fluids daily. Patient 1 was at risk for fluid volume overload or deficit due to diagnoses of congestive heart failure (CHF), chronic renal failure, intermittent edema (swelling of the lower extremities) and being prescribed two different diuretics (medications which increase urination). These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 100000015 |
Crescent Court Nursing Home |
030009571 |
B |
08-Nov-12 |
MMG711 |
14139 |
Welfare & Institutions Code - 15630 (a) Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. Welfare & Institutions Code - 15630 (b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report sent within two working days, as follows:(A) If the abuse has occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the report shall be made to the local ombudsperson or the local law enforcement agency.Except in an emergency, the local ombudsperson and the local law enforcement agency shall, as soon as practicable, do all of the following:(i) Report to the State Department of Health Services any case of known or suspected abuse occurring in a long-term health care facility, as defined in subdivision (a) of Section 1418 of the Health and Safety Code.(ii) Report to the State Department of Social Services any case of known or suspected abuse occurring in a residential care facility for the elderly, as defined in Section 1569.2 of the Health and Safety Code, or in an adult day care facility, as defined in paragraph (2) of subdivision (a) of Section 1502.(iii) Report to the State Department of Health Services and the California Department of Aging any case of known or suspected abuse occurring in an adult day health care center, as defined in subdivision (b) of Section 1570.7 of the Health and Safety Code.(iv) Report to the Bureau of Medi-Cal Fraud and Elder Abuse any case of known or suspected criminal activity. 72523 - Patient Care Policies And Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit to the facility on 12/4/09 for the investigation of complaint # CA00195839, a facility reported event. The Department determined the facility failed to: 1. Report Certified Nurse's Assistant (CNA) 1's abusive behavior. 2. Prevent resident/patient abuse. 3. Implement abuse prevention policies and procedures. 4. Ensure that certified staff (e.g., CNA 1) was properly screened for criminalBackground and ensure all staff understood role as mandated reporters. 5. Identify and plan patient care needs based on initial and continuousassessment. Patient 1 was a 64 year old man admitted to the facility on 4/25/09. He had diagnoses including paralysis on one side of his body and cerebral vascular disease. A Physician's Order, dated 4/25/09, indicated Patient 1 was capable of making all of his healthcare decisions.A comparison of Patient 1's admission Minimum Data Set (MDS - an assessment tool), dated 5/18/09, revealed his short-term and long-term memory were intact. However, Patient 1's quarterly MDS, dated 7/24/09, indicated Patient 1 had developed some difficulty with short-term memory. No other cognitive deficits were noted. Further comparison of Patient 1's MDSs did not reveal any behavioral concerns. The MDSs noted that Patient 1 required limited assistance with bed mobility, locomotion, and transfer due to limited range of motion in his arm and lower leg. He required extensive assistance with dressing, toilet use, personal hygiene, and bathing. Nurse's Notes, dated 7/21/09 at 10:30 a.m., indicated "...[Patient 1] asked to talk [with] me [regarding] a certain CNA who works day shift. I spoke [with] him [approximately] 15-20 minutes [and] then relayed his statements to the [Administrator] [and] the Ombudsman who were in the facility." There was no documented evidence of a physical assessment or physician notification and response. The facility's policy titled Abuse, Prevention of, dated February 2009, indicated the purpose of the policy was "to ensure that resident's rights are protected by providing a method for the prevention of any type of resident abuse." The section titled Policy, indicated "Abuse...will not be tolerated in this facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from...neglect, ...physical, mental abuse... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff..." The section titled Procedure included Screening which directed, "Certified staff will be properly screened for criminal background and approved by the Certification or license verification board." Under Prevention, the Procedure directed, "Administrative staff, Nursing Supervisors/Charge Nurses are responsible for directing, supervising and evaluating all resident care activities..." Also included was the direction "Facility will identify, correct and intervene in situations in which abuse, neglect...are more likely to occur (i.e.,...supervision of staff to identify inappropriate behaviors and the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect." The section titled Protection directs, "If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps: Provide a safe environment for resident(s) as indicated by the situation; (b) If the suspected perpetrator is an employee, i) Remove the employee immediately from the care or vicinity of the resident, and ii) Suspend the employee during the investigation." The section titled Investigation directs, "All incidents of suspected or alleged abuse will be investigated by the assigned staff...report shall include: 10 Date and time the incident took place, b) Circumstances surrounding the incident, c) Where the incident occurred, d) Names of witnesses and their account when applicable, e) Resident's/representative's account of incident, f) Employee's account of incident, when applicable, g) Accounts of any other individuals involved, h) Recommendations for corrective action, if applicable, i) Outcome of investigation, and j) Follow-up resolution or further action if necessary." The section titled Reporting directs, "1) All mandated reporters are required by law to report incidents of known or suspected abuse... 3) The Licensed Nurse shall be responsible for completing a physical assessment of the resident(s) involved and documenting all findings in the resident's record, 6) The Licensed Nurse shall document objective data in the medical record and initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence. The section titled Administrative Procedure directs, "Administrator/designee will verify that mandated in-services are presented on a timely basis. If the investigation involves a staff member, verify that the employee involved attended that appropriate in-service." On 12/4/09, the Administrator provided a copy of the Director of Nurses (DON) investigation notes, dated 7/22/09, in response to the Patient's allegation. The DON notes indicated, "...[Patient 1] asked if he could speak with me (DON) about something he was concerned about. I spoke with this resident in private for approximately 30 minutes in which he hesitantly told me that [CNA 1] was 'rough' with him when doing his '[Activities of Daily Living (ADLs)]." He described her demeanor as like the 'Military Police' barking orders and that she seemed to 'always be in a hurry.' [Patient 1] described one incident where he states that [CNA 1] turned him onto his side so fast and so hard that he 'hit the wall' (On 12/4/09, his bed was observed pushed up against the wall). [Patient 1] said he wasn't injured but he was 'afraid of [CNA 1]' and does not want her to take care of him anymore. [Patient 1] also said that this kind of thing had been going on 'for about three months, gradually getting worse,' but he did not say anything until now. He said he just got 'fed up with it.'" Further review of the facility's investigation, dated 7/21/09, including interviews with three other CNAs, revealed that CNA 1 had a known history of being abrupt. The three handwritten declarations from CNAs 2, 3, and 4 revealed the following statements:"[CNA 1] has also yelled [at] a particular resident in the dining room that "NO, you may not go lay down, you must stay your lazy self right where you are." "CNA 1 seems very short tempered at work, a lot of CNA's, including me, tip toe around [CNA 1]." "Very uncomfortable work place." "She has a tendency to yell and throw fits by throwing things around when she's irritated.""Over the past year she has retaliated against residents and coworkers alike...If a resident makes her angry she will make them stay up or something else they don't want to do..."Based on the documents and declarations, facility staff failed to abide by the mandated reported requirements and the facility's abuse policy when they failed to report CNA 1's inappropriate behavior. An interview was conducted with the Director of Staff Development (DSD) on 12/4/09 at 12 p.m. The DSD was questioned about CNA 1's abuse prohibition training. The DSD reviewed her records and the employee file. She was unable to locate any evidence of CNA 1's background screening and abuse training. The DSD explained, "The CNA has worked at the facility off and on throughout the years" and, as a result, she was unable to locate evidence of annual abuse (prohibition) training. According to the facility's abuse policy, certified staff, such as CNA 1, will be properly screened for criminal background, and the Administrator/designee will verify that the employee involved attends the mandated in-services including elder/dependent adult abuse prohibition. An interview was conducted with the Administrator on 12/11/09 at 11:30 a.m. to discuss the investigative findings. The Administrator conducted a concurrent review of the employee file, abuse policy, and abuse investigation. She stated that after investigating the patient's allegation regarding CNA1's rough care, she suspended the CNA and initiated an investigation. The Administrator reported that all of CNA 1's previous performance evaluations were good. She explained that when she interviewed CNA 1's peers she learned the CNA had a history of yelling at staff. When asked if she discussed their role as mandated reporters, she did not respond. She stated that based on her investigative findings, CNA 1 was terminated on 7/27/09. After additional review of the CNA's employee file, the Administrator confirmed that there was no evidence a criminal background screen had been completed per facility policy. She also confirmed the CNA's who had knowledge of CNA 1's behavior failed to assume the role of a mandated reporter after witnessing CNA 1 yell at patients and behave in a threatening manner.After reviewing Patient 1's medical record, the Administrator confirmed licensed staff failed to document their physical assessment in the patient's record and develop a care plan as directed in facility policy. When asked if a summary of the facility's investigative findings had been completed and submitted to the Department, she was unable to provide any documented evidence that an investigative summary had been completed and submitted to the Department per facility policy. An interview was conducted with Patient 1 on 12/11/09 at 3 p.m. Patient 1 revealed that CNA 1 had been rough with him in the past. He confirmed that CNA 1 had slammed him up against the wall when she pulled him up in bed and she had rolled him into the wall when changing him in the past. The patient stated, "[CNA 1] always seemed to be in a hurry" and he is not able to do as much for himself as he used to. He stated that CNA 1 "told me that she had a lot of other residents (patients) to take care of and did not have time to help him." Patient 1 stated he "did not report [the abuse] because staff wouldn't do anything and he was afraid." The Department determined the facility failed to: 1. Report Certified Nurse's Assistant (CNA) 1's abusive behavior. 2. Prevent resident/patient abuse. 3. Implement abuse prevention policies and procedures. 4. Ensure that certified staff (e.g., CNA 1) was properly screened for criminalbackground and ensure all staff understood role as mandated reporter(s). 5. Identify and plan patient care needs based on initial and continuous assessment These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 030001815 |
Courtyard Health Care Center |
030009613 |
B |
28-Nov-12 |
HW7R11 |
5543 |
72311. Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.The following citation was written as a result of unannounced visits initiated on 08/11/09 to investigate complaint #CA00196584. As a result of the investigation, the Department determined the facility failed to: Provide a continuing assessment to establish a plan of care to ensure proper treatment and handling of an intravenous line (a tube placed inside a vein for delivery of medications or fluids). Patient A, an 82 year old, was admitted from a general acute care facility (GACH) on 7/17/09 at 4 p.m. Patient A required care following recent hospitalization for placement of a coronary artery stent for coronary artery disease. Medical record review was conducted on 08/11/09. In review of a Minimum Data Set (MDS- an assessment tool), dated 7/23/09, Patient A was noted to have intact cognitive skills with no short or long term memory loss. There was documentation in the MDS that Patient A was receiving IV (intravenous) medication. There were no IV meds ordered by the physician while at the facility. A physician order dated 7/17/09 at 2 p.m., prior to transfer to the SNF (skilled nursing facility), the acute care facility MD stipulated "PICC line ok to be d'cd (discontinued) at SNF". A copy of the order was attached to the Interagency Referral Form from the GACH. A PICC line is a peripherally inserted intravenous line.The Resident-Data Collection form, Status on Admission, completed by a licensed nurse (LN1) on 7/17/09 at 4 p.m., failed to document the presence or removal of a PICC line. The Nurse's Notes form dated 7/17/09 at 10 p.m., and completed on admission by LN1 failed to mention of the presence or removal of a PICC line. The Interdisciplinary (ID) Progress Notes dated 7/20/09 (an admission review) completed by the ID Team failed to indicate the presence or removal of the PICC line. The Nursing Weekly Summary Review, dated 7/17/09 to 7/21/09, failed to document the body check/weekly skin inspection. The History & Physical, completed by the physician on 7/20/09 (three days after admission with no time noted), failed to include a reference to the presence or removal of a PICC line. Six days after admission, in a nurse's note dated 7/23/09 at 9 a.m., a licensed nurse (LN2) documented a telephone request for the physician to order a dressing change for the PICC line. LN2 also documented she informed the DON (Director of Nursing) of the presence of the PICC line and the order for the dressing change.In a physician order dated 7/23/09 at 9 a.m., the MD stipulated "Change PIC site dressing on the rt. Arm once weekly (Thursday)". There was no evidence the physician assessed the need for a PICC line, as Resident A was not receiving any IV medications. In Nurse's Notes dated 7/25/09, Patient A was noted to have an elevated temperature of 100.2 Fahrenheit and was observed to be shaking. The physician was notified and an order was received for Cipro (Ciprofloxin - an antibiotic) 250 mg. to be given orally twice a day.Nurse's Notes dated 7/25/09 at 11:30 p.m. documented Patient A was observed to have a temperature of 105.5 Fahrenheit with agitation and restlessness. The physician was notified at 11:40 p.m. and Patient A was transferred to an acute care facility at 11:55 p.m. Patient A required admission to the acute care facility and was diagnosed and treated for MRSA (methicillin resistant staphylococcus aureus - bacteria resistant to standard antibiotic therapy) plus pseudomonas (bacteria) sepsis secondary to the peripherally-inserted central catheter line infection.In an interview with the Director of Nursing (DON) on 09/11/09 at 1 p.m., she acknowledged that the nursing staff was not aware of the PICC line in the right are of Patient A. The DON stated the admitting nurse "should have noted the physician's order from the acute care facility to remove the catheter or she should have observed the PICC line on the initial admitting skin assessment."LN1 was interviewed on 8/17/09 at 4 p.m. LN1 acknowledged she should have observed the presence of the PICC line during Patient A's admission assessment and then would have obtained orders to flush the catheter and change the dressing as ordered by the physician. LN1 was not aware of the order to discontinue the PICC line. A facility policy titled "Best Practice Skin Integrity Procedures", dated March 2005, stated (in part), "all new admissions will have a skin risk assessment and an initial head to toe skin assessment by a Licensed Nurse and/or designated wound nurse as soon as possible within the first two hours of admission but no later than within 24 hours of resident admission".Therefore, the Department determined the facility failed to: Assess the presence of a PICC line at the time of Patient A's admission on 7/17/09 and ensure a continuing assessment was conducted during the subsequent days in the facility with a plan of care developed to meet the patient's needs.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001815 |
Courtyard Health Care Center |
030009698 |
B |
18-Jan-13 |
D7US11 |
3802 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of four unannounced visits (07/07/09, 07/14/09, 08/11/09 and 12/04/09) to investigate facility reported incidents of resident to resident abuse #CA00152040, #CA00152583, #CA00153330, #CA00154846, #CA00157068, #CA00173777, #CA00183459, #CA00183470 and #CA00194415. The Department determined the facility failed to: Follow State Law and facility policies and procedures for reporting alleged and suspected abuse within 24 hours. 1. Resident A struck Resident B in the left lower jaw in an altercation which occurred on 5/27/08 at 6:20 p.m. and was reported to the Department on 5/29/08 at 1:29 p.m., approximately 43 hours after the event. 2. Resident B kicked Resident C in the genitals in an altercation which occurred on 6/01/08 at 4 p.m. and was reported to the Department on 6/04/08 at 9:40 a.m., approximately 66 hours after the event. 3. Resident A slapped Resident B on the right side of his face in an altercation which occurred on 6/07/08 at 9 p.m. and was reported to the Department on 6/11/08 at 8:55 a.m., approximately 84 hours after the event. 4. Resident D "smacked" Resident E in the back of the head in an altercation which occurred on 6/23/08 at 12 p.m. and was reported to the facility on 6/25/08 at 12:36 p.m., approximately 48.5 hours after the event. 5. Resident A "punched" Resident B in the neck causing a small skin tear in an altercation which occurred on 7/14/08 at 10:25 a.m. and was reported to the Department on 7/15/08 at 1:39 p.m., approximately 27 hours after the event. 6. Resident C "punched" Resident F in the face causing a bloody lip in an altercation which occurred on 1/04/09 at 11:30 a.m. and was reported to the Department on 1/05/09 at 3:09 p.m., approximately 27.5 hours after the event. 7. Resident C hit Resident G in the arm with a closed fist in an altercation which occurred on 3/29/09 at 1:15 p.m. and was reported to the Department on 4/01/09 at 10 a.m., approximately 45 hours after the event. 8. Resident H scratched Resident C behind the ear in an altercation which occurred on 3/31/09 at 6:20 a.m. and was reported to the Department on 4/01/09 at 10:22 a.m., approximately 28 hours after the event. 9. Resident H scratched Resident C at the side of his nose causing him to bleed slightly in an altercation which occurred on 7/04/09 at 6:30 a.m. and was reported to the Department on 7/09/09 at 8:13 a.m., approximately 106 hours after the event. In a review of a facility policy titled, "Abuse Policies and Procedures" revised 01/00, physical abuse was defined as hitting, slapping, pinching, kicking, etc.In an interview with the Social Services Director on 7/07/09 at 3:20 p.m., she stated she was responsible to do abuse reporting, including the notification of the Department and the filing of the SOC-341. In an interview with the Director of Nursing on 07/14/09 at 11 a.m., she stated she was aware there were some delays in reporting events of abuse.In a further review of the facility policy titled, "Abuse Policies and Procedures", revised 01/00, there was a stipulation the facility would report resident to resident abuse to the appropriate agencies. There was no direction to report the event within 24 hours.The Department determined the facility failed to follow state regulations by not reporting nine incidents of physical abuse to the Department within 24 hours.Failure to meet the requirements of the California Health & Safety Code Section 1418.91 (a) (b) shall be a B citation. |
| 030001817 |
Cottonwood Healthcare Center |
030009770 |
B |
07-Mar-13 |
QOTO11 |
6007 |
Nursing Service - 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. An unannounced visit was made to the facility on 12/14/10 to investigate an entity self-report #CA00248164. The Department determined the facility failed to: 1) Ensure Patient A was free from physical abuse.This failure resulted in Certified Nursing Assistant (CNA) 1 putting both her hands over Patient A's mouth and telling the patient to stop screaming. Patient A's clinical record was reviewed on 12/14/10 and documented he was a 65 year old male with a re-admission back to the facility on 3/16/10. Patient A's diagnoses include altered mental status, Schizophrenia, spastic quadraparesis (muscle weakness affecting all four limbs), and dementia with behavioral disturbances. Patient A's Quarterly Minimum Data Set (MDS, a standardized assessment tool), dated 9/24/10, documented Patient A as having both short or long-term memory problems, as having severely impaired cognitive skills for daily decision making, usually able to make himself understood and usually able to understand others. The MDS documented Patient A as needing extensive assistance with bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. The MDS also documented Patient A as having verbally abusive behavioral symptoms, socially inappropriate/disruptive behavioral symptoms and resists care. Patient A's clinical record contained a care plan regarding "Impaired Mood: Mood and Behavior," dated 5/11/10, which indicated Patient A had a behavior of "continuous yelling" and "continuous fixation and screaming about [his] bowels......" Review of a Nurse's Note, dated 11/2/10 at 12:43 p.m. indicated two staff members (Maintenance & Janitor) reported they were working inside Room 124's bathroom when Patient A starting yelling/screaming and then the tone of the Patient A's voice changed. The two staff member went out of the bathroom to check on the patient and observed CNA 1 covering Patient A's mouth with both her hands. CNA 1, upon seeing the other two staff members, took her hands off and left the room. The Nurse's Note documented Patient A was assessed with no injuries noted and no complaint of pain or discomfort from Patient A. According to the Nurses Note Patient A was asked about the incident. Patient A stated, "I think it happened yesterday or may be not." CNA 1 was sent home immediately.The facility's investigation report was reviewed on 12/14/10 and contained a written statement by CNA 1. According to CNA 1's statement, dated 11/2/10, she went into Room 124 because Patient A was yelling and screaming. CNA 1 stated she saw that Patient A had his pull-up briefs down around his knees. CNA 1 stated she tried to communicate with him that she was going to try to help him pull the briefs up. CNA 1 stated Patient A kept yelling so she put her mouth next to his ear to tell him to stop screaming. CNA 1 stated she was standing right next to Patient A when she was talking to him when he started to yell again so she "put my hand on his mouth till I could move my head away from his mouth." CNA 1 then stated she asked Patient A to roll over so she could pull his brief up. When Patient A rolled over he yelled "Ow" but CNA 1 didn't know why. CNA 1 stated Patient A started yelling again when I saw his nose was running so I wiped his nose. She then stated she asked Patient A to help her pull up his brief again but Patient A continued to yell again. CNA 1 then stated she asked Patient A to open his eyes to look at her. The facility's investigation report also contained a written statement by Maintenance. Review of Maintenance's statement, dated 11/2/10, indicated he was in Room 124's bathroom repairing a toilet when he heard Patient A screaming and then he heard what sounded like when someone is holding their breath. The Maintenance Staff told the janitor to look out the bathroom door. The Janitor told him he saw CNA 1 holding both her hands on the patient A's mouth. Maintenance Staff state he then looked and also saw CNA 1 had both her hands on Patient A's mouth and telling him to stop screaming. Maintenance was interviewed on 12/14/10 at 9 a.m. He confirmed what was written in his statement. He and the Janitor were in Room 124 replacing a toilet when he heard screaming twice then he didn't hear anything. He stated he asked the Janitor to look outside the door to see if the patient was alright. The Janitor told him he saw CNA 1 holding both her hands over Patient A's mouth. The Maintenance Staff then went out of the bathroom door to check for himself and stated he saw CNA 1 with both her hands over Patient A's mouth. During an interview with the Janitor, on 12/14/10 at 9:08 a.m., he stated Maintenance and him were in Room 124 changing the toilet out when they heard screaming then what sounded like muffled sounds. The Janitor stated Maintenance asked him to peek out the door to see if the patient was alright. When he looked out the door he saw CNA 1 with both her hands over patient A's hands. He stated he told Maintenance what he observed and Maintenance then looked out the door and also observed CNA 1 with both her hands over Patient A's mouth. The Janitor further stated when Maintenance looked out the door CNA 1 saw him and she immediately left the room. The Administrator was interviewed, on 12/14/10 at 9:48 a.m. He stated based on the CNA 1's statement he substantiated the allegation of abuse and terminated CNA 1.The Department determined the facility failed to: 1) Ensure Patient A was free from physical abuse.This failure resulted in Certified Nursing Assistant (CNA) 1 putting both her hands over Patient A's mouth and telling the patient to stop screaming. These violations had a direct or immediate relationship to the health, safety or security of a long-term care facility patient or resident. |
| 100000021 |
Casa Coloma Health Care Center |
030010252 |
B |
14-Nov-13 |
MWG511 |
4295 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.This citation was written as a result of an unannounced visit on 10/15/13 to investigate facility reported incident number CA00372475. The Department determined the facility failed to report an allegation of abuse by Patient 1 within 24 hours of becoming aware of the allegation that the facility had stolen money and personal items from her and a staff member threw a pillow at her. Patient 1 was admitted to the facility on 9/12/13. She had diagnoses including dementia and paranoid personality disorder. An admission Minimum Data Set (an assessment tool), dated 9/19/13, indicated Patient 1's memory was intact and she needed extensive assistance with her Activities of Daily Living (self-care). A Nurses Note, dated 9/30/13, indicated Patient 1 had made several "false" accusations to multiple employees during the shift. She complained a large black staff member had thrown pillows at her. A Social Service Progress Note, dated 9/30/13, indicated Patient 1 had stated a large black staff member threw paper and a pillow at her. She also stated the "manager" had fired the staff member, but she had come back "today", and "walked by me sneering." A Mental and Behavioral Health Visit Note, dated 10/1/13, under History of Present Illness indicated, "Staff report patient with intermittent confusion delusions and false accusations...Delusional, paranoid with false accusations (states "the big black lady threw pillows and cut up paper at me last night" and "I heard him talking in the hallway and firing another nurse who is back at work today")." A Social Service Progress Note, dated 10/2/13, indicated Patient 1 had listed 5 personal items were missing including $580.00. The note also indicated the investigation of abuse on 9/30/13 revealed no black staff had been working at the facility at that time. An interview was conducted with the Director of Nurses (DON) on 10/15/13 at 11:30 a.m. She stated she was aware Patient 1 had spoken with staff on 9/30/13 about a staff member throwing pillows at her earlier. The DON stated she did her own investigation. She interviewed staff members, and with the knowledge that there were no "black" staff working at the facility, came to the conclusion that alleged abuse had not happened. She stated she did not inform the Department or Patient 1's physician of the alleged abuse. When asked why she eventually reported the incident to the Department on 10/7/13, she stated, "We decided that since she kept saying these things we should report to the Department." An interview was conducted with Patient 1 on 10/15/13 at 12:30 p.m. She discussed the alleged abuse, stating a large black woman threw pillows at her. She stated, "I reported the incident and I overheard the man firing the woman in the hallway." She then stated, "The woman was back the next day." She stated the man who fired the woman was the Assistant Administrator (AA). When asked, Patient 1 stated she did not feel safe in the facility. The AA was interviewed on 10/15/13 at 1:30 p.m. He stated he had not fired anyone concerning the alleged abuse. He acknowledged Patient 1 had first reported the incident on 9/30/13 and the Department was not notified until 10/7/13. He also stated he was aware the facility was required to report abuse allegations to the Department within 24 hours of when the facility becomes aware of the incident. The facility's undated policy titled Reporting, under Procedure directed, "Mandated Reporter will report suspected or alleged abuse promptly to reporting agency as required by law. Reporting will be completed within 24 hours." The Department determined the facility failed to report an allegation of abuse by Patient 1 within 24 hours of becoming aware of the allegation by Patient 1 that the facility had stolen money and personal items from her and a staff member threw a pillow at her head. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000522 |
Casa Del Mar #3 |
030010272 |
B |
26-Nov-13 |
8JZL11 |
9843 |
W&I 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (d) A right to prompt medical care and treatment. This citation was written as a result of an unannounced visit on 11/22/11 to investigate facility reported incident number CA00290364 and complaint number CA00290355, regarding client abuse involving Client 1 during her stay in the facility. The Department determined the facility failed to provide adequate health care monitoring and services for Client 1 when six months of amenorrhea (lack of menstruation) occurred, which was not reported to the physician for timely follow-up. The failure resulted in the determination that Client 1 was approximately 25 weeks pregnant on 11/18/11. The delay in diagnosis of Client 1's amenorrhea increased the risk to Client 1's health and the health of the fetus. Client 1 was 33 years old and was admitted to the facility on 8/31/99. She had diagnoses including profound mental retardation (marked delays in all areas, not capable of self-care), cerebral palsy (motor disorder characterized by impaired voluntary movement), seizure disorder, and cortical blindness (blindness due to loss or injury to the part of the brain responsible for vision). Client 1 was non-verbal and non-ambulatory. Monthly Nursing Summaries, dated 3/2011 through 10/2011, indicated Client 1 had no new problems or changes in condition that needed to be addressed in the plan of care. Quarterly Nursing Summaries, dated 11/2010-01/2011 and 5/2011-7/2011, included assessment information regarding "Genito-Urinary."(Genitourinary refers to the sex organs and urinary system.) The quarterly summaries indicated only that Client 1 was incontinent.A Semi-annual Nursing Summary, dated 11/2010-04/2011, indicated Client 1 had last received a gynecological evaluation on 3/9/10 and was not due for another until "03/13." The nursing care plan associated with the semi-annual summary included, "2. Seizure disorder ... monitor for [side effects] of medications ..." The care plan did not specify what side effects would be monitored, how monitoring would be accomplished, or what follow-up, if any, would be necessary. An Annual Nursing Summary, dated 11/2010-10/2011, indicated, "2. Seizure disorder ... monitor for [side effects] of medications ..." The care plan did not specify what side effects would be monitored, how monitoring would be accomplished, or what follow-up, if any, would be necessary. The annual summary indicated it was a "fairly uneventful report period," there was a weight gain of 7.4 pounds in the previous six months, and Neurontin was discontinued on 10/7/11.There was no documented evidence the facility had developed a plan of care for Client 1 related to the potential side effect of amenorrhea with use of the anticonvulsant drugs. Review of Client 1's menstrual cycle history revealed she did not have menstrual cycles from 6/2011-11/2011 (six months), which represented a five-month period covered in the Annual Nursing Summary above. Physician's Orders, dated 11/15/11, indicated Client 1 was to have a pelvic and vaginal ultrasound as well as multiple laboratory blood tests. Review of Nurse's Notes, dated 5/1/11-11/18/11, revealed no documented evidence the facility's nursing staff was aware, was monitoring, or had notified the physician of Client 1's amenorrhea. A pregnancy blood test was ordered by Client 1's physician on 11/15/11. The blood was drawn on 11/17/11. Client 1's Prolactin (a hormone released by the pituitary gland that stimulates breast development and milk production in women) level was 166.9. Pregnancy is established when the prolactin level is 10.0 - 209.0.A pelvic ultrasound was performed on 11/20/11. The ultrasound revealed a single live fetus estimated to be 25 weeks of age. The estimated date of delivery was March 4, 2012. Review of the clinical record indicated the physician ordered the following medications for Client 1: a. 6/10/09 - Zonegran (zonisamide) 700 milligrams (mg) at every bedtime for seizures.Zonegran is an anticonvulsant drug used in combination with other drugs to treat certain types of seizures.Potential side effects of Zonegran include amenorrhea. b. 2/8/11 - Topamax (topiramate) 75 mg twice per day for seizures. Topamax is an anticonvulsant drug used in the treatment of seizures. Potential side effects of Topamax include menstrual irregularities. c. 3/10/11 - Lamictal (lamotrigine) 50 mg twice per day for seizures. Lamictal is an anticonvulsant drug used in the treatment of seizures. Potential side effects of Lamictal include dysmenorrhea (painful or difficult menstruation). d. 5/19/11 - Neurontin (gabapentin) 300 mg at every bedtime for seizures. Neurontin is an anticonvulsant drug used in the treatment of seizures. Potential side effects of Neurontin include ovarian failure. e. 9/8/11 - Lyrica (pregabalin) 50 mg twice per day for seizures. Lyrica is an anticonvulsant drug used in the treatment of seizures. All of the anticonvulsant drugs Client 1 received carried risks related to pregnancy including teratogenic effects (combined consequences of consuming substances on a developing fetus; may manifest itself as growth deficiency and/or mental retardation), increased incidence of cleft lip and/or palate, and skeletal abnormalities. (http://online.lexi.com/crlsql/servlet/crlonline; retrieved 12/16/11.) Teratogenic effects occur during the first trimester (first three months) of pregnancy.Client 1's Physician (MD) 1 was interviewed on 12/16/11 at 6 p.m. MD 1 stated his first notification by the facility of Client 1's amenorrhea was on 11/15/11. MD 1 stated he ordered a pregnancy test for Client 1 per "protocol." MD 1 stated protocol for females aged 12-60 years with amenorrhea was to first rule out pregnancy. MD 1 stated he would have expected the facility to notify him after three months of missed periods and a pregnancy test would have been ordered at that time as well. MD 1 stated after pregnancy was ruled out, drugs used by Client 1 or other causes of amenorrhea would have been ruled out. (Causes of amenorrhea include pregnancy, certain drugs, hormonal imbalances, ovarian failure, brain tumors, and thyroid dysfunction. [http://www.nlm.nih.gov; retrieved 2/13/12].) Direct Care Staff (DCS) 2 was interviewed on 1/3/12 at 1:35 p.m. DCS 2 stated, "Every time [Client 1] has a period, we mark it in the book. We have to tell somebody, the nurse [if periods were missed]." DCS 2 stated when Client 1 missed her periods for six months, it was reported to the nurse. DCS 2 stated she did not report to the nurse prior to that time. Licensed Nurse (LN) 1 was interviewed on 1/4/12 at 1:10 p.m. LN 1 stated she was not aware Client 1 had amenorrhea for six months. LN 1 stated DCS 2 reported missed periods of "three months" to her in November, 2011. LN 1 stated she in turn reported to the facility's Registered Nurse (RN) for follow-up, both in person and via "sticky note." LN 1 stated she did not review Client 1's record and reported to the RN that Client 1 had missed only three periods. LN 1 stated the clients' menses (periods) records were not a "flow sheet," so it would require nursing staff to go back through months of records in order to track the individuals' monthly cycle. Quality of Life Manager (QLM) 1 was interviewed on 1/4/12 at 2:45 p.m. QLM 1 stated she was made aware of Client 1's missed periods by DCS 2. QLM 1 stated DCS 2 reported a "few months" of missed periods. QLM 1 stated she in turn verbally reported the information to LN 1 and the RN. QLM 1 stated, "Almost a month later," DCS 2 again reported Client 1 had missed her period and that "she looked a little puffy." QLM 1 stated she checked on Client 1 and "noticed stomach felt a little weird ..." QLM 1 stated she notified the RN and reported missed periods and "puffy; I think she might be pregnant." RN 1 was interviewed on 1/17/12 at 12:30 p.m. RN 1 stated the facility had "no real tracking system for [menstrual cycles]. The first I heard was that she missed three periods ... on 11/2." RN 1 stated clients' menstrual cycles were "not something that we really tracked; no tracking system." RN 1 stated there were no care plans in place or documentation in nursing notes or summaries regarding the fact Client 1 had amenorrhea. The facility's Job Description for the "Facility Registered Nurse," dated 11/5/06, indicated the RN was "... responsible for all client healthcare ..." Duties for the RN included, "... 3. Development of care plans for individual client problems using the nursing diagnosis ... 5. Health management recommendations and assessments. 6. Preparation for physician visits and coordination of information to physician ..." The Department determined the facility failed to provide adequate health care monitoring and services for Client 1 when six months of amenorrhea (lack of menstruation) occurred, which was not reported to the physician for timely follow-up. The failure resulted in the determination that Client 1 was approximately 25 weeks pregnant on 11/18/11. The delay in diagnosis of Client 1's amenorrhea increased the risk to Client 1's health and the health of the fetus. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000522 |
Casa Del Mar #3 |
030010273 |
A |
26-Nov-13 |
8JZL11 |
6746 |
W&I 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. This citation was written as a result of an unannounced visit on 11/22/11 to investigate facility reported incident number CA00290364 and complaint number CA00290355, regarding sexual abuse involving Client 1 during her stay in the facility. The Department determined the facility failed to provide protection for Client 1 from sexual abuse by Direct Care Staff (DCS) 1 during the night shifts when DCS 1 worked alone in the facility. The failure resulted in increased risk of further sexual abuse to Client 1 as well as other clients living in the facility when DCS 1 was on duty. Client 1 was 33 years old and was admitted to the facility on 8/31/99. She had diagnoses including profound mental retardation (marked delays in all areas, not capable of self-care), cerebral palsy (motor disorder characterized by impaired voluntary movement), seizure disorder, and cortical blindness (blindness due to loss or injury to the part of the brain responsible for vision). Client 1 was non-verbal and non-ambulatory. The Department was notified by the facility on 11/18/11 (via Special Incident Report - SIR) that laboratory results "noted that [Client 1] is pregnant." The SIR indicated Client 1 was a victim of a crime and the police department, adult protective services, ombudsman, regional center, and physician were notified.A pregnancy blood test was ordered by Client 1's physician on 11/15/11. The blood was drawn on 11/17/11. Client 1's Prolactin (a hormone released by the pituitary gland that stimulates breast development and milk production in women) level was 166.9. Pregnancy is established when the prolactin level is 10.0 - 209.0.A pelvic ultrasound was performed on 11/20/11. The ultrasound revealed a single live fetus estimated to be 25 weeks of age. The estimated date of delivery was March 4, 2012. Client 1 was observed on 11/22/11 at 12:50 p.m. Client 1 was non-verbal and had a gastrostomy tube (surgical opening through the abdomen into the stomach for nutrition) in place. Area Director (AD) 1 was interviewed at the time regarding the functional status of Client 1. AD 1 stated Client 1 was not interviewable, was "very profound"...[will] "sometimes" turn her head toward sound or comply with requests, such as "hands down." Review of documentation provided by the County Sheriff's Office, dated 11/18/11, indicated Client 1 was "severely developmentally disabled...She is unable to communicate or consent to sexual intercourse due to her level of developmental disability." The documentation indicated DCS 1 was included in the list of suspects for the crime of "RAPE" against Client 1. The facility's Qualified Mental Retardation Professional (QMRP) was interviewed on 11/22/11 at 2:05 p.m. The QMRP stated the facility's night shift was covered by two different male direct care staff. Review of records provided by the facility indicated DCS 1's date of hire was 12/11/09. Review of timecard documentation provided by the facility indicated DCS 1 worked full-time (five nights a week) and alone on the night shift. County Sheriff's Department documentation indicated Client 1 delivered a baby on 2/27/12. DNA samples were obtained from Client 1, Client 1's baby, and the parents of DCS 1. The DNA report results indicated the genetic data supported that a child of the parents of DCS 1 was the biological father of Client 1's baby, i.e., DCS 1 was the likely source of Client 1's pregnancy. DCS 1 was arrested on 12/12/12. A DNA sample was obtained from DCS 1. Documentation regarding the Sheriff's Department interview of DCS 1 on 12/12/12 indicated when asked if he knew why the sheriff was there to talk to him, he replied, "Rape." DCS 1 stated he worked at the facility from 2010 to the end of 2011. He worked both P.M. shift and nights. He stated when he was working the night shift there was only one person working in each house and he worked in house three (the house Client 1 lived in). DCS 1 stated he used drugs while working and "that's how he ended up raping his client." DCS 1 stated he was doing his "rounds" and went into Client 1's bedroom to change her brief. Once he took her brief off, he became aroused and "got in her bed." He stated it was "the first and the last" time he had raped Client 1. DCS 1 stated the clients are "all handicapped. They can't do nothing for themselves."The Discharge summary from the acute care hospital, dated 2/29/12, indicated Client 1 had diagnoses including "Pregnancy result of rape." Under the heading Patient Active Problem List, the summary noted "Pregnancy... high risk." Under the heading Hospital Course, it was noted the baby had bradycardia (slow heart beat) prior to birth and required delivery with forceps (device used to pull the baby out of the uterus). Client 1 sustained a cord avulsion, a rare complication of labor. This occurs when the umbilical cord separates from the placenta before the placenta has been delivered resulting in difficulty delivering the placenta. The placenta then had to be manually extracted. Client 1 was raped. She was forced to experience a pregnancy and its associated medical risks including possible high blood pressure, stroke, bleeding or clots, and sexually transmitted diseases, to which she did not consent. Client 1's labor was induced on 2/27/12 and she delivered a baby weighing 7 pounds, 3 ounces.The Department determined the facility failed to provide protection for Client 1 from sexual abuse by Direct Care Staff (DCS) 1 during the night shifts when DCS 1 worked alone in the facility. This failure resulted in increased risk of further sexual abuse to Client 1 as well as other clients living in the facility when DCS 1 was on duty. 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. |
| 100000826 |
Creekside Center |
030012617 |
B |
5-Oct-16 |
2UL011 |
4821 |
Health & 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 this section shall be a class "B" violation. The following citation is written as a result of complaint #CA00492618. Unannounced visits were made to the facility on 7/14/16, 7/15/16, 8/2/16, and 8/3/16 to investigate an allegation of abuse. The Department determined the facility failed to: Report to the Department an allegation of abuse of Resident 1 immediately, or within 24 hours. A complaint, received on 6/6/16, disclosed an allegation that allegedly occurred in January 2016. The complaint alleged licensed nurse (LN) 1 stated to Resident 1, "You stink!" Resident 1 had a quarterly Minimum Data Set (MDS, an assessment tool) completed on 12/27/15, an annual MDS completed on 4/15/16, and another quarterly MDS completed on 6/22/16. Part of the MDS consisted of conducting a Brief Interview of Mental Status (BIMS, the scores were 13, 13, and 15 respectively). Fifteen (15) is the highest score on the BIMS indicating intact mental function. An interview was conducted with Resident 1 on 7/14/16 at 2:50 p.m. Resident 1 stated, LN 1 said, "You stink." When Resident 1 was asked if she told anyone at the facility, she said, "The Director of Nurses (DON) knew all about it." Resident 1 stated the comment "hurt my feelings." She added she does "feel safe" to be cared for by LN 1." An interview was conducted with the facility's Administrator on 7/14/16 at 4:45 p.m. The Administrator stated, "[We] felt with all the complaining going on [from a family member] we didn't feel it had validity so after our investigation, we didn't report it. We always report everything." An interview was conducted with Certified Nurse's Assistant (CNA) 1 on 7/15/16 at 2:10 p.m. CNA 1 stated LN 1 helped to get Resident 1 to agree to take a shower and while CNA 1 gave the shower, LN 1 changed the linens on the bed. CNA 1 stated Resident 1 said, "Thank you." CNA 1 later told the resident, due to a complaint, she (CNA 1) could not take care of Resident 1 for a while. Later, when Resident 1 had asked CNA 1 for assistance, CNA 1 told the resident she was not allowed to take care of her anymore. CNA 1 stated Resident 1 felt bad and spoke to the DON. Resident 1 requested CNA 1 be her CNA again. An interview was conducted with Resident 1 on 7/15/16 at 2:15 p.m. Resident 1 stated, "I want them [both] to take care of me. I am not afraid." An interview was conducted with LN 1 on 7/15/16 at 2:52 p.m. LN 1 stated she never said, "You stink," to Resident 1. She continued to explain Resident 1 frequently refused showers and her bed was full of crumbs. It had been one month since the resident had taken a shower (only bed baths). LN 1 stated she told Resident 1, "You need to take a shower; maybe you'll feel better." LN 1 explained Resident 1 did take a shower and LN 1 cleaned and sanitized her bed and changed the linens. LN 1 further explained that after the complaint was made by the family member alleging abusive behavior, the DON told LN 1 she was not allowed to take care of Resident 1 after "yelling at her." LN 1 stated that after two hours, Resident 1 was requesting LN 1 to be her nurse again. The facility's investigation, dated 1/27/16, indicated LN 1 and CNA 1 were not allowed to take care of Resident 1. They were not suspended pending the investigation. The facility's policy titled Abuse Prohibition, revision date 5/1/16, under the section PROCESS, directed, in part, "5.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. 5.1.3 All reports of suspected abuse must also be reported to the patient's family and attending physician. 6. Upon receiving information concerning a report of suspected or alleged abuse... the Center Executive Director (CED) or designee will perform the following. 6.3.2 Provide a written report to the local Ombudsman, the L&C Program District Office... within 24 hours utilizing California Report of Suspected Dependent Adult/Elder Abuse form. 8. The CED or designee will report findings of all completed investigations to the L&C Program District Office via fax... in accordance with state law within five (5) working days of the incident and take all necessary, corrective actions depending on the results of the investigation." The facility was unable to provide documented evidence to indicate the allegation was reported to the California Department of Public Health, L&C program, as required. The Department determined the facility failed to: Report to the Department an allegation of abuse of Resident 1 immediately, or within 24 hours. |
| 040000798 |
COALINGA REGIONAL MEDICAL CENTER D/P SNF |
040009205 |
B |
03-Apr-12 |
GSR111 |
6401 |
Title 22 DIV5 ART372523 (a) Patient Care Policies and Procedures. Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/23/11 at 10:00 a.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident of injury to a patient, CA 00290641. The facility failed to implement their policy and procedure on mechanical lifts for Patient 1 when CNA 1 (Certified Nurse Assistant) used a Hoyer lift (mechanical lifting device) without the assistance of another staff member.A review of Patient 1's Medical Record and MDS assessment indicated she was a 90 year old female admitted for long term placement and had the following diagnoses: Alzheimer's disease (degenerative brain disease), Parkinson's disease (central nervous system disease causing tremors), Huntington disease (central nervous system causing loss of control of voluntary movement), seizure disorder (episodes of disturbed brain function with uncontrolled muscle movement). Patient 1 required total assistance with ADL (Activities of Daily Living) and required Hoyer lift with two persons to transfer at all times. The MDS assessment dated 3/10/11, indicated, Patient 1's Cognitive Patterns included poor short term memory, capable of making needs known, alert but confused, and could respond to yes/no questions. The MDS section titled, "Functional Limitation in Range of Motion" documented, "Impairment of one side of upper extremities and both sides of lower extremities."A review of the Facility Reported Event dated 11/22/11, indicated Patient 1 was found lying on the floor in a supine (flat on back) position with CNA 1 standing next to her. CNA 1 was unable to find assistance to transfer Patient 1 with Hoyer lift and attempted to perform the transfer by herself. Patient 1 fell approximately four feet from the lift during the transfer and struck her head on the floor. LVN 1(Licensed Vocational Nurse) intervened to immobilize the patient's head, assessed her condition and transferred Patient 1 to a gurney for transport to the Emergency Department. Patient 1 was treated in the Emergency Department for a 2.5 centimeter (approximately 1 inch) laceration (cut) to the back of her head. On 11/23/11 at 9:10 a.m., CNA 1 was interviewed concerning the patient injury that occurred on the previous day. CNA 1 stated, on 11/22/11 she was in Patient 1's room and getting her up for the day. The Hoyer lift was at Patient 1's bedside with the sling support attached. Patient 1 was lying in bed. CNA 1 stated she looked in the corridor and went to the nurses' station for help. CNA 1 was unable to locate an additional staff member to assist with the transfer. CNA 1 stated she then decided to transfer Patient 1 alone. "I went back to the room to get her (Patient 1) up by myself. I thought I could do it by myself. I know the policy, I should have got help." CNA 1 positioned the sling underneath Patient 1 while she was lying on the bed, then lifted Patient 1 from the bed toward her wheelchair. At this point CNA 1 stated the right hook holding the sling support came unhinged. Patient 1 tipped backwards and fell out of the sling onto the floor. Patient 1 struck the back of her head on the linoleum floor. CNA 1 stated she saw blood, yelled for help and LVN 1 immediately came into the room. CNA 1 stated LVN 1 immobilized Patient 1's head with towels and took vital signs (blood pressure 151/96 mmHg (millimeters of mercury), heart rate 99 beats per minute, respirations 16 breaths per minute). LVN 1 then stabilized Patient 1's head with a Cervical Collar (neck brace). CNA 1 stated Patient 1 was moaning through this series of events and no loss of consciousness was noted. CNA 1 stated LVN 1 called the on-call physician to report the injury and was advised to transfer Patient 1 to the adjoining hospital's ED (Emergency Department). The Emergency Physician Record dated 11/22/11 indicated Patient 1 was examined at 10:00 a.m. by the ED physician. Patient 1 was found to have a 2.5 centimeter laceration to the back of her scalp. Four mg (milligrams) of Morphine (narcotic pain reliever) was administered for pain control. The open wound required five staples to close. The scalp wound was closed and dressed with a gauze bandage. A series of diagnostic tests were ordered and performed. After the results were obtained. Patient 1 was returned to the facility at 2:50 p.m. On 11/23/11 at 10:00 a.m., during an interview, the DON (Director of Nurses) confirmed the sequence of events that occurred with Patient 1 as stated by CNA 1.The DON emphasized that the 2-staff Hoyer lift technique was mandatory.On 11/23/11 at 2:15 p.m., Patient 1 was observed lying in bed with eyes closed. Patient 1 was found to have gauze dressing (approximately 4 inches by 4 inches) applied to lower right crown of her head. When spoken to, Patient 1 opened her eyes moaned softly and closed her eyes. The MDS assessment (Minimum Data Set) for Patient 1 specifically stated under "...Transfer - how resident moves between surfaces including to or from bed, chair, wheel chair - total dependence and 2+ persons physical assist." According to the facility's Resident Safety Contract, "...2. Hoyer should be used for all transfers (with two staff) for any resident who is unable to stand without assistance. ...4. Any resident who is not able to understand how to keep extremities out of the way of moving parts of equipment should be monitored during operation of equipment by second staff member to ensure limbs do not get injured. This includes... Hoyer lift. NO ONE IS TO USE HOYER TRANSFER WITHOUT TWO STAFF MEMBERS. NO EXCEPTIONS." The facility failed to implement the 2-person mechanical lift (Hoyer) policy/procedure when CNA 1 knowingly decided to transfer Patient 1 alone. Patient 1 fell approximately four feet from the Hoyer lift during the transfer and struck her head on the floor. Patient 1 was treated in the Emergency Department for a 2.5 centimeter (approximately 1 inch) laceration (cut) to the back of her head. Four mg (milligrams) of Morphine (narcotic pain reliever) was administered for pain control. The open wound required five staples to close. The above violation had a direct or immediate relationship to patient health, safety, or security and therefore constitutes a Class "B" Citation. |
| 040000308 |
CASA FLAMENGOS |
040009853 |
B |
25-Apr-13 |
839X11 |
6720 |
Title 17, Section 50510 (a) (8) 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 (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 was free from neglect when Direct Support Staff (DSS) 1 intentionally failed to report Client A had fallen from a mechanical lift, sustained physical injuries and was in physical pain.A review of Client A's clinical record revealed Client A was admitted to the facility on 4/15/04. Client A's history included a fracture of the left hip with an open reduction internal fixation (surgical method to repair a fractured hip). Client A was dependent on staff for most activities of daily living due to his complex health needs. Client A was non-verbal and dependent on staff for all of his physical and medical needs.A review of Client A's incident report dated 12/21/12, written by DSS 1, indicated at 7:00 p.m., while DSS 1 was moving Client A for a shower, Client A hit his face on the door. Client A's forehead was bleeding and required first aide as the result of the incident. (No other injuries were indicated).On 12/27/12 at 2:15 p.m., during an interview, Qualified Mental Retardation Professional (QMRP) stated, Client A had been admitted to the hospital on 12/22/12 due to a fractured right hip. The QMRP stated the orthopedic surgeon stated it would be dangerous for Client A to have surgery on the hip. Client A had been admitted to the hospital and then later transferred to a skilled nursing facility. On 12/27/12 at 3:15 p.m., DSS 2 was interviewed. The DSS 2 was on shift the evening of 12/21/12 when the incident occurred with Client A. The DSS 2 had entered Client A's bedroom at 7:45 p.m. and saw DSS 1 cleaning a fresh wound on Client A's forehead. DSS 2 asked what happened to Client A's forehead and DSS 1 stated Client A had hit his head on the door. DSS 2 instructed DSS 1 to complete an incident report and call the Licensed Vocational Nurse (LVN). DSS 1 left his shift at 8:00 p.m. At 8:30 p.m. DSS 2 returned to Client A's room to administer his medication. As DSS 1 prepared to move Client A to administer his medication, Client A yelled, "No, No, No" and he appeared to be in extreme pain with facial grimacing and swinging his arms in the air. DSS 1 stated she had never seen Client A act in that manner before. DSS 1 then noticed his right hip was loose and it flopped around when she moved him. DSS 1 called the LVN to notify her of Client A's physical condition. On 12/27/12 at 4:05 p.m., LVN was interviewed. LVN stated on 12/21/12 at 8:50 p.m. LVN received a call from DSS 2 who told her Client A's right leg was loose and he appeared to be in pain when she moved him. LVN arrived at the facility at 9:00 p.m. and noted Client A's right hip was swollen, red, and warm to the touch. LVN called and gave a report of her findings to the Registered Nurse (RN).A "Declaration Statement" written by the RN in regards to Client A's incident that occurred on 12/21/12 was reviewed. The RN indicated she noticed at 8:30 p.m. she had missed a phone call from the facility placed at 8:02 p.m. RN called the facility and DSS 2 told her Client A had a skin tear on his forehead, reddened areas on his left upper arm and on his right hip. DSS 2 stated she did know what caused the injuries. RN instructed DSS 2 to call the LVN and have her go to facility and assess Client A. RN received a call from the LVN at 9:00 p.m. and was told Client A's right hip was warm to the touch and swollen. RN arrived at the facility at 10:20 p.m. and confirmed Client A's injuries. Client A was transferred to the emergency department via ambulance at 11:45 p.m. (Four hours and 45 minutes after the incident that caused the physical injuries occurred). Client A's emergency department "Physician Notes" dated 12/22/12 at 1:01 a.m., indicated Client A had a fractured femur, closed fracture of the right anterior fourth rib with right pleural effusion, and a head injury . On 12/22/12 at 6:20 a.m. Client A was admitted to hospital. On 12/28/12 at 10:55 a.m., the RN was interviewed. RN stated when she arrived at the facility on 12/21/13 at 10:20 p.m., she attempted to call DSS 1 to question him about how Client A received his injuries. DSS 1 did not answer her calls. RN stated on 12/22/12 at 1:00 p.m., she spoke with DSS 1. At that time DSS 1 had not been made aware of Client A's multiple injuries. DSS 1 told the RN that Client A had hit his head on the door when he was taking him back to his bedroom from his shower. After the RN informed DSS 1 of Client A's injuries, DSS 1 told her Client A had fallen from the mechanical lift when he was transferring him from the shower chair to the bed. RN stated DSS 1 had no explanation why he did not report Client A's fall.On 12/31/12 at 11:20 a.m., during an interview, DSS 1 stated he did not report Client A falling from the mechanical lift prior to leaving his shift on 12/21/12. DSS 1 stated the incident report he wrote on 12/21/12 regarding Client A's accident was not a complete account of what had happened. Client A's injury to his head had occurred when he fell and hit his head on the mechanical lift. DSS 1 was not able to state why he had not reported the incident to DSS 2 when she asked how Client A received the injury to his head.The facility failed to ensure Client A was free from neglect when Direct Support Staff (DSS) 1 intentionally failed to report Client A had fallen from a mechanical lift, sustained physical injuries and was in physical pain. As a result of the injuries, Client A was unable to return to his home upon discharge from hospital. Client A was discharged to a skilled nursing facility and was later discharge back to his home on 2/11/13 (51 days later). On 2/20/13 (9 of days after admitted back to home) Client A was admitted back into the hospital due to further complications. Client A expired on 2/26/13 due to hypoxia (when blood oxygen concentrations fall below the level necessary to sustain life), aspiration (inhaling food or liquid into the lungs), and pneumonia.The above violation had a direct relationship to the health and well-being of the client. This violated Client A's rights and therefore constitutes a Class "B" Citation. |
| 100000036 |
CRESTWOOD MANOR |
040010097 |
B |
15-Aug-13 |
LX0F11 |
6017 |
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 a comprehensive assessment and plan of care. On 3/15/13 an investigation was conducted of Entity Reported Incident #CA00335226, regarding Resident Safety/Falls. The facility failed to: Ensure Resident 1 received and was provided the necessary care to maintain the highest practicable physical well-being in accordance with Resident 1's plan of care when CNA 1 failed to use a two person lift when transferring Resident 1. Resident 1 was admitted to the facility on 3/8/11. She had diagnoses that included: cerebrovascular accident (stroke), degenerative (wasting away) joint disease and dystonia (abnormal muscle movement). Resident 1's quarterly Minimum Data Set (a tool used to determine cognitive and physical ability) assessment dated 10/2/12, indicated her cognition was moderately impaired and included disorganized thinking. She was totally dependent on staff to provide all of her activities of daily living (mobility, transfers, etc.). Resident 1 required 2 staff physical assistance with all transfers, and movement to her upper and lower extremities was impaired on both sides of her body due to a previous stroke, joint disease and hand contractures. On 12/14/12 at 10:35 a.m., during an observation and concurrent interview, Resident 1 was sitting in the hallway outside her room in a reclining chair. She had an immobilizer present on her right shoulder, and both hands had contractures. When asked what had happened to her shoulder, Resident 1 immediately leaned forward and stated loudly and clearly, "[CNA 1] dropped me." On 3/13/13 at 10:44 a.m., during a telephone interview, CNA 1 stated Resident 1 had been agitated and combative after breakfast on 12/4/12 between 8:30 a.m. and 9 a.m., and he had decided to take Resident 1 back to her room. CNA 1 stated he knew Resident 1 required 2 staff to assist with transfers. CNA 1 stated, "It was busy and everyone was behind. I just thought I could do it [transfer Resident 1] by myself." He stated, when he got Resident 1 up from her chair she was yelling and cussing and started pushing at him, and "She started to go down [to the ground]". CNA 1 stated he grabbed Resident 1 under the arms and got her into bed. He stated Resident 1 started complaining of right shoulder pain immediately. On 3/15/13 at 1:50p.m., during an interview, the Charge Nurse (CN) stated, on 12/4/12 between 11:00 a.m. and 11:15 a.m., CNA 1 had informed her Resident 1 was complaining of right shoulder pain. The CN stated she immediately checked Resident 1, and "Her face and eyes had the look of pain." The CN stated Resident 1 had told her [CNA 1] had dropped her. On 3/15/13 at 2:10 p.m., during an interview, the Unit Manager (UM) stated at approximately 12 p.m. on 12/4/12 she had assessed Resident 1's right shoulder. Resident 1 had been unable to move it, and it had been swollen. The UM stated, "She [Resident 1] was in pain." The UM stated Resident 1 told her CNA 1 had dropped her while trying to put her into bed. She stated, "I believe she was being genuine, because when she's delusional her statements are consistently the same topics." On 3/15/13 at 3:15 p.m., during an interview the Director of Nursing (DON) was asked how CNAs are given information regarding which residents need assistance with activities of daily living. The DON stated each resident has a "Locker Note" inside their closet that lists specific pertinent needs for each resident, including how a resident should be transferred.Review of Resident 1's Locker Note titled "INDIVIDUAL RESIDENT CARE BY CNA" dated 10/3/12, indicated, Resident 1 was not weight bearing and required 2 person physical assistance for transfers. Review of Resident 1's clinical record indicated an onsite x-ray was done on 12/4/12 at 4:21p.m. The x-ray report indicated, "Exam: SHOULDER RIGHT...RESULTS: fracture of the head and neck [refers to the top portion of the bone in the upper arm] with modest displacement of the right shoulder...CONCLUSION: Modestly displaced fracture." On 3/13/13 at 11:55 a.m., during an interview, the Medical Doctor (MD) who interpreted the x-ray stated, "It's not likely a fracture of this type would be caused by grabbing someone under the arms. I would expect a dislocation not a fracture." The MD stated, "The mechanical force required to break the head and neck of the shoulder would more likely be caused by a fall to the floor." Review of Resident 1's hospital imaging report dated 12/4/12 at 8:40 p.m., indicated, "...XR SHOULDER COMPLETE RIGHT...FINDINGS: ...There is a comminuted (bone is crushed, splintered or broken into pieces) fracture of the proximal humerus (bone in the upper arm that forms the shoulder bone)." Resident 1's right arm had been placed in an immobilizer, and she had been returned to the facility. On 3/15/13 at 10:30 a.m., during an observation and interview (3 months after Resident 1's right shoulder fracture), Resident 1 was resting in bed with an immobilizer on her right shoulder. She was pleasant and smiling. Resident 1 was asked if she remembered how she had broken her arm. She stated, "Yes. [CNA 1] dropped me. Resident 1 was tearful, and as she explained the incident she became more tearful. The facility's failure to implement the plan of care for a two man lift during transfer resulted in an injury (comminuted fracture of the proximal humerus [bone in the upper arm that forms the shoulder bone]). This caused Resident 1 immediate pain, swelling and inability to move her right arm. Three months after her fall and fracture Resident 1 continued to express emotional distress that brought her to tears when she retold how she had fallen. She sobbed, "[CNA 1] dropped me." The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 100000036 |
CRESTWOOD MANOR |
040010178 |
B |
03-Oct-13 |
MJDE11 |
8388 |
483.13(b) - Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. On 7/30/13 an investigation was conducted of Entity Reported Incident #CA00337332, regarding resident Quality of Life. The facility failed to: Ensure Resident 1 was free from verbal, physical and mental abuse when Certified Nursing Assistant) CNA 1 harassed, cursed at, pinched and slapped Resident 1. Resident 1 was admitted to the facility on 7/26/10. He had diagnoses that included; cerebrovascular accident (stroke) and schizophrenia (mental illness). Resident 1's quarterly Minimum Data Set (an assessment tool used to determine mental and physical ability, etc.) (MDS) assessment dated 11/06/12 indicated he had a short term memory problem and required cues and supervision when making decisions regarding tasks of daily life. His MDS assessment indicated he was able to remember staff names and faces, and the location of his room in the facility. The MDS assessment indicated Resident 1 was totally dependent on staff for transfers from his bed to his wheel chair and required 2 staff physical assist with transfers. The MDS assessment indicated Resident 1's lower extremities were impaired due to a previous stroke. On 12/27/12 at 10:30 a.m., during an interview, CNA 2 stated she had seen CNA 1 randomly "mess around with" Resident 1. CNA 2 (clarified) and stated, "She [CNA 1] would walk by or go up to him [Resident 1] and grab and pinch his ears or nose, or tap his head to mess around with him." CNA 2 stated Resident 1 would get upset and yell or cuss when CNA 1 would do this to him. CNA 2 stated she observed CNA 1 do this more than twice. CNA 2 stated she had asked CNA 1 not to treat Resident 1 that way, "Because it made him mad and upset." CNA 2 stated CNA 1 put her finger to her mouth and said "Shh, this is how me and him work." CNA 2 stated she had not reported the incidents she had witnessed.On 12/27/12 at 1 p.m., during an interview, Resident 1 stated CNA 1 had mistreated him, "All the time." Resident 1 stated, "She pinches my face and ears, slaps my hands, and the top of my head." Resident 1 stated, "She moves the call light so I can't reach it." Resident 1 stated CNA 1 had used foul language when speaking to him but wouldn't specify which words. Resident 1 stated he had told CNA 1 to, "Stop it! Leave me alone. That's called abuse. Don't be abusive!" When asked how CNA 1's treatment had made him feel, Resident 1 yelled, "It hurt. It made me mad. Hell, it pissed me off! "On 12/27/12 at 3 p.m., during an interview, CNA 3 stated from late October 2012 through 12/20/12, she had observed on more than one occasion CNA 1 physically and/or verbally abuse Resident 1. CNA 3 stated on one occasion she had heard raised voices and cursing from Resident 1's room. CNA 3 stated she went into the room and had observed Resident 1 take a swing at CNA 1. CNA 1 then slapped Resident 1's hands. CNA 3 stated, "She [CNA 1] wasn't trying to block his swing or push his hands away. She slapped him. Like you would a child's hands if they're doing something wrong." CNA 3 stated Resident 1 yelled, "Stop it. Leave me alone." CNA 3 stated, "I must have had a look of shock on my face, like, what's going on?" CNA 3 stated CNA 1 looked at her and said, "Don't tell anyone. This is the relationship we [Resident 1 and CNA 1] have." CNA 3 stated she had not reported the incidents she had witnessed.On 12/27/12 at 3:30 p.m., during an interview, CNA 4 stated she had heard CNA 1 use inappropriate language and pinching while caring for Resident 1. CNA 4 stated Resident 1 would ask to get up and kept using his call light continuously, so CNA 1 had taken Resident 1's call light away from him. CNA 4 stated Resident 1 asked for his call light back and CNA 4 yelled at him, "No. You can't have the f***ing call light." CNA 4 stated Resident 1 had continued asking to get up and to have his call light back. CNA 4 stated, "She [CNA 1] then pinched his [Resident 1] ears and face until he was red." CNA 4 stated, "She [CNA 1] saw the look of concern on my face, and she said, "Shh, don't tell anybody." CNA 4 stated, "She [CNA 1] acted like it was okay to do it [yell, curse and pinch Resident 1]." CNA 4 stated, "She [CNA 1] left the room and never did get Resident 1 out of bed." CNA 4 stated she had not reported the incidents she had witnessed. On 12/27/12 at 11 a.m., during an interview, CNA 1 stated, "He [Resident 1] is demanding. He yells and cusses at staff." When asked how she responds to Resident 1's behavior, CNA 1 stated, "I try to calm him down. I rub his back and try to soothe him." CNA 1 denied taking the call light away from Resident 1 and placing it where he could no longer reach it. CNA 1 denied cursing, yelling, pinching, or slapping Resident 1. On 12/27/12 at 11:30 a.m., during an interview, the Director of Nursing (DON) stated all staff had received training on resident/elder abuse when they were hired and had signed a form that they understood the facility abuse policy. The DON stated the abuse training included; mandated reporting, abuse definitions and examples of abuse, watching the Department of Justice's video on elder abuse, the ombudsman program and review of the facility's resident abuse policy. Review of the facility's undated training document titled, "Part 1: You are a Mandated Reporter" indicated, "Abuse of an elder or dependent adult is defined as: physical abuse, neglect, ...deprivation by a custodian [facility staff] of services...that are necessary to avoid...mental suffering. Mental suffering means...agitation...or other forms of serious emotional distress...brought about by...harassment or other forms of intimidating behavior." Further review of the same document indicated, "Part 2: What You Report." "Examples of Physical Abuse:" [summarized] a resident grabs a CNA's shirt and CNA slaps the resident's hands. "Examples of Neglect:" [summarized] a resident repeatedly uses a call light to get attention. A CNA unplugs the light so the resident can no longer use it. Review of the facility's policy titled, "ELDER AND ADULT ABUSE REPORTING REQUIREMENTS" dated 9/23/99, indicated, "[Facility] is committed to do all that is within its control to prevent occurrences of abuse through the following:Protection of residents through prevention...and reporting of abuse...Staff...shall be encouraged to report incidents of suspected abuse...without fear of reprisal." Review of the facility's "RESIDENT/ELDER ABUSE" training signature page indicated the following: "I certify that I have viewed the Department of justice Elder Abuse Video, ...and understand the attached policy on Resident/Elder Abuse." Review of CNA 1's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 1/12/01.Review of CNA 2's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/12/10. Review of CNA 3's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/09/12. Review of CNA 4's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/09/12. Review of the facility's undated position description titled, "CERTIFIED NURSING ASSISTANT" indicated, "CHARACTERISTIC DUTIES AND RESPONSIBILITIES - ESSENTIAL FUNCTIONS... 4. Provides services that support the care delivered to the resident, both physically and behaviorally.... 8. Conducts self in a professional manner in compliance with unit and facility policies... GENERAL RESIDENT CARE... 16. Approaches residents in a nurturing manner... C. Provides consistent and continuous care, essential for the psychiatric...resident. D. Recognizes and reports patterns or behavior noting escalation and agitation and implements appropriate intervention techniques." The facility's failure to keep Resident 1 free from verbal, mental and physical abuse resulted in Resident 1 being harassed physically and verbally, cursed and yelled at and pinched and slapped by CNA 1 from October 2012 to present (11 months) before facility staff reported his abuse.This caused Resident 1 to become agitated and angry, and he stated, "Hell, it pissed me off! That's called abuse." The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000474 |
Community Subacute and Transitional Care Center |
040010961 |
B |
28-Aug-14 |
17L211 |
3381 |
Class B Citation CFR 483.13 (b) - Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. On 7/29/14 an investigation was conducted of Entity Reported Incident #CA00407483, regarding resident Abuse. The facility failed to: Ensure Resident 1 was free from verbal abuse when Licensed Nurse 1 (LN 1) cursed at Resident 1. Resident 1 was admitted to the facility on 5/21/14. She had diagnoses that included anxiety, and bipolar disorder. Resident 1's admission Minimum Data Set (MDS-an assessment tool used to determine mental and physical ability, etc.) assessment dated 6/13/14, indicated her BIMS (Brief Interview for Mental Status (an assessment tool used to determine the cognitive level of residents) score was 15 out of 15, which indicated she was cognitively intact.On 7/29/14 at 10:53 a.m., Health Facilities Evaluator Nurse (HFEN 1) was in the hallway near Resident 1's room, conducting an abbreviated survey on an unrelated matter, when HFEN 1 heard, "I can't f***ing stand you." HFEN 1 had seen LN 1 go into Resident 1's room immediately before this was heard. On 7/29/14 at 12:17 p.m., during an interview, on an unrelated matter, Resident 1 stated, "Did you hear that nurse (LN 1) wearing a blue shirt, cussed me out when she brought me my meds [medications]. She gave me meds twice, so I asked her if I was supposed to take the second ones, and she got all mad and said, 'I can't f***ing stand you', and slammed my meds on the table." Resident 1 cried and was visibly upset when she recalled the incident. She stated she was very upset that she was treated so meanly and felt she did not deserve to be treated so disrespectfully. Resident 1 was oriented to person, place, time, and situation during the interview. On 7/29/14 at 12:40 p.m. during an interview, the Director of Nursing (DON) stated Resident 1 had told staff immediately after the incident, that LN 1 had cussed her out. The DON stated she believed Resident 1 was telling the truth because she had checked the Medication Administration Records and it showed LN 1 had provided medication to Resident 1 at the time of the complaint. The DON also stated she had received complaints from other staff members that LN 1 was often rude or "had an attitude" with them, so she was not surprised when she heard about this incident.On 8/4/14 at 3:00 p.m., during an interview, the DON stated the facility's investigation was completed and LN 1 was to be terminated 8-7-14. On 8/4/14 at 3:38 p.m., during an interview, Resident 1 was able to recall the incident of LN 1 cursing at her, exactly as previously told. She again became visibly upset when she recalled the incident. She was oriented to person, place, time, and situation during the interview. Review of the facility's Policy and Procedure titled, "Abuse Policy-Investigative and Prohibitive Protocol", dated 8/17/2010, indicated, "The resident has the right to be free from verbal...abuse...and to attain/maintain physical, mental, psychosocial well-being..." The facility's failure to keep Resident 1 free from verbal abuse resulted in Resident 1 being cursed at by LN 1, which made her feel humiliated and disrespected The above violation had a direct or immediate relationship to the resident's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000833 |
Claremy House |
040011427 |
B |
01-May-15 |
1ZMU11 |
8180 |
50510 (a)(8) Rights of Persons with Developmental Disabilities Each person with a developmental disability 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 (b) (8) A right to be free from harm, including unnecessary physical restraints, or isolation, excessive medication, abuse or neglect. Medications 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 the right of the client to be free from isolation and abuse when a direct care staff (DCS) 1 was reported to have placed a client (Client A) in a closet and close the door shut while the client was having a behavior. The facility's Incident Report dated 12/18/14 at 8:30 a.m., indicated "I [Program Manager (PM)] was informed by a direct care staff (DCS 4), that while they were on shift with [DCS] 1, they observed her putting a client [Client A] in the closet and closing the door while the client was having a behavior."Clinical record review indicated, Client A had moderate mental retardation; legally deaf but had some hearing and legally blind but possibly sees shadows; does not understand simple verbal and gestural instructions; and does not understand instructions requiring a decision. On 12/23/14 at 3:45 p.m., during a telephone interview, DCS 1 stated she had not forcefully put Client A inside the closet but had directed the client to the closet where the box of toys were located when the client had tantrums. DCS 1 stated redirecting Client A inside the closet was not included in Client A's Behavior Plan and she had not informed the owner [Licensee/Qualified Intellectual Disabilities Professional (Licensee/QIDP)] nor the PM regarding what she had been doing.On 12/23/14 at 4:02 p.m., during a telephone interview, DCS 4 stated on 12/7/14 at 2:30 p.m., while he had been working at the facility, he had witnessed DCS 1 place Client A inside a closet and held the closet door shut by leaning on the door, while the client had a behavior. DCS 4 stated, "Client A had banged the door, had cried and had tried to get out of the closet." DCS 4 stated he asked DCS 1 what had been going on, and DCS 1 had informed him it was okay to place Client A inside the closet until the client had calmed down.On 12/24/14 at 9:10 p.m., during an interview, PM stated on 12/18/14, DCS 4 had informed him he witnessed DCS 1 place Client A inside a closet and closed the door while the client had a behavior on two different occasions. PM stated DCS 4 had not reported to him the incidents immediately because according to DCS 4, he had not known what to do. PM further stated, DCS 4 had informed him, after so much thought about the incidents, he had realized what he witnessed was not right and eventually decided to report the incidents to him on 12/18/14 (11 days after the incident was first witnessed). PM stated he reported the abuse incidents to the Licensee/QIDP on 12/19/14. The PM stated he should have done something right away and not waited another day to inform Licensee/QIDP about the incidents. On 12/24/14 at 11:10 a.m., during a follow-up telephone interview, DCS 1 stated while performing one-on-one supervision of Client A, she had observed putting Client A inside the closet had calmed her down and "I had found it had been effective and I had kept on doing it." DCS 1 stated, "I had been doing this since I had worked with [Client A] and I had not done anything out of the ordinary."On 12/24/14 at 1:50 p.m., during a follow-up telephone interview, DCS 4 stated, on 12/14/14 towards the end of the morning shift (6 -2), he had witnessed again DCS 1 physically leading Client A inside the closet and then had held the closet door shut to prevent the client from going out. DCS 4 had explained, sometimes Client A had hit other clients and Client A had been immediately removed and placed into the closet to prevent injury to other clients. DCS 4 stated, "But it was not right to put Client A inside the closet and hold the closet door shut." DCS 4 stated he had let Client A out of the closet that time and had reported the incidents to the PM on 12/18/14 at 8:45 a.m. When asked why had he not reported the incident the first time he witnessed the incident, and why had he reported the second incident so late, DCS 4 stated, "I had thought a lot about it, but had not known what to do." DCS 4 stated he remembered the video on Mandated Reporting, then had summoned the courage to report the incidents to the PM. On 12/24/14 at 4:10 p.m., during a telephone interview, DCS 3 stated she started work at the facility on 10/7/14. DCS 3 stated on her first week of orientation at the facility, she observed DCS 1 put Client A inside the closet, had closed the door and had held the doorknob to prevent the client from going out. DCS 3 stated, DCS 1 had explained to her this was done to calm down the client but DCS 3 observed it made Client A mad. When asked how long had the client been inside the closet, DCS 3 stated she had not known since she had left to go to the kitchen. DCS 3 further stated, she had observed DCS 1 many more times doing this but had not reported this to her supervisor because, "I was told by DCS 1, it was okay to do this and that was how they had dealt with Client A's behavior..."On 12/29/14 at 8:15 a. m., during a telephone interview, when informed of DCS 1's practice of putting Client A inside the closet since the month of October 2014 to the present, Licensee/QIDP stated, "I had no idea, but if it had happened, this practice had not been done in his presence." On 12/29/14 at 9:25 a.m., during a telephone interview, the PM stated he visited the facility on the AM and PM shifts once a week in order to observe staff-client interactions. The PM stated he had not made any documentation of his observations and had not asked staff routine questions to ensure incidents of abuse had been prevented. When informed of DCS 1's practice of putting Client A inside the closet since the month of October 2014, the PM stated, "I had no idea." Review of Client A's Behavior Plan for Physical Aggression dated 6/1/10, indicated, Long Range Goal : "To reduce incidents of self - injurious behavior, improve social skills and behaviors so she can benefit more fully from social and training opportunities. Behavior Interventions: When staff note Client A is becoming agitated, they will escort Client A to an area where she can let out her frustrations (outside for a walk or the backyard) for her safety. When she is calm they will assist her and escort her to the icon table for her next scheduled activity. 1. If this is occurring while completing a task, express to Client A that you know she is upset and give her time to calm down. 2. If Client A escalates to a tantrum, use the appropriate block and deflect techniques. Remain calm during this time and give her time to calm down. 3. After the aggressive episode is over, begin the next activity as scheduled. It is important to remain on her schedule and be consistent daily. ALWAYS TREAT [CLIENT A] WITH RESPECT & DIGNITY]. The facility's policy and procedure titled, "ABUSE AND NEGLECT OF CLIENTS" undated, indicated "To ensure that abuse and neglect of client's does not occur." The facility failed to implement written policies to prohibit abuse for one sampled client, (Client A), when DCS 1 placed Client A in a closet against her will and held the door closed, not allowing Client A to exit from the closet. This practice of physical restraint emotionally placed Client A in mental distress as it was witnessed Client A attempted to open the closet door, banged on the door and could be heard crying. The above violation had a direct impact on Client A's safety and emotional well-being, therefore constitutes a Class 'B' Citation. |
| 040000474 |
Community Subacute and Transitional Care Center |
040012044 |
B |
24-Feb-16 |
63X511 |
13982 |
Amended to reflect Citation Issuance date F221: CFR 483.13(a) Restraints The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. During a Recertification Survey conducted from 10/6/15 to 10/14/15, the facility failed to ensure the residents' right to be free of physical restraints imposed for purposes of convenience, in an effort to control behavior, for 1 of 21 sampled residents (Resident 12) when:1. Physical restraints were used for six months without documentation that alternative and least restrictive methods had been attempted. An abrasion to the wrist occurred under the restraint. 2. A nursing care plan was not developed and implemented to include a method to reduce the use of physical restraints. This failure resulted in psychosocial and physical harm to Resident 12, evidenced by restlessness and behaviors which led to multiple falls to the floor in an attempt to be free from the physical restraints. Resident 12 developed an abrasion of the wrist near the area of wrist restraint when Resident 12 attempted to pull hand out of the restraint. Resident 12's clinical record indicated he was admitted to the facility on 2/12/15, and readmitted on 3/13/15, with diagnoses of chronic heart failure, dysphasia (difficulty swallowing), intracerebral hemorrhage (bleeding into the brain), tracheotomy (trach) (a tube in place in the neck to provide an artificial airway), and gastrostomy (insertion of an artificial feeding tube into the stomach called a G-Tube or GT). During an observation on 10/6/15 at 9:15 a.m., Resident 12 laid in bed, sleeping on his back, with a tracheotomy. "Charge Nurse (CN) 1 stated Resident 12 did not speak English, and displayed behaviors which included restlessness and pulling out the trach tube. CN 1 stated bilateral (both left and right) wrist restraints were in place in order to prevent Resident 12 from pulling out the trach tube. Resident 12's physician order dated 2/26/15 at 10:30 a.m., indicated, "Bilateral soft wrist restraint at all times to prevent fall and to prevent pulling of life sustaining devices..."Resident 12's physician orders dated 10/15, indicated the following physician order to apply bilateral wrist restraints at all times to prevent pulling tubes.In an interview on 10/6/15 at 1:10 p.m., Registered Nurse (RN) 1 stated Resident 12 had become increasingly agitated since admission, with episodes of pulling out his trach and G tube, and had a recent episode which required multiple staff assistance to control his behavior. RN 1 stated the resident was usually calm and restraints were removed when Resident 12's family visited.Nursing Notes, dated 5/18/15 at 11 p.m., indicated, "Patient found on mat between his bed and bed A...left wrist restraint attached to patient and bed..." During an observation on 10/6/15 at 1:20 p.m., Resident 12 was observed in bed asleep. Wrist restraints were in place and were not removed while Resident 12 was observed sleeping. Resident 12's untitled Plan of Care (POC) dated 3/13/15, indicated under Problems/Strengths, "Impaired Physical Mobility; Risks: (At risk for falls/self-injury due to spasms,...and/or altered mental status." Under Interventions it indicated, "...Restraint use will be evaluated and efforts to reduce use will be attempted on a regular basis." Social Services notes dated 3/31/15 at 12:15 p.m., indicated, "Resident exhibit[s] episodes of hitting staff at times...had episodes of restlessness, rolling on and off bed, pulling out GT and kicking or hitting staff. Resident is alert to self with episodes of confusion and forgetfulness...he currently has bilateral wrist restraint due to pulling at tubes...Staff is encouraged to assess for basic needs and environment for possible triggers..." The note was signed by Social Work Coordinator 1 (SWC 1). Nursing Notes, dated 5/19/15 at 11:30 a.m., indicated, "Paged [doctor] for the second time due to pt.'s [patient's] attempt to get out of bed, tugging and finally tearing his restraint. He also started to appear tearful..." Nursing Notes, dated 5/28/15 at 7:10 p.m., indicated, "....pt. attempted to pull hand out of restraint, and upon inspection noted abrasion to wrist..." Nursing Notes, dated 6/2/15 at 10:20 p.m., indicated, "Called R/P [responsible party] to get verbal consent to apply mitten to L [left] hand. R/P did not consent. R/P said he feels the pt. [patient] will become more agitated....he [patient] wants to sit up; R/P suggested staff observe patient closely if pt. is agitated, trying to take restraint off, then take restraint off and have pt. sit up at side of bed for 45 minutes." Nursing Notes, dated 6/3/15 at 2:30 a.m., indicated, "Pt. had multiple attempts of pulling at tubing, pulling on restraint to untie, attempting to get out of bed. Pt. education provided on the importance of not pulling on tubing, trach, restraint, getting out of bed. Pt continued behaviors. Distraction, dim lights were provided and were not effective. R [right] wrist was applied per PRN [as needed] order. Pt. continued to pull at restraints, get out of bed..." Nursing Notes, dated 8/25/15 at 11:40 a.m., indicated, "...Pt was received this morning very agitated, pulling, struggling and trying to get out from bed kicking his leg. Pt. attempted by bending his body to grab his trach mask off ..." In an interview on 10/7/15 at 9 a.m., the Director of Nursing (DON) stated Resident 12 had a history of pulling out his trach tube and G-Tube and restraints were required to control this behavior. When asked about his assessment, and the interventions attempted to decrease or eliminate the use of his restraints, she stated antipsychotic medication was ordered, and lights were dimmed in his room. When asked about the effectiveness of those interventions in reducing Resident 12's behaviors, she stated, "They [behaviors] really didn't change much." She further stated obtaining psychiatric evaluations for residents was difficult, and the resident had not been evaluated by a mental health professional. In an interview on 10/7/15 at 2:30 p.m., the DON stated she reviewed Resident 12's clinical record, but did not provide a care plan or targeted interventions to address Resident 12's behaviors and the use of restraints. No documented evidence was provided that indicated an effort was made to implement alternate means of addressing Resident 12's behavior.In an interview on 10/7/15 at 4:15 p.m., Registered Nurse (RN) 2 stated she cared for Resident 12 three to four times a week. When asked whether she provided input toward Resident 12's care planning, she stated she was not asked to provide it. She further stated, "The family told us he doesn't want to be here, he wants to go home...he was crying one day." She stated his family visited almost daily and had recently requested a wheelchair to take him outside during their visits.In an interview on 10/8/15 at 7:45 a.m., Clinical Supervisor 1 (CS 1) stated she attended all of Resident 12's IDT (Interdisciplinary Team) meetings, which focused on behaviors and medication changes. She further stated there had not been improvement in those behaviors. During an observation on 10/6/15 at 3:15 p.m., Resident 12 was observed quiet and alert, looking toward his room entrance. A family member was observed entering his room. Upon the family member's entrance, Resident 12's facial expression changed immediately. He made direct eye contact with her, produced a large smile, and attempted to move his body toward the family member. She greeted him in a warm manner.Nursing Notes, dated 3/17/15 at 12:30 a.m., indicated, "Patient found on mat lying on stomach. Loose BM [bowel movement] noted...Assisted back to bed and cleaned x [by] three staff members..." Nursing Notes, dated 3/17/15 at 5:30 a.m., indicated, "Patient found on mat on side of bed lying on stomach." Nursing Notes, dated 4/2/15 at 2 p.m., indicated, "Pt. [patient] found lying on the mattress/floor pad..." Resident 12's untitled Plan of Care dated 3/13/15, indicated under Problems/Strengths, "Impaired Physical Mobility; Risks: (At risk for falls/self injury due to spasms,...and/or altered mental status." Under Interventions it indicated, "...Restraint use will be evaluated and efforts to reduce use will be attempted on a regular basis." An untitled Plan of Care dated 3/13/15, indicated under Problems/Strengths, "Psychosis as manifested by [blank space]." Under Goals, it stated, "Resident will remain free of psychotic symptoms. Review Q [each] month in Team Conference." Under Interventions it stated, "...Obtain psychiatric consultation...." An untitled Plan of Care dated 3/13/15, indicated under Problems/Strengths, "...Inability to meet own social and emotional needs." Under Interventions it indicated, "Social service coordinator to provide supportive social visits at least 3 times per month or more often as needed." Resident 12's Plan of Care dated 3/13/15, indicated under Problems/Strengths, "Mood/Behavioral concerns as evidenced by: Episodes noted of resident pulling out tubes, constantly moving in and out of bed. 3/18/15: Episode of striking staff. Risks: depression, anger, isolation, lack of socialization. Strengths: He has good family support." Under Interventions it indicated, "Obtain psychiatric consult as needed. MD to assist as needed. Staff to refer resident to [city] County Mental Health as needed...SS [Social Services] to provide 1:1 [one to one] visits to resident as needed for psychosocial needs and issues...Staff to assess for possible triggers of behavior and basic needs."In an interview on 10/7/15 at 2:30 p.m., the Director of Nursing stated she reviewed Resident 12's clinical record, but was unable to produce documentation of a care plan or targeted interventions initiated. When asked about family involvement toward restraint reduction, she did not respond. She stated she did not attend the interdisciplinary (IDT) meetings for Resident 12.In an interview on 10/8/15 at 7:45 a.m., Clinical Supervisor 1 (CS 1) stated she attended all IDT meetings for Resident 12, which focused on behaviors and medication changes. CS 1 stated no input was used to implement alternative methods of physical restraints from Resident 12's family regarding his behaviors or potential interventions to minimize the use of restraints.In an interview on 10/8/15 at 8:15 a.m., the Medical Director (MD) stated he attended all IDT meetings for Resident 12. He further stated he had no knowledge of targeted restraint reduction interventions, and did not know whether family input was obtained in planning Resident 12's care. In an interview on 10/8/15 at 10:05 a.m., the Social Work Coordinator (SWC) 1 she stated she had recently seen Resident 12 outside in the garden with family, and stated, "[Resident 12] was fine, he was so calm, it was a nice view to see." When asked how her observation was used for planning Resident 12's care, she stated, "I don't know." She further stated she wrote Resident 12's untitled POC for Mood/Behavioral concerns dated 3/13/15. When asked if Resident 12 was referred for psychiatric assessment or to county mental health, she stated, "No." When asked about her resident one on one visits as documented in Resident 12's care plan, she stated she had not visited him. When asked how often she observed Resident 12 outside his room with staff, she stated she had never seen it, other than for his shower.In an interview on 10/8/15 at 11 a.m., Family Member (FM) stated Resident 12 became agitated when he wanted to get out of bed, or be placed back in bed, and his agitation increased when facility staff forced him to do something. FM stated, "He is not as agitated with family...occasionally...my mother is able to control him and can calm him down." The FM stated Resident 12 enjoyed doing yard work in his spare time and spent time outdoors. FM stated the family recently requested a wheelchair to take him outside during visits. He stated he had never found Resident 12 outside his room when he visited. In an interview on 10/8/15 at 2:50 p.m., the Assistant Director of Nursing (ADON) stated the facility did not have a system in place at the current time for residents requiring psychiatric assessment or behavioral health services. The facility policy and procedure titled, "Interdisciplinary Team Duties in Team Conference" dated 6/23/15, indicated under II. Policy, "D. Responsible Disciplines and Duties as follows: ...4. Clinical Nurse Supervisor/Charge RN a. Gives the nursing update, states nursing goals and revises nursing care plan as indicated with input from resident/family and the team....c. Answers resident/family questions/concerns regarding nursing care...."6. Social Services Coordinator...c. Updates resident and/or family on any social issues or concerns...f. Identifies ways to contribute to the team goals." The facility policy and procedure titled, "Minimum Data Set (MDS) Assessment and Care Planning" dated 1/5/15, indicated under III. Policy, "...The assessment information is used to develop a comprehensive resident care plan to allow the resident his/her highest practicable level of physical, mental, and psychosocial functioning....The care plan is based on the individual needs of the resident. Resident care planning includes participation from all involved health care disciplines with continual reassessment and updating until resident's discharge. It is an interdisciplinary effort...with the resident and/or family."These violations resulted in psychosocial and physical harm to Resident 12, and has a direct or immediate relationship to patient health, safety, or security, evidenced by the presence of an abrasion to the wrist, tearfulness, restlessness and behaviors which led to multiple falls to the floor in attempting to free himself of the physical restraints, and therefore constitutes a class B Citation. |
| 040000474 |
Community Subacute and Transitional Care Center |
040012057 |
B |
02-Mar-16 |
63X512 |
9309 |
Class B Citation-Resident Behavior and Facility Practices-Physical Restraints. The resident has the right to be free from any physical restraints (a limb encircling cuff, with ties attached to fasten to a bed frame, used to prevent freedom of movement) imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.On 12/18/15, 12/21/15 and 12/30/15 unannounced visits were made to the facility for a Recertification Revisit Survey.The facility failed to ensure Resident 11 was free of physical restraints imposed for the purpose of staff convenience when the facility failed to assess, monitor, check and release the restraint every two hours. This failure resulted in a skin abrasion of the left wrist to Resident 11. Resident 11 had not been evaluated for the implementation of an alternative method to be used to keep the resident from pulling out the supra-pubic catheter (tube placed through the skin above the pelvic region to drain urine from the bladder) or the Gastrostomy tube] (a tube inserted through the abdomen to deliver nutrition directly to the stomach)..."Resident 11's untitled Plan of Care (POC) dated 11/30/15, indicated, "Soft left wrist restraint...restraints will be checked Q (every) 30 minutes and released Q 2 hours, assess environment for potential risks of skin breakdown, assess skin integrity to left wrist Q 2 hours..." Manufacturer guidelines titled, "Limb Holders" dated 9/14, indicated, "...Correct application is essential for proper functioning of the product ...Contraindications do not use on a patient who is or may become highly aggressive or agitated...Warnings improper application or use of any restraint may result in serious injury or death...Precautions...be sure to follow your facility's policies and guidelines for frequency of patient monitoring..." Resident 11's clinical record indicated he was admitted to the facility on 6/14/13, with diagnoses that included anoxic encephalopathy (brain damage due to lack of oxygen), hemiparesis (weakness of one side of the body), dysphagia (difficulty swallowing), and a subdural hematoma (bleeding between the brain cover and the brain). On 12/18/15 at 11:10 a.m., Resident 11 was observed lying in bed on his right side. A soft restraint was attached to Resident 11's left wrist. A pillow case was under the wrist restraint. Resident 11 was nonverbal and exhibited facial grimacing as he pulled, turned and twisted his left wrist under the wrist restraint. A brown line of scarred skin tissue was observed on the arm in the area the left wrist restraint came in contact with the skin.Resident 11's physician orders dated 12/15, indicated the following, "Apply left soft wrist restraint at all times to prevent pulling out suprapubic catheter and G-tube [Gastrostomy TubeOn 12/18/15 at 2 p.m., during an interview and concurrent review of Resident 11's restraint record, Certified Nursing Assistant (CNA) 1 stated the restraint record was a document used for staff to record each time a restraint placement was checked, released or removed. CNA 1 stated the form dated 11/15 , indicated multiple missing entries for 11/1/15 from 12:01 a.m. to 9:30 a.m., from 11:30 a.m. to 10:30 p.m., 11/3/15 from 3:30 p.m. to 11 p.m., 11/5/15, 11/6/15 and 11/7/15 from 7:30 a.m. to 3 p.m., 11/8/15 from 7:30 a.m. to 7 p.m., 11/11/15 from 12:01 a.m. to 3:30 p.m., 11/13/15 from 4 p.m. to 11:30 p.m., 11/20/15 from 12:01 a.m. to 3:00 p.m., 11/21/15 from 12:01 a.m. to 11 p.m., 11/26/15 from 6:30 a.m. to 3 p.m., 11/27/15 from 7:30 p.m. to 3 p.m., and 11/28/15 from 7:30 a.m. to 7 p.m.CNA 1 stated the form used to document restraint activity was missing the date, "December 2015," on the forms heading. CNA 1 stated the restraint record for December 2015 indicated multiple missing entries for 12/2/15, 12/4/15, 12/6/15, and 12/7/15 from 7:30 a.m. to 2:30 p.m., 12/8/15 and 12/9/15 from 12:01 a.m. to 7 p.m., 12/10/15 from 7:30 a.m. to 2:30 p.m., 12/11/15 from 7:30 a.m. to 10:30 a.m., 12/13/15 and 12/15/15 from 7:30 a.m. to 2:30 p.m., 12/16/15 and 12/17/15 from 12:01 a.m. to 7 a.m., 12/16/15 from 3:30 p.m. to 11:30 a.m. CNA 1 stated, "We document on it every day, any blank entries means the restraint was not released." On 12/29/15 at 11 a.m., during an interview, the Director of Staff Development (DSD) stated Resident 11 had a tendency to pull and yank on his wrist restraint so often and so hard he caused the side rail to come off from his bed.On 12/29/15 at 11:35 a.m., a concurrent observation and interview with CNA 2 was conducted. Resident 11 was observed lying awake in bed. A soft restraint was attached to Resident 11's left wrist with a pillow case under the wrist restraint.On 12/29/15 at 11:40 a.m., an observation and concurrent interview with Resident 11 and CNA 2 was conducted. Resident 11 was asked if CNA 2 could remove the restraint in order to view his wrist and skin condition. Resident 11 nodded yes. CNA 2 removed the wrist restraint and pointed to an abraded (worn down by scraping or rubbing) area which resembled a friction related abrasion (the wearing down or rubbing away by means of friction). CNA 2 stated, "He can sometimes move his arm and wrist so much that it caused him to get a burn mark around the area of the wrist restraint." CNA 2 stated Resident 11 did not like to have the restraint and made many attempts to remove it. Resident 11 nodded yes when asked if he disliked the wrist restraint. Resident 11 nodded yes when asked if the restraint caused him discomfort.On 12/29/15 at 11:45 a.m., Resident 11 was observed tugging on the wrist restraint and rotating his arm within the restraint. Resident 11 continued tugging and pulling on the restraint with a continued rotation of his left wrist causing friction to skin underneath restraint.On 12/29/15 at 12:55 p.m., during an observation and concurrent interview with the DSD, the DSD stated the abrasion measured 3 centimeters (a metric measurement) by 1 cm. The DSD confirmed the abrasion was linear starting from the radius (long bone connecting to the elbow and thumb) aspect of the arm and proceeded inward toward the inner arm. The DSD confirmed the skin had a brown discolored line which looked like healed scar tissue; and there was a deep marooned colored abrasion with redness right next to it. On 12/29/15 at 1:30 p.m., during an interview, the DSD stated Resident 11 did not have a treatment order for the left wrist abrasion and there was no monitoring of the left wrist abrasion done by the nursing staff to assess the abrasion status.On 12/29/15 at 1:30 p.m., during an interview and concurrent record review with the DSD, Resident 11's Treatment Record (TR) dated 12/11/15 was reviewed. The TR indicated, "Re-evaluate two intact burn marks to left upper wrist. Start date 12/24/15." The DSD stated there was no documented evidence that a re-evaluation took place on 12/24/15.On 12/29/15 at 3:20 p.m., during a telephone interview, Resident 11's responsible party (RP) stated restraints had been used on Resident 11 since he was admitted to the facility. The RP stated she would be happier if the facility utilized other means to keep him from pulling on his tubes. Resident 11's Physicians Orders dated 12/11/15, indicated, "Monitor intact burn marks to left upper wrist for signs and symptoms of deterioration or signs and symptoms (s/s) of infection for 14 days."Resident 11's untitled POC dated 12/11/15, indicated under Problems/Strengths, "Intact burn marks to left upper wrist." Interventions indicated, "Monitor Q shift for s/s of infection or deterioration...reassess tx [treatment] in 2 weeks...skin barrier/protectant applied, assess pts [patients] environment for s/s of skin pressure and potential risks..." 2. Resident 11's Inter Disciplinary Team (IDT) note dated 11/12/15 indicated, "Stable unable to make needs known...splints applied for protection of removing supra pubic [catheter]." The section of the note under alternative and reduction for the use of restraint was left without documented entry of efforts to reduce restraint use.Resident 11's IDT note dated 12/10/15 indicated, "Stable unable to make needs known restraints started for self-harm due to pulling of tubes." Alternative and reduction for the use of restraint on the document did not include a documented entry of efforts attempted to reduce restraint use.On 12/29/15 at 10:38 a.m., an interview, and concurrent clinical record review for Resident 11, was conducted. The DSD was unable to produce documentation that least restrictive measures were attempted for the use of physical restraints and was unable to produce restraint assessments for Resident 11. The DSD stated we do not have any assessment form to document the least restrictive measures being considered or implemented.The facility Policy and Procedure (P&P) titled, "Physical (soft wrist and mitt) Restraints" dated, 1/05/15, indicated, "...It is the policy of this facility to utilize padded mittens/soft wrist under the direction of a physician's order, after the physician has received informed consent and only after alternative interventions have failed." The above failure had a direct and immediate relationship to the health, safety and wellbeing of Resident 11, and therefore constitutes a Class B Citation. |
| 030000066 |
Ceres PostAcute Care |
040012076 |
B |
14-Mar-16 |
WW6Z11 |
8989 |
F 224: CFR 483.13 (c) Staff Treatment of Resident Misappropriation of Property The facility must develop and implement written policies and procedure that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. During an investigation of Entity Reported Incident CA00466410 on 12/2/15, the facility failed to implement policies and procedures to prohibit misappropriation of resident property when a personal bank account of 1 of 4 sampled residents (Resident 1) was deliberately and wrongfully accessed by the Business Office Manager (BOM) and a total amount of $17,610.72 was spent from Resident 1's personal bank account without Resident 1's authorization or consent.This failure resulted in misappropriation of Resident 1's personal finances and caused psychosocial harm due to Resident 1 feeling exploited, confused and fearful of not having a safe place to live in the skilled nursing facility. Resident 1's clinical record indicated she was admitted to the facility on 11/1/10 and readmitted on 4/5/13 with diagnoses of Essential Hypertension (high blood pressure), Unspecified Osteoarthritis (worn down cartilage on the end of bones), and Unspecified Dementia without Behavioral Disturbance (loss of memory and other mental capabilities), Major Depressive Disorder Recurrent (a mood disorder), and Anemia (Low red blood cell count).On 12/2/15 at 3:50 p.m., during an interview, the facility Administrator (Admin) stated on 11/18/15 Social Service Designee (SSD) 2 unlocked and opened a desk drawer used by former SSD 1. An ATM (automated teller machine) card belonging to Resident 1, an unmarked envelope containing $500 in cash, and retail store receipts with Resident 1's name were found inside the desk drawer. On 12/2/15 at 3:50 p.m., during an interview, the Admin stated SSD 2 notified the BOM of the items found in former SSD 1's desk drawer. SSD 2 was instructed by the BOM to turn in the ATM card, the $500 cash and retail receipts to the BOM on 11/18/15.On 12/2/15 at 3:50 p.m., during an interview, the Admin stated an investigation was conducted by the facility and it was determined the $500 dollars cash found in SSD 1's desk drawer belonged to Resident 1.On 12/2/15 at 3:50 p.m., during an interview, the Admin stated the $500 dollars found in former SSD 1's desk drawer was withdrawn from Resident 1's personal bank account by SSD 1 to be used as payment for Resident 1's share of cost (SOC) (insurance monthly deductible).On 12/3/15 at 10:20 a.m., during an interview, the Admin stated SSD 1 began withdrawal of Resident 1' s money from Resident 1 's personal checking account on 10/14/14. The Admin stated SSD 1 should not have been allowed to make withdrawals from Resident 1's personal bank account. The Admin stated facility staff are not authorized to access residents' bank accounts. The Admin stated the Chief Clinical Officer (CCO) for the corporation discovered the Share of Cost for Resident 1 had not been paid from October 2014 through November 2015 (a total of 13 months). On 12/2/15 at 3:50 p.m., during an interview, the Admin stated the Quality Assurance (QA) nurse interviewed SSD 1 regarding the ATM card transactions and withdrawals from Resident 1's personal checking account, and the unpaid SOC. The Admin stated during the QA nurses investigation she discovered that SSD 1 had made $500 dollar cash withdrawals beginning 10/20/14 through 11/19/15 (a total of 13 months) and hand delivered the money to the BOM as payment for Resident 1's monthly share of cost. The Admin stated there were no records of receipt for the SOC cash payment delivered to the BOM.On 12/2/15 at 3:50 p.m., during an interview the Admin stated the facility had obtained bank statements which indicated dates, locations and amounts of withdrawals from Resident 1's personal bank account. The Admin stated there was an ATM withdrawal at a gas station using Resident 1's ATM card on 11/19/15. The Admin stated the only one that had access to Resident 1's ATM card was the BOM. The Admin stated the facility obtained a filmed security recording dated, 11/19/15 of the BOM making a cash withdrawal from an ATM machine located inside a gas station. The Admin stated the gas station was the same location identified on Resident 1's bank statements and was the same date and time of the withdrawal. On 12/2/15 at 3:50 p.m., during an interview the Admin stated the BOM had not been authorized to use Resident 1's ATM card. The Admin stated, "This is on me." The Admin stated she was responsible for the oversight of the BOM and SSD 1 activities and she had trusted them to do the right thing.Resident 1's Minimum Data Set (MDS- a resident assessment tool for cognitive and physical abilities) assessment dated 11/11/15, indicated the Brief Interview for Mental Status summary score was 15, which indicated there were no cognitive deficits and the resident was able to make own decisions. On 12/2/15 at 1:55 p.m., during an interview, Resident 1 stated she could not recall anyone discussing her finances with her. Resident 1 stated SSD 1 had bought her candy and sodas. Resident 1 stated SSD 1 had not purchased clothes, shoes, or any other articles for her. Resident 1 stated she had not given SSD 1 permission to use her ATM card.On 12/2/15 at 1:55 p.m., during an interview Resident 1 stated the misuse of her ATM card made her feel like she was being used. Resident 1 stated, "You trust someone and they do that to you?" While Resident 1 wrung her hands and had a frown on her face she stated she felt worried. Resident 1 stated she was afraid she may be asked by the facility to move out of her home because the SOC had not been paid for over a year.On 12/15/15 at 8:27 a.m., during an interview Resident 1 stated, "It [removal of the resident monies] made me feel like I was nothing; I had no control over it. I felt violated, as if I was a dog with a bone. You can easily come and take his bone, I felt like that. I don't know how much they took from me, they never really told me."On 1/14/16 at 4:16 p.m. during a concurrent interview and document review, the Clinical Consultant (CC) stated the following entries were from Resident 1's personal bank account statement titled, "[Resident 1's] ATM Withdrawals dated 11/17/14 - 11/19/15, indicated four vertical columns which contained the receipt dates as follows: "10/20/14, 11/17/14, 12/15/14, 12/18/14, 12/22/14, 12/29/14, 1/12/15, 1/20/15, 02/09/15, 03/02/15, 03/09/15, 03/30/15, 04/13/15, 05/04/15, 05/11/15, 05/18/15, 05/21/15, 06/05/15, 06/08/15, 06/15/15. ..07/13/15, 07/20/15, 08/10/15, 08.17/15, 08/24/15, 08/31/15, 09/08/15, 09/14/15, 09/21/15, 09/28/15, 10/05/15, 10/14/15, 11/09/15, 11/19/15, 11/19/15 ... " The second vertical column indicated, "Amount" and listed monies withdrawn monthly from a range of $202.25 to $503 over a 13 month period totaling $16,910. 50.On 12/03/15 at 10:20 a.m., during a concurrent interview and administrative document review, the Admin stated Resident 1's personal bank account statement totaled 31 withdrawals of $500 dollars for the following dates: 10/20/14, 11/17/14, 12/15/14, 12/18/14, 12/22/14, 12/29/14, 1/12/15, 1/20/15, 02/09/15, 03/02/15, 03/09/15, 03/30/15, 04/13/15, 05/04/15, 05/11/15, 05/18/15, 05/21/15, 06/08/15, 06/15/15, 07/13/15, 07/20/15, 08/10/15, 08/17/15, 08/24/15, 08/31/15, 09/08/15, 09/14/15, 09/21/15, 09/28/15, 10/05/15, 11/09/15 totaling $15,500. There was documentation which indicated two withdrawals of $503.00 on 06/05/15, and 10/14/15 which totaled $1006.00. There were also two withdrawals of $202.25 on 11/19/15 which totaled $404.50. The total amount of money withdrawn totaled $16,910.50 from Resident 1's personal bank account.On 1/15/16 at 5:30 p.m., during a concurrent interview and administrative document review, the Admin stated the following retail register receipt contained Resident 1's name and were the receipts found in SSD 1's desk drawer. The receipts were from May 2014 to November 2015 totaled $ 702.22.Review of Resident 1's "Transaction Journal " from [ ...] bank, indicated withdrawals beginning from 10/20/14 through 11/19/15 totaled an amount of $16,910.50 and the receipts totaled an amount of $702.22 had a total sum of $17,610.72. The facility Policy and Procedure titled, "Abuse Prohibition Policy," undated indicated, "POLICY: The Facility will prohibit ..., mistreatment...and misappropriation of property for all patients through the following...Prevention of occurrence...Definitions...Exploitation is defined as the act or process of taking advantage of an elderly person by another person or caretaker whether for monetary, personal, or other benefit, gain, or profit." These violations resulted in psychosocial and financial harm to Resident 1and had a direct or immediate relationship to patient health, safety, or security as evidenced by an expression of fear, a general loss of well- being, financial losses and therefore constitutes a Class B Citation. |
| 040000308 |
CASA FLAMENGOS |
040012239 |
A |
09-May-16 |
0AEJ11 |
17441 |
Class A 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's abnormal laboratory results were not followed up and treated according to the physician's orders in a timely manner; the physician's orders for seizures and constipation were not followed as written; a manual disimpaction was done without a physician's order; Client A developed skin breakdown and the facility did not notify the physician for treatment, did not develop and implement a care plan for the skin breakdown and did not educate direct care staff on nursing measures to prevent further skin breakdown.On 1/7/16, Entity Reported Incident (ERI) CA00470725 was investigated. Concurrent interviews and clinical record and administrative document review indicated the following: 1. Client A's "Face Sheet" indicated she was admitted to the facility on 3/4/13 with diagnoses which included profound mental retardation (a developmental disorder characterized by inability to learn and impaired social adjustment). Client A's physician's order dated 12/15, indicated an order for Dilantin (an anti-seizure drug also known as phenytoin), 125 milligrams [mg] per 4 milliliters [ml], by mouth (PO) three times a day for seizures (uncontrolled electrical activity in the brain, which may produce a physical convulsion [shaking] and thought disturbances).Client A's laboratory report dated 12/19/15 indicated she had a Dilantin level drawn on 12/15/15. On 12/19/15, the laboratory sent the "Final Report" document to Client A's physician. The "Final Report" indicated Client A's Dilantin level was 35.6 ug/ml (micrograms per milliliter). The reference range was 10 - 20 ug/ml. The same report included an "Alert" for Client A to be clinically evaluated for signs of potential Dilantin toxicity and a digitally signed physician's order dated 12/23/15, to hold Client A's Dilantin doses for one week. Registered Nurse (RN) 1 documented on the Nurse's Notes dated 12/23/15 at 7 a.m., Client A had episodes of vomiting. There was no documentation RN 1 followed up on the physician's order to hold Client A's Dilantin.RN 1 documented on the Nurse's Notes dated 12/29/15 at 8:50 p.m., she called and informed the physician, she had just received Client A's Dilantin result and his [12/23/15] order to hold the Dilantin for 1 week (from 12/30/15 to 1/5/16), then repeat a Dilantin level draw on 1/6/15.RN 1 documented on the Nurse's Notes dated 12/31/15 at 7:30 a.m., Client A had not eaten her breakfast and was very lethargic (slow movement).On 1/7/16 at 1:10 p.m., RN 1 stated during an interview, Client A was transferred to the hospital via ambulance after dialing 9-1-1 on 12/31/15 at 8 a.m. Client A stayed at the hospital for two days (until 1/2/16). RN 1 stated upon Client A's return, her physician ordered a repeat Dilantin level on 1/4/16. The hospital document titled "History and Physical (H & P)" dated 12/31/15, indicated Client A presented to the emergency room with lethargy. The same H & P indicated Client A had a Dilantin level of 24.2 ug/ml and sodium (salt) level of 160 milliequivalents per liter (mEq/L). The reference range for sodium level is 135 - 145 mEq/L. Client A was subsequently admitted and treated with intravenous (IV) fluids due to Dilantin toxicity (condition caused by intentional or accidental ingestion of Dilantin in quantities greater than what is recommended), hypernatremia (high level of salt in the blood), dehydration, urinary tract infection, and pneumonia. She was discharged and returned to the facility on 1/2/16.On 1/7/16 at 3:25 p.m., during an interview, RN 1 stated she just received (as of 1/7/16) Client A's Dilantin level laboratory report which was sub therapeutic (less than the amount required for a therapeutic effect) at 0.7 ug/ml. RN 1 stated she informed the physician who had ordered to resume Client A's Dilantin beginning 1/7/16. On 1/7/16 at 12:00 p.m., Client A's Medication Administration Record (MAR) dated 12/15 and 1/16 were reviewed with RN 1. The MAR indicated that from 12/23/15 to 12/29/15 [6 days], Client A continued to receive Dilantin even though her Dilantin level laboratory result was high and potentially toxic; despite having a physician's written order [12/23/15] to hold it for 1 week. The MAR [1/16] indicated that Client A's Dilantin was not resumed on 1/7/16 as ordered, until 2 days later on 1/9/16, even though her Dilantin level was sub-therapeutic. On 1/7/16 at 2:00 p.m., during an interview, RN 1 stated she did not receive Client A's abnormal laboratory results and physician's order until 12/29/15 [14 days after the draw] days due to a "systems failure." She stated she had asked the house manager (HM) for the results but the HM did not know where the results were. RN 1 stated she called Client A's physician but did not leave a message because it was the "holiday season." RN 1 stated, "It looked like the result was faxed from the physician's office to the facility's' corporate office on 12/23/15, and the corporate office staff faxed the result to the facility on 12/28/15 [5 days later]... but we did not receive it until 12/29/15, because there was no paper in the fax machine..."During the same interview, RN 1 stated she did not know the (facility's) process for obtaining laboratory results; she was not oriented to the facility's [Nursing] policies and procedures; and, she did not think of calling the laboratory directly to get the results. RN 1 stated, "I should have called the laboratory myself because I knew her dilantin levels were up and down..." The facility document titled "LAB ORDERS" dated 10/31/09, indicated "... RN/LVN [licensed vocational nurse] will follow-up laboratory result within 2-3 days if result is not faxed after 24 hours..." The information from online.lexi.com dated 2016 indicated, "...The toxic level for phenytoin (Dilantin) is 25-50 microgram per milliliter (mcg/ml)... Symptoms of phenytoin overdose include nausea and vomiting, lethargy, dizziness, confusion, unsteady gait, respiratory or circulatory depression, slurred speech, and coma... Phenytoin toxicity may manifest progressively with ataxia (loss of full control of body movements)...seizures... Patients can have life-threatening complications including arrhythmias (abnormal heart beats) and hypotension (low blood pressure)..."2. The physician's order dated 12/15, indicated Client A had constipation and diverticulitis (pouches [diverticula] form in the wall of the colon which can become inflamed or infected). The physician's orders also included PRN (as needed) orders for dulcolax suppository (stimulant laxative) 10 mg, 1 suppository rectally PRN every 3rd day if no bowel movement; and Fleet enema (lubricant laxative that softens the stool), 1 rectally PRN every 4th day if no bowel movement.On 1/14/16 at 9:27 a.m., a concurrent clinical record review and interview was conducted with Direct Care Staff (DCS) 2. The "LAXATIVE and B.M. (bowel movement) RECORD" dated 2015 indicated the following: a. On 9/7, 9/8, 9/20, 9/28, 10/5, 10/15, 11/11, 11/16, and 12/8, and 12/8/15, DCS 2 gave Client A dulcolax suppository even when she had small, medium, or large BMs.b. On 9/10, 9/11, 9/12, and 9/13/15, Client A did not have a bowel movement. On 9/13/15 (4th day of no BM), DCS 2 gave Client A a suppository instead of a Fleet enema as ordered. c. On 12/25, 12/26, and 12/27/15, Client A did not have a bowel movement. On 12/27/15 at 8:00 p.m., DCS 2 gave Client A a suppository with no result. On 12/28/15 (4th day of no BM), Client A was not given Fleet enema as ordered.d. The PRN MAR dated 12/29/15 indicated that on 12/30/15, Client A was given Fleet enema even though she had [medium- size] bowel movement after a digital stool extraction on 12/28/15.On 1/14/16 at 9:35 a.m., during an interview, when asked why the physician's orders for dulcolax and Fleet enema were not followed, DCS 2 stated, "I only give her [Client A]suppositories... especially when she has small or medium BM because I want her to have 'xxl' [extra, extra large] BM... I never give Client A enema because I do not know how to do it..., I was not trained how to do it..." When asked what she did when Client A did not have a bowel movement after she had given the suppositories, DCS 2 stated she would then give Client A more prune juice, more milk of magnesia, and more miralax. When asked what adverse effects or symptoms staff should watch for when giving multiple laxatives to an individual client, DCS 2 stated, "I really don't know..." On 1/14/16 at 9:40 a.m. during an interview, RN 3 stated the basic nursing care standard was for staff to administer the clients' medications as prescribed. When asked if direct care staff/caregivers had been trained on detecting symptoms of illnesses, adverse drug reactions and use of Fleet enema or other types of laxative, RN 3 stated, "I am new to the company and I don't know about what training had been or should be given to the staff..."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..."3. RN 1 documented in the Nurse's Notes dated 12/28/15 at 8:30 p.m., Client A had no BMs for four days. RN 1 documented she performed a manual stool extraction [MSE] (manual removal of stool from the rectum) on Client A. There was no documentation RN 1 informed the physician that Client A had no BM for 4 days, nor was he informed of the manual stool extraction done on the client.On 1/7/16 at 2:55 p.m., when asked for the facility's policy and procedure for manual stool extraction , RN 1 was not able to provide one. When asked if Client A's physician was informed of the MSE, RN 1 stated "No." When asked if she obtained a physician's order to perform the MSE, RN 1 replied, "No." When asked about any precautions taken prior to the MSE, RN 1 stated she put on gloves and did the MSE "slowly." When asked if she provided any training to the DCS on what symptoms to monitor and report after the procedure (MSE), RN 1 stated she did not.On 1/14/16 at 9:40 a.m., during an interview, when asked for written proof of training given to direct care staff on how to care for the clients' health needs or conditions, health maintenance, and disease prevention; Administrative Staff 1, Qualified Intellectual Disabilities Professional (QIDP), RN 1, RN 2, and the Licensee/Owner (LO) could not provide the requested training documents.The information from the Merck Manual titled "Complications From an Impacted Bowel" dated 2015 indicated, "... Severe constipation can lead to bowel or fecal impaction...occurs most frequently in the elderly and mentally challenged people... causes abdominal distention, vomiting, and appetite loss... The manual fragmentation (breaking up) and disimpaction of the [stool] mass is painful, so peri-rectal and intrarectal application of local anesthetics (example: lidocaine 5%) is recommended." 4. Client A's "Nurses' Notes" dated 12/28/15 at 8:30 p.m., indicated "... Noted beginning of blister forming to right inferior foot. Instructed staff to elevate bilateral feet and place pillows between her legs..." There was no documentation RN 1 performed an assessment describing the size, color, and condition of the blister and its' surrounding tissues. There was no documentation that Client A's physician was notified for treatment or a plan of care developed. On 1/13/16 at 11:20 a.m., the L/O was interviewed by phone. The L/O stated the nurses she hired were good nurses even though they were not familiar or experienced with the client population served. When asked if RN 1 had been provided with training regarding facility standards of practice, pertinent Federal and State regulations, written policies and procedures, the L/O stated RN 1 had not had formal training or orientation since her hire date on 12/16/15.On 1/14/16 at 8:38 a.m., during an interview DCS 1 stated she did not notice Client A's pressure sore until 12/28/15. She stated there had been at least 5 per-diem/part-time licensed nurses who had come and gone, and no one had provided them with in-service education on how to care for or respond to the clients' health care needs.On 1/14/16 at 3:30 p.m., when asked if she reported Client A's pressure sore to the physician, RN 1 stated, "I did not know I had to do that." RN 1 described the area as a "pressure-related blister." She stated it looked like a blister, with a small amount of fluid, still intact. She stated she did not measure it, did not call the physician to get treatment orders, and did not train DCS on a plan of care to prevent it from worsening. During the interview, RN 1 stated, "I did not follow up; staff not following MD orders placed (Client A) at risk for harm..."The facility document titled "SKIN CARE AND PREVENTION OF PRESSURE SORES" dated 11/86 indicated, "All clients' bodies will be frequently checked for signs of skin breakdown... DCS will inspect the clients' skin carefully... Report immediately to the Licensed Nurse (LN)... The LN will notify the physician... The LN is responsible for carrying out treatment as prescribed by the physician and document treatment in the nurses' notes and all pertinent observations including location, size, depth, color, drainage, odor, and stage. All clients at risk for pressure sores will have a program that may include mobilization, range of motion, massage, nutritional supports, pressure relieving devices... Direct care staff will be in-serviced at least quarterly regarding prevention of pressure sores... The training will include risk factors, assessment tools, skin assessment, use of support surfaces, development and implementation of skin care program, and, documentation..." The facility document titled "SPECIFIC JOB DESCRIPTION - NURSING SERVICES" dated 6/6/13 indicated, "... carry out nursing functions regarding client health issues within the scope of the Nursing Practice Act... Develop, implement and monitor nursing care for clients who are medically challenged... Advise and provide the Qualified Intellectual Disability Professional (QIDP) and direct care staff with information and guidance on appropriate methods to reinforce, implement, and to monitor nursing treatment plan objectives..."The facility failed to provide Client A with Nursing Services in accordance with her needs when:1. Client A's Dilantin level was determined to be in the toxic range and not followed up in a timely manner. The physician's orders to stop administering the Dilantin medication were not followed. As a result, Client A had a progressive change of condition: She vomited on 12/23/15, developed a pressure sore on her right foot on 12/28/15, and had zero food intake and lethargy on 12/31/15. Client A was transferred to the emergency room and was subsequently hospitalized, diagnosed with, and treated for Dilantin toxicity, hypernatremia (high level of salt in the blood), dehydration, urinary tract infection, and pneumonia.2. The physician's orders for PRN medications for constipation were not followed due to staff's lack of understanding and education on why, when, and how these medications were to be administered. As a result, Client A did not receive the correct PRN medications ordered by the physician to treat her constipation. 3. Client A developed a blister on her right inner foot, and the facility did not notify the physician for treatment, did not develop and implement a care plan; and did not educate direct care staff on nursing measures to prevent further skin breakdown.4. Registered Nurse (RN) performed a manual stool extraction without a physician's order and without after care instructions being provided to the caregivers.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 and therefore constitute a Class 'A' Citation. |
| 030000088 |
Central Valley Post Acute |
040013225 |
B |
25-May-17 |
MJXP11 |
18121 |
F 204 483.15 (c) (7) Preparation for a safe/orderly transfer/discharge.
(c) (7) Orientation for Transfer or Discharge
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
On 2/2/17, an unannounced visit was made to the facility to investigate complaint CA00518850 regarding an allegation of unsafe discharge from the facility.
The facility failed to provide sufficient preparation for a safe and orderly discharge when Resident 1, who was known by the facility to have serious mental illness, inability to care for herself and an unhealed right foot wound that required treatment, was permitted to plan her own discharge to a women's center 70 miles away without staff verifying if shelter or services were available to meet Resident 1's needs. Resident 1 was discharged to the care of a taxi driver and traveled by taxi and bus to a city 70 miles away from the facility with no arranged wound care, personal care or housing in place upon arrival.
This failure placed Resident 1 at risk for serious physical harm from an untreated wound and lack of ability to meet her own need for food and shelter.
Resident 1's clinical record titled, "Admission Record," indicated Resident 1 was admitted to the facility on XXXXXXX16 with diagnoses that included; Anxiety Disorder (disorder characterized by feelings of uneasiness, apprehension and dread), Psychotic Disorder (disorder characterized by impaired thinking and loss of contact with reality), Stage 4 Pressure Ulcer of the Right Heel (full thickness tissue loss with exposed bone, tendon or muscle), Difficulty in Walking, Chronic Pain Syndrome, Neuropathy (disorder causing nerve pain, numbness and tingling of the extremities), Hypertension (high blood pressure) and Noncompliance with Medical Treatment and Regimen (failure to follow medical recommendations and treatments).
Review of Resident 1's clinical record from the Acute Care Hospital (ACH) 1 titled, "Diagnostic Impression for [ACH 1]. Mental Health Exam [of Resident 1] dated 12/14/16, indicated "... Insight - poor; Judgment- poor; Impulse control - poor ... Very limited coping techniques ..."
Resident 1's Care Plan dated initiated 12/15/16, indicated "Focus: Resident has multiple behavior/mood issues such as verbal and physical aggression, uses foul language, paranoid (thinks everyone is trying to hurt her or steal from her), constant talking to self and others not present (frequently tells imaginary person to "get off me"), very frequent refusals of care including meds [medications] and wound care, can be very delusional[beliefs that are firmly held, contrary to reality]/flight of thoughts, very poor reality awareness, nonsensical conversations ..."
Review of Resident 1's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool used to plan care) assessment, dated 1/18/17, indicated Resident 1 had not walked in the hallway during the 7 days prior to the assessment and required extensive assistance of two staff members for personal hygiene. The MDS indicated Resident 1 had delusions and verbal behavioral symptoms directed toward others such as threatening, screaming and cursing.
Review of Resident 1's clinical record titled, "Wound Care Specialist Initial Evaluation," dated 12/9/16, indicated, "... Stage 4 pressure wound of the right heel...on my examination I noted an exposed bone in the wound bed [on the right heel] ... There is moderate serous exudate [clear drainage]."
Resident 1's Physician's order dated 12/19/17, indicated, "Cleanse stage 4 [stage 4 pressure ulcer on the right heel] with normal saline [a sterile salt water solution], pat dry. Apply calcium alginate with silver [type of wound dressing that absorbs drainage, protects against bacteria and reduces odor] dressing and cover with dry dressing every day."
Review of Resident 1's clinical record titled, "Wound Care Specialist Progress Note," dated 1/6/17, indicated "... Assessment & Plan: Stage 4 pressure wound of the right heel - no change ..."
On 2/2/17 at 11:15 a.m., during an interview, Social Services Director (SSD) 1 stated Resident 1 was discharged from the facility on XXXXXXX17. SSD 1 stated Resident 1 had been talking about going to a women's center in (a city 70 miles from the facility) and to a women's shelter two blocks from the women's center. SSD 1 stated, "[Resident 1] said there was a women's shelter 2 blocks away from the center and that she had stayed there before several times. I didn't get the name [of the shelter]. She [Resident 1] did not share any information about the shelter ..." SSD 1 stated the facility's Interdisciplinary Team (IDT, a team of facility healthcare professionals who meet to plan resident care) did not meet before Resident 1's discharge on XXXXXXX 17 to plan Resident 1's possible discharge to the women's center. SSD 1 stated she communicated with the facility Administrator (Admin) and Resident 1's Medical Doctor (MD) 1 regarding the discharge. SSD 1 stated she asked the facility nurses to contact MD 1 for a discharge order for Resident 1. SSD 1 stated she wrote MD 1 a letter regarding Resident 1's discharge from the facility. SSD 1 stated a taxi ride from the facility to the bus station was set-up the day before Resident 1's discharge on XXXXXXX17. The SSD stated a bus voucher and a wheelchair were purchased for Resident 1. The SSD stated the taxi took Resident 1 to the bus station and Resident 1 took the bus to (city 70 miles away from the facility). SSD 1 stated she called a taxi company in (the city 70 miles away from the facility) to arrange for a taxi to meet Resident 1 at the bus station and transport Resident 1 from the bus station to the women's center. SSD 1 stated she purchased two backpacks for Resident 1 to take with her upon discharge. One backpack contained wound care supplies and the second backpack contained clothes and personal care supplies. SSD 1 stated the facility gave Resident 1 $30.00 in cash, two packs of cigarettes and a $25.00 gift card upon discharge.
On 2/2/17 at 12:39 p.m., during an interview, Licensed Nurse (LN) 3 stated Resident 1 had a stage 4 pressure ulcer on her right heel that required treatment while she was in the facility. LN 3 stated, "I don't think she is capable of taking care of herself because of this schizophrenic [severe mental illness causing loss of contact with reality] personality that she has, plus her wound. She won't have proper care ...lots of potential problems."
On 2/2/17 at 12:58 a.m., during an interview, Licensed Nurse (LN) 1 stated, "It was about one to two days before discharge that I did her wound care last. The wound had maceration [moist white tissue] around the edges ...0.3 cm [centimeter, a linear measurement] deep, three inches by five inches around on the right heel. Yes it was a stage 4 sore. She [Resident 1] refused teaching about her wound care ...She has the mental capacity to take care of the wound if she tries. The question would be ...would she do it?"
On 2/2/17 at 1:26 p.m., during an interview, LN 2 stated, "Most of the time she [Resident 1] is in her own world; talking away; soft to loud to yelling. I don't know if it was safe to discharge her [Resident 1 on XXXXXXX17]. I am scared for her."
On 2/3/17 at 10:50 a.m., during an interview, the Admin stated the facility IDT normally met to discuss and plan resident discharges but the IDT did not meet to plan Resident 1's discharge on XXXXXXX17. The Admin stated Resident 1 left against medical advice (AMA, leaving the facility despite physician recommendations to stay and continue treatment) and the IDT did not meet if the discharge was AMA. The Admin stated there was no psychiatric evaluation of Resident 1's condition prior to discharge on XXXXXXX17 because Resident 1 left the facility AMA.
Review of Resident 1's clinical record titled, "Social Service Progress Note" dated 1/5/17 at 11:26 a.m., indicated, "Resident [Resident 1] has been stating that she wants to leave this facility. Social Services has called the shelter and they only have breakfast from 8-11 [a.m.] and then everybody leaves. It [the women's center] is not a shelter. They do not have rooms. They are a hospitality place. Resident will not be discharging to [women's center]." The progress note was signed by SSD 2.
Review of facility document, untitled, dated 1/9/17, indicated "[MD 1], Can you please re-evaluate [Resident 1's] orders for capacity [mental capacity]? Please re-evaluate and update so we can have appropriate orders ..." The document was signed by SSD 1. MD 1's response indicated, " ...She [Resident 1] clearly understand what she want and not want and decide what she want and not want clearly. But she has mental issues which need psych eval [evaluation by psychiatrist] and treatment."
Review of facility document, untitled, dated 1/11/17, indicated "[MD 1] [Resident 1] is requesting to be discharged to a women's center in [city]. She wants to take a taxi to the bus station, a bus to [city], and then a taxi to the women's center. We have called and verified that the women's center assists with food, clothing, shelter, etc. At this time [Resident 1] continues to have the open wound on her foot which she seldom allows us to treat. [Resident 1] states that she would allow HH [home health] RN [registered nurse] to come to the women's center and provide wound care. We have contacted [HH] and they go to the center. I have contacted the Ombudsman [name] and she has spoken to [Resident 1]. She agrees that [Resident 1] has the right to go. So our question is, can we get a Discharge order such as: Discharge to Shelter of choice, Follow up with local clinic for wound care. Continue current meds as ordered. Or ...AMA?" The document was signed by SSD 1. Review of MD 1's response indicated, "Had a detail discussion with my NP [nurse practitioner] about patient care and DC [discharge plan]. Both of us agree that patient need more care than at woman shelter with home health for wound care. She refuses care at SNF. We cannot hold pt [patient] against her will. She can be discharged at AMA. We still can try to arrange what she needs. But will be AMA discharge." The response was signed by MD 1.
Review of facility document titled, "[MD 1] Discharge Instructions" dated 1/11/17, indicated "1) Check list for discharge if: Vital signs stable and wound improved/stabilized ...Cleared by Physical Therapy. Home safety evaluation done, and home health care set up as indicated." The document was signed by MD 1.
Review of Resident 1's clinical record titled, "Progress Notes" dated 1/18/17 at 5:17 a.m., indicated, "Pt [patient ] was assisted into taxi cab, seatbelt fastened, at 0430 hours [ 4:30 a.m.], leaving facility AMA. Pt refused all care when preparing to leave, including shower, clean clothes, dressing change to foot wound, clean socks and protective booties ...Pt was offered oral medications, but refused, stating, "I will see my own doctor when I get there" ...Pt was asked to sign the AMA statement, she refused ..."
On 2/2/17 at 2:28 p.m., during an interview, Licensed Social Worker (LSW) from the acute care hospital (ACH) 1 in (city) stated Resident 1 arrived in the ACH 1 Emergency Department (ED) on 1/18/17 at about 8 p.m. and spent the night in the ED. The LSW stated Resident 1 told her the skilled nursing facility gave her a bus voucher earlier that day and she had come to the ER from the bus depot which was about two blocks from ACH 1. The LSW stated ACH 1 found a board and care placement for Resident 1 and Resident 1 was transferred to the board and care on XXXXXXX17. The LSW stated Resident 1 was "kicked out" of the board and care the next day for aggressive behavior. The LSW stated the board and care owner had called 911 (emergency response number) to take Resident 1 to ACH 2.
Review of ACH 1 record, titled, "Clinical Social Work Progress Note," dated 1/19/17, indicated placement for Resident 1 was initially made at a motel with referral to a senior placement organization to follow up. The note indicated, "This writer witnessed pt [Resident 1] outside attempting to get into cab; pt unable to transfer self. Pt soiled her clothes. This writer and SW [ACH 1 LSW] went out to assess situation. Pt is currently unable to transfer self or toilet self at this time. Pt does not have a way to care for self or obtain food while staying in hotel for 3 days; this discharge plan deemed unsafe ...new plan in process ...needs higher level of care ...Approval granted for 1 month of board and care as well as case mgmt. [management] services ..."
Review of ACH 1 progress notes dated 1/20/17 and signed by ACH 1 LSW indicated Adult Protective Services (APS) had been notified of Resident 1's situation regarding removal from the board and care facility. The progress note indicated, "APS worker reported that she has contacted all [hospitals] in the surrounding area however have not been able to locate pt [Resident 1]. As of the time of this writing pt [Resident 1] has not returned to [ACH 1]."
Review of Resident 1's clinical record from ACH 1 indicated an admission date of XXXXXXX17 and a discharge date of XXXXXXX17. The clinical record titled "ED Progress Notes" section "Medical Decision Making" indicated "... this is a 79 year old female who has dementia (cognitive deficits and memory loss) ...She is clearly unable to care for herself ..."
On 2/13/17 at 3 pm during a telephone interview, SSD 1 stated she had not verified services offered at the women's center prior to Resident 1's discharge on XXXXXXX 17. SSD 1 stated she understood SSD 2 had verified services were offered at the center. SSD 1 stated no arrangements were made with the women's center and the women's center was not notified by the facility regarding Resident 1's pending arrival on 1/18/17.
On 2/13/17 at 6:12 p.m., during an interview, the Social Worker (SW) from the woman's center stated she had been in front of the women center about 1:30 p.m. on 1/18/17. The SW stated as she was leaving the center a taxi pulled up with Resident 1 inside. The SW stated Resident 1, upon arrival, was disheveled, very confused and agitated. The SW stated, "Somebody did this person wrong. It was the worst scenario ever. I could not believe that a facility would have sent this person to us that way. I have never known a facility to do that. It was pouring rain. This woman came to the center in a taxi. I went out and told the taxi driver and the woman to not even get out of the taxi. I told the taxi driver to take her to the Emergency Room." The SW stated, "We are open only from 7:30 a.m. to 11:30 a.m. Why would a facility send a patient to here in a bus without any arrangement of any kind? There's no available shelter in [city]. I have many, many people waiting for a shelter. If the facility would have asked for me, I would have told them not to send anybody up this way because there is no available placement up here. That woman [Resident 1] was in no form to take care of herself. It really bothered me that a facility would trust that person's judgement."
Review of facility policy titled, "Transfer and Discharge" dated 7/1/16, indicated "II. Compliance Guidelines 1. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the resident at the time of transfer...5. Refusal of treatment does not constitute grounds for transfer, unless the needs of the resident cannot be met or the health and safety of others is endangered...12 d. Orienting caregivers at the receiving site to the resident's daily patterns and psychosocial needs identified by the resident's assessment and care plan...14. For an anticipated discharge (not an emergency or not due to the resident's death), a discharge summary is prepared that includes: a. A recapitulation of the resident's stay; b. A final summary of the resident's status for all MDS items at the time of discharge; and c. A post-discharge plan of care developed in conjunction with the resident and his or her family."
Review of facility policy titled, "Discharge Against Medical Advice" dated 7/1/16, indicated "I. Purpose: To delineate the procedure when a resident chooses to leave the facility against medical advice. II. Policy: ...B. The charge nurse and/or the Skilled Nursing Director, Director of Nursing as to the necessity of continued treatment as ordered by the physician, the social worker or other members of the staff who have developed positive relations with the patient may be asked to assist. C. If the resident insists on leaving against medical advice, a report will be made to Adult Protective Services if determined necessary because of anticipated harm to the resident...E. The facility will provide discharge information necessary for the continuity of care..."
Therefore the facility failed to provide sufficient preparation to ensure a safe and orderly discharge for Resident 1. Resident 1, who had serious mental health issues and was unable to provide self-care, informed the facility she would travel to a city 70 miles from the facility and would be provided food, shelter and wound care at the women's center in that city. The facility did not verify the services available at the women's center and made no arrangements regarding Resident 1's required care needs with the women's center staff. As a result of these failures, Resident 1 was transported by taxi and bus to the women's center 70 miles away from the facility, which had closed for the day, and no shelter, food, personal care or wound care was available upon arrival. Resident 1 was transported from the women's center to the acute care hospital for evaluation and placement.
This violation had a direct or immediate relationship to Resident 1's health, safety and security and thus constitutes a class "B" citation. |
| 050000047 |
COUNTRY OAKS CARE CENTER |
050011030 |
A |
25-Nov-14 |
4JR311 |
2258 |
CFR 483.25 (H) Accidents. The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide adequate supervision to Resident A, who was identified to be at risk for elopement. As a result, Resident A left the facility undetected, fell, and sustained a large hematoma (a collection of blood because of an injury) on her forehead, laceration above the left eyebrow with bruising, and skin injuries. Resident A was an 85 year old female admitted to the facility with diagnoses including Alzheimer's dementia (a loss of brain function that gradually gets worse over time) and anxiety.On 5/26/14, the facility assessed Resident A to be at risk for elopement with a history of wandering behavior, severely impaired cognition, and only able to walk with minimum supervision. On 5/27/14, the facility identified Resident A has increased wandering tendencies after 3 p.m., has increasing confusion, The facility's plan of care included interventions to redirect, monitor desire to leave facility, and frequent visual checks (not defined). On 9/3/14, prior to Resident A's elopement, Resident A was observed in the front lobby asking staff "can I go out the door; I want to go home." Staff admitted Resident A would try anything to leave and witnessed Resident A in the lobby "antsy" looking at a magazine. There was no evidence Resident A was redirected from the lobby nor increased supervision provided. Staff last saw Resident A at 7:30 p.m. in the front lobby. At 8:24 p.m., a passerby found Resident A on the ground in the street having fallen from the curb. Resident A was transported via ambulance to a local emergency department. Resident A sustained a large hematoma to the forehead with small laceration above left eyebrow, bruising around left eye, and an abrasion to left side of eye.At 9 p.m., the facility was not aware Resident A had left until Resident A's husband contacted the facility informing them Resident A was in the emergency department being evaluated for injuries.This failure presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 050000005 |
COUNTRY CARE CONVALESCENT HOSPITAL |
050011239 |
A |
02-Apr-15 |
SCMM11 |
2890 |
CFR 483.25 (h) ACCIDENTS- The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to clarify and follow physician orders of resident bed rest, provide transfer training, and utilize assistance devices to prevent an injury when transferring Resident A from the bed to the wheelchair. The facility did not consider the use of a lift device or log rolling Resident A in an effort to replace the mattress. As a result, during a transfer from the bed to the wheelchair, Resident A fell and sustained a fractured leg requiring surgical repair. Resident A's chart contained conflicting information regarding activity and weight bearing status (from bed rest, no weight bearing to touchdown weight bearing). Prior to clarifying the activity status of Resident A, two certified nursing assistants (CNA) transferred Resident A from the bed to the wheelchair. During the transfer, neither CNA were able to support Resident A's weight causing Resident A to bear weight on the non-weight bearing right leg resulting in a fractured thigh, hospitalization, and surgical repair.Resident A was an 82 year old male admitted to the facility with diagnoses including aftercare for healing fracture of the right hip and non-weight bearing to the right leg. The facility assessed Resident A as a fall risk with extensive assistance of two people for transfer. Extensive assistance is defined as resident involved in activity, staff provide weight bearing support. Physician orders indicated Resident A was "non-weight bearing" to the right leg. On October 13, 2014, two certified nursing assistants attempted to transfer Resident A from the bed to a wheelchair. During the transfer, the two CNAs were not able to support the weight of Resident A. Resident A applied weight to the non-weight bearing right leg resulting in a fracture and immediate pain.During an interview on 2/19/15 at 2:51 p.m., facility staff verified the facility had available mechanical Resident transfer lifts but had not considered using a mechanical lift to transfer Resident A, who was on a non-weight bearing status. The two involved CNAs had not been instructed by physical therapy how to move Resident A from the bed to the wheelchair which was the typical practice of the facility prior to transferring a resident who had been on bed rest.The facility's failures to clarify and follow physician orders of no weight bearing for Resident A, provide training to staff, and utilize assistance devices for transfer created an unsafe environment for Resident A. As a result, Resident A sustained a fractured leg requiring hospitalization and surgical repair. 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. |
| 050000005 |
COUNTRY CARE CONVALESCENT HOSPITAL |
050013143 |
B |
8-May-17 |
OPA411 |
2632 |
California Health and Safety Code 1418.91 (a)(b)-Failure to Report:
(a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The Department determined the facility was in violation of the above statute by its failure to report to the Department immediately or within 24 hours an allegation of abuse towards Resident 1. The facility reported the allegation of abuse to the Department seventy two (72) hours after the allegation of abuse occurred. Resident 1 was allegedly secluded involuntarily in his room, with the door shut, alone and screaming to get out, but was ignored by his assigned certified nursing assistant (CNA 1).
During interviews with a facility employee (FE 1) on 1/11/17, at 4:50 p.m., on 3/2/17 at 9:39 a.m., and on 3/3/17 at 10:15 a.m., FE 1 indicated witnessing CNA 1 roughly pushing Resident 1 in his wheelchair into his room and slamming the door shut on 1/8/17, at 10 a.m. Resident 1 was screaming to open the door but CNA 1 would not open it. Resident 1 kept on screaming to open to door. CNA 1 stated "I will put him [Resident 1] outside in the (profanity) rain if that's what it takes to shut him up!" FE 1 indicated it was pouring rain outside that day. FE 1 confirmed this incident was not reported to the facility's abuse coordinator or to the administrator.
During interviews with a facility employee (FE 2) on 1/11/17, at 5:10 p.m. and on 3/3/17 at 9:53 a.m., FE 2 indicated witnessing CNA 1 putting Resident 1 in his room and closing the door on 1/8/17. Resident 1 kept on screaming to open the door, but CNA 1 walked away and left Resident 1 in his room by himself with the door closed. During an interview with a facility employee 2 (FE 2), on 1/11/17, at 5:10 p.m., FE 2 indicated witnessing CNA 1 involuntary secluding Resident 1 in his room on 1/8/17. FE 2 also confirmed this incident was not reported to the facility's abuse coordinator or the administrator.
Review of a complaint received on 1/11/17 indicated, the allegation of abuse (involuntary seclusion) occurred at the facility on 1/8/17. The facility did not report until the investigation was started by the Department at the facility on 1/11/17, seventy two (72) hours after the allegation of abuse occurred.
The facility should know or should have known they have to report to the Department immediately, or within 24 hours, the allegation of abuse by an employee towards a resident but failed to do so. |
| 050000005 |
COUNTRY CARE CONVALESCENT HOSPITAL |
050013144 |
B |
8-May-17 |
OPA411 |
5394 |
Title 42 Code of Federal Regulations 483.13(c)(1)(l) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
The Department determined the facility failed to prevent Resident 1 from involuntary seclusion. Resident 1 was separated from other residents and was involuntarily confined to his room, with the door closed, alone and was screaming to get out but was ignored by his certified nursing assistant. This was against the resident's will and the will of the responsible party. This was not authorized as a therapeutic intervention.
The facility policy and procedure titled "Abuse Policy and Procedure" updated 12/16, indicated "Involuntary seclusion is defined as separation of a resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative (sponsor)...Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs."
During a record review of the clinical record for Resident 1 on 2/2/17, the Admission Record, undated, indicated Resident 1 had diagnosis of right dominant side hemiplegia (paralyzed on one side of the body) and was originally admitted to the facility on XXXXXXX11. The comprehensive assessment dated 10/20/16, indicated Resident 1 had functional impairment of one side of the body, used a wheelchair and was not able to transfer from a seated to a standing position on his own. Resident 1 was assessed to have a moderate impairment in his cognitive (mental awareness) status.
During interviews with a facility employee 1 (FE 1) on 1/11/17, at 4:50 p.m., on 3/2/17 at 9:39 a.m., and on 3/3/17 at 10:15 a.m., FE 1 indicated witnessing a certified nursing assistant (CNA 1) roughly pushing Resident 1 in his wheelchair into his room and slamming the door shut on 1/8/17, at 10 a.m. Resident 1 was screaming to open the door, but CNA 1 would not open it. Resident 1 kept on screaming to open to door. CNA 1 stated "I will put him (Resident 1) outside in the (profanity) rain if that's what it takes to shut him up!" FE 1 indicated, it was pouring rain outside that day.
During interviews with a facility employee (FE 2) on 1/11/17, at 5:10 p.m. and on 3/3/17 at 9:53 a.m., FE 2 indicated witnessing CNA 1 putting Resident 1 in his room and closing the door on 1/8/17. Resident 1 kept on screaming to open the door, but CNA 1 walked away and left Resident 1 in his room by himself with the door closed.
During an interview with a facility employee (FE 3), on 1/11/17, at 4:10 p.m., FE 3 indicated on the day of the incident (1/8/17) FE 1 reported to FE 3 witnessing CNA 1 pushing Resident 1 into his room, closing the door, and walking away while Resident 1 was yelling to open the door.
During an interview with a facility employee (FE 4), on 1/11/17, at 4:15 p.m., FE 4 indicated on the day of the incident (1/8/17) FE 1 notified FE 4 about witnessing CNA 1 pushing Resident 1 into his room and walking out of the room.
During an interview with CNA 1 on 2/2/17, at 9:55 a.m. and on 3/2/17, at 10 a.m., CNA 1 indicated on 1/8/17 she (CNA 1) put Resident 1 in his room by himself and closed the door. CNA 1 confirmed nobody was in the room at that time and confirmed Resident 1 was "...yelling to open the door." CNA 1 indicated she went across the hall to another resident's room to provide care and did not open Resident 1's room door until she was done providing care to another resident, indicating Resident 1 was not monitored while he was secluded. CNA 1 confirmed, she isolated Resident 1 and stated "I should not have closed the door, because that makes it isolation."
During an interview with the administrator (ADM) and the director of nursing (DON), on 3/1/17, at 3:26 p.m., both confirmed closing the door and leaving Resident 1 in his room, not monitored is considered seclusion. DON indicated it is expected for certified nursing assistants to notify a nurse in case a resident's behavior escalates. DON also indicated CNA 1 should have stayed with Resident 1 or should have kept the door opened. ADM confirmed, there was no care plan in place indicating Resident 1 could be secluded in his room.
Review of Resident 1's clinical record starting on 1/11/17 indicated, there was no evidence that Resident 1 nor Resident 1's responsible party permitted involuntary seclusion to Resident 1's room or any isolation room inside the facility for a limited period of time as a therapeutic intervention to reduce agitation until a plan of care is developed to meet the Resident 1's needs.
The facility should know or should have known not to subject Resident 1 to involuntary seclusion without the resident's nor the responsible party's permission unless this was permitted for a limited time as therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs.
This violation of resident's right caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1. |
| 050000005 |
COUNTRY CARE CONVALESCENT HOSPITAL |
050013145 |
A |
8-May-17 |
OPA411 |
19279 |
CFR 483.25 (c) 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.
The Department determined during the investigation of a complaint, the facility failed to ensure Resident 1 did not develop avoidable pressure ulcer. Resident 1 was left lying on bed pan for an extended period of time resulting to a pressure ulcer on Resident 1's buttocks. In addition, the facility did not provide the necessary care and services to prevent the formation of additional pressure ulcers for Resident 1.
During a record review of the clinical record for Resident 1 on 4/1/2017, the Admission Record, undated, indicated Resident 1 was admitted to the facility on XXXXXXX2016 with no pressure ulcers. Resident 1 had diagnoses including lumbar stenosis (degenerative narrowing of the lower spinal canal that causes pressure on the nerves, leading to pain and reduced mobility) and generalized muscle weakness. Resident 1 was "Chair fast-makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently."
Review of Resident 1's comprehensive assessment (Minimum Data Set - an assessment tool) dated 4/26/2016, indicated Resident 1 had intact cognition (mental awareness), was at risk of developing pressure ulcers and had no pressure ulcers. Resident 1 had active diagnosis of hemiplegia (paralysis of one side of the body). Resident 1 needed extensive assistance and two plus person assistance for moving about in bed, moving from bed to chair, dressing, bathing, and toileting. Resident 1 required one person assist for personal hygiene such as washing face, combing hair, and brushing teeth.
Review of Resident 1's Admission Evaluation and Interim Care Plan dated 4/19/2016 revealed, the "Braden Scale (tool to help health professionals, especially nurses, assess a resident's risk of developing a pressure ulcer) for Predicting Pressure Sore Risk" indicated Resident 1 had completely limited sensory perception (ability to respond meanfully to pressure-related discomfort), was considered to be very moist (degree to which skin is exposed to moisture), was chair fast (confined to sitting in a chair and unable to walk), and had a potential problem with friction and shear. Resident 1 was scored at "Total Score 12 - High Risk", indicating Resident 1 was considered to be at high risk for developing pressure ulcers. Prior to the incident of leaving Resident 1 on the bedpan during the NOC (night) shift on 4/28/16, the facility had not developed a care plan relating to repositioning Resident 1 every two hours. Interview with the director of staff development (DSD) on 3/1/17 at 5:35 p.m., the DSD acknowledged a care plan had not been developed until 5/19/16. The DSD explained the facility would "expect staff to follow the standard of practice. If a resident is bed-bound or chair bound he/she needs to be repositioned every two hours."
During an interview on 3/2/2017, at 5:55 p.m., the DSD confirmed, Resident 1's clinical record indicated Resident 1 was admitted to the facility, 4/19/16, without pressure ulcers, but was assessed to be at high risk for developing them.
During an interview on 3/1/2017, at 1:42 p.m., Resident 1 indicated, days shortly after admission to the facility, at 9:20 p.m., he requested to use a bedpan and was provided by a certified nursing assistant (CNA). Resident 1 did not recall the name of the CNA since Resident 1 was new to the facility. Resident 1 indicated no one came for the bedpan in the next 45 minutes, so he fell asleep on the bedpan.
Review of Progress Notes dated 4/29/16, 11:10 a.m. indicated, "Patient (Resident 1) states he was left on the bedpan on NOC and he now has some redness on buttocks area and a red ring the shape of the bed pan."
During an interview on 3/2/2017, at 11:45 a.m., the facility employee (FE 1) indicated, he was providing care to Resident 1 the next morning (4/29/16) after Resident 1 was left on the bedpan (night shift 4/28/16) and noticed Resident 1 had "skin breakdown in a circular shape" on the buttocks. FE 1 stated "I have no doubt this was from a bedpan. I have seen injuries from falling asleep on the toilet and it looked just like that. The skin was open and red."
During an interview on 3/2/2017, at 5:08 p.m., a certified nursing assistant (CNA 1) confirmed, he saw Resident 1's on buttocks on 4/29/16 and stated, "Those looked exactly like he (Resident 1) was left on the bedpan for too long."
During an interview on 3/2/2017, at 6:40 p.m., a licensed nurse (LN 1) confirmed, she was the nurse who took care of Resident 1 the next day (4/29/16) after the incident (4/28/16, left on bedpan during the NOC shift). LN 1 stated "He (Resident 1) clearly had marks on skin from the bedpan...it looked exactly like a bedpan..."
Review of physician's Progress Notes dated 5/3/2016 indicated "Bedpan injury reported today. Was on bedpan overnight...Buttocks: outline of bedpan with L (left) buttock with blister covered with dressing..."
During a record review of the clinical record for Resident 1 on 3/2/2017 Occupational Therapy Plan of Care for the period from 4/19/16 to 6/20/16, indicated Resident 1 was "Near Total Dependence (90 to 95 % assist) with toileting and "Near Total Dependence (90 to 95 % assist) with rolling bed mobility.
During an interview with the facility employee (FE 1), on 3/2/17, at 11:45 a.m., FE 1 confirmed Resident 1 required assistance with bed mobility and toileting and stated "He (Resident 1) required a lot of assistance, especially when he was first admitted...he (Resident 1) was max-assist with everything. (Resident 1) was totally dependent on others."
According to "Fundamentals of Nursing - 7th Edition", (Potter and Perry; 2009) "Positioning interventions reduce pressure and shearing force to the skin ...Clients need repositioning at least every 2 hours on a schedule."
During an interview with Resident 1 on 3/1/17, at 1:42 p.m., Resident 1 indicated the facility staff repositioned him twice per shift and stated "They (facility staff) turn me twice per shift now and that is what they did from the admission, hit or miss..." The CNA staff worked eight hour shift which would require Resident 1 to be turned at least four times per shift.
During an interview with the director of nursing (DON) on 3/2/17, at 1:28 p.m., DON indicated it would be expected for staff to reposition Resident 1 every two to three hours. Repositioning every two hours is standard of care, even if no care plan is in place. DON also indicated it is expected for staff not to leave a resident on a bedpan for more than 15 minutes. Staff needs to stay in resident's room behind the privacy curtain and check up on the resident.
During record review and a concurrent interview with the DSD, on 3/1/17, at 5:35 p.m., DSD confirmed Resident 1's clinical record had no repositioning care plan prior to the date of the incident and indicated it is expected for facility staff to follow the standard of practice and reposition a chair-bound patient every two hours.
During an interview with the DSD, on 3/2/17, at 6:15 p.m., DSD indicated the facility does not have a policy and procedure about repositioning requirements and bedpan use. DSD indicated the facility follows the standard of practice.
Review of Resident 1's clinical record on 3/6/17, Skin/Wound Note dated 5/22/16, indicated Resident 1 developed two open areas on right buttock with outer wound measuring at 11 cm (centimeters or 4.33 inches) long and 4 cm (1.57 inches) wide, and the inner wound measuring at 6.5 cm (2.55 inches) long and 4.5 cm (1.77 inches) wide. Resident 1 also developed blisters on bilateral heels.
Review of Health Status Note dated 5/26/16, indicated Resident 1 developed a blister on left shin (the front of the leg below the knee)/calf (the back of the leg between the knee and the ankle) area.
Review of Health Status Note dated 5/27/16, indicated Resident 1 developed left hip red discoloration and wound on left buttock measuring at 10 cm (3.93 inches) long and 6 cm (2.36 inches) wide. Resident 1 was identified to have cellulitis of right hip (bacterial skin infection).
Review of Health Status Note dated 5/31/16, indicated Resident 1 had multiple wounds: a wound on left buttock, two wounds on upper left thigh, multiple small pink open areas on left buttock, a wound on right buttock, a wound on right outer thigh, a wound on left heel, a wound on right heel, and a wound on left shin.
Review of Health Status Note dated 6/23/16, indicated Resident 1 had multiple wounds: a stage 4 pressure ulcer (very deep wound, reaching into the muscle and bone, causing extensive damage) on left buttock, a wound on left shin, two wounds on left upper back thigh, a wound on left heel, a wound on right back outer thigh, a wound on right heel.
During an interview with Resident 1, on 3/1/17, at 1:42 p.m., Resident 1 indicated he also developed a sore on his leg which resulted from laying on Foley catheter (tube inserted into the bladder through the urethra) tubing all night.
Review of Resident 1's clinical record on 3/6/17, Health Status Note dated 7/8/16, indicated Resident 1 developed a new pressure ulcer from lying on Foley catheter tubing, which extended from right mid-buttock to right hip and was 24 cm (9.44 inches) long.
Review of Skin/Wound Note dated 7/8/16, indicated Resident 1 had the following wounds at the time of assessment: two wounds on left buttock, a wound on left heel, a wound on right back upper outer thigh, a wound on right heel, a wound on left outer shin, a wound on right mid-buttock extending to the right hip from Foley tubing, and a wound on right outer shin.
Review of Skin/Wound Note dated 11/13/16, indicated Resident 1 had the following wounds: a stage 4 pressure ulcer on left shin, an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by dead tissue in the wound bed) on left shin, a stage 4 pressure ulcer on right outer ankle, a stage 4 pressure ulcer on right outer shin, two stage 2 pressure ulcers (the topmost layer of skin (epidermis) is broken, creating a shallow open sore) on right buttock, and a stage 2 pressure ulcer on left buttock.
During an interview with Resident 1, on 1/11/17, at 5:15 p.m., Resident 1 stated "I've been miserable!" when asked how the wounds he developed affected him.
During an interview with Resident 1, on 3/1/17, at 1:42 p.m., Resident 1 indicated sores on the buttocks took over four months to heal and stated, "These sores affected my progress and delayed the discharge from the facility. I could not sit in the wheel chair, only if I had to go to an appointment. I would stay in bed to try to keep the pressure off."
During an interview with the facility employee (FE 1), on 3/2/17, at 11:45 a.m., FE 1 indicated Resident 1's injuries on the buttocks had an effect on Resident 1's performance and affected the amount of time Resident 1 could be out of bed.
The Department determined that the facility failed to ensure Resident 1 did not develop avoidable pressure ulcer. Resident 1 was left lying on bed pan for an extended period of time resulting to a pressure ulcer on Resident 1's buttocks. In addition, the facility did not provide the necessary care and services to prevent the formation of additional pressure ulcers for Resident 1.
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. |
| 630012563 |
CRESCENT HOME |
060008928 |
A |
20-Jan-12 |
9N6W11 |
20605 |
HEALTH AND SAFETY CODE, SECTION 1265.6.1265.6: Notwithstanding any other provision of law, a registered nurse within his or her scope of practice may require direct care staff in an intermediate care facility/developmentally disabled habilitative or an intermediate care facility/developmentally disabled-nursing to administer blood glucose testing for a person with developmental disabilities who resides at the facility and who has diabetes, if all of the following criteria are met: (b) Prior to performing the blood glucose testing, the direct care staff shall be trained by the registered nurse to perform the testing and shall demonstrate proficiency in performing the testing while under the immediate supervision of the registered nurse.(c) Training of direct care staff to perform blood glucose testing shall include, but not be limited to, an overview of the basic disease process of type I and type II diabetes, recognition of the signs and symptoms of hypoglycemia and hyperglycemia, the role of nutrition management in diabetes, diabetes and blood sugar control, long-term complications of diabetes, specific instruction in utilizing and the use of a specific over-the-counter glucose monitoring device that is approved by the FDA, including the cleaning and maintaining the accuracy of the client-specific glucose monitoring device, proper infection control practices related to the use of the device, including the handling and disposal of infectious waste, and recording accurate records of blood glucose readings in the client medical record. Records of blood glucose readings shall be reviewed by the facility registered nurse at least monthly. (d) A signed written statement shall be prepared by the registered nurse that includes a certification of the direct care staff's competence to perform the testing and that identifies the clients residing at the facility for whom the certification is applicable. This certification shall be placed and maintained in the direct care staff's training record. (f) The registered nurse shall be responsible for monitoring and implementing the direct care staff blood glucose testing. At least once every three months, the registered nurse shall observe and confirm the direct care staff person's proficiency in performing the approved testing and shall update the certification. The proficiency determination shall include a determination by the registered nurse that the direct care staff remains proficient in demonstrating the specified method for cleaning and recalibration of the glucose monitoring device. (h) A facility shall develop a written policy and procedure governing blood glucose testing for clients residing at the facility that shall include procedures for the training and competency assessment of direct care staff as required by this section. The above statute was NOT MET as evidenced by: Based on interview, clinical record review, and document review, the facility failed to ensure six of seven direct care staff (DCS) members were trained to perform blood glucose testing for a client with a diagnoses of "Brittle Diabetes" (also called labile diabetes, a term used to describe uncontrolled type 1 diabetes [insulin dependent]). Furthermore, the facility failed to ensure one DCS member, who worked alone during the night, was thoroughly trained to perform finger blood sticks and perform basic management for a client (Client 1) with diabetes mellitus (DM). The lack of staff training put the client at risk for experiencing adverse side effects related to the disease process including diabetic coma and stroke.In addition, the facility failed to ensure the DCS was monitored by the registered nurse consultant (RNC) every quarter in regards to blood glucose testing. The failure to monitor the DCS members' proficiency resulted in the failure to administer medication to stabilize blood glucose levels which delayed treatment of hypoglycemia (low amounts of glucose circulating in the blood. Severe cases can lead to diabetic coma and/or death). The facility failed to ensure the policy and procedure (P&P) that addressed DCS and blood glucose testing was adequate. As a result, there was no protocol available for the staff to follow when managing the health needs of one client with DM. Findings: On 12/13/11, the Department was informed that Client 1 was treated by paramedics for hypoglycemia. On 12/20/11, the investigation was initiated.a. The Special Incident Report (SIR) form, dated 12/13/11, was reviewed on 12/20/11. The SIR showed on 12/12/11, Client 1 experienced an episode of hypoglycemia. The SIR showed the nocturnal (NOC) staff, DCS 1, performed a finger blood stick to obtain the client's blood glucose (BG) level. The results were 43 milligrams per deciliter (mg/dl) (the American Diabetic Association recommends a pre-meal BG level of 90 - 130 mg/dl and a post-meal BG level of less than 180 mg/dl). The SIR further showed that 911 was called and the paramedics treated the client for hypoglycemia. On 12/20/11 at 1520 hours, RNC 1 was interviewed. The RNC was asked whether any of the DCS had been trained to perform BG testing. The RNC stated the only documentation that she was able to locate that showed training for the DCS was in the in-service record. RNC 1 stated the training was done by RNC 2, the RNC that worked at the facility prior to RNC 1's employment with the facility. The in-service log was reviewed on 12/20/11. Review of the in-service log revealed an in-service form that addressed blood glucose testing. The in-service form was dated 5/18/11. The lesson outline showed BG testing was discussed.The training materials showed DCS 1 had not signed the in-service form as evidence of her attendance during the training. Further review of the training materials revealed that DCS 5 was the only staff member that was present during the training on 5/18/11. The other names included on the sign in sheet belonged to staff members that were no longer employed by the facility. On 12/20/11 at 1600 hours, DCS 1 was interviewed. DCS 1 clarified that she had conducted a finger stick in order to obtain Client 1's BG level on 12/12/11. When asked if she was trained to perform finger blood stick testing, DCS 1 stated the Assistant RN (RN 3) spoke to her regarding the procedure for finger blood sticks in late October 2011. DCS 1 stated RN 3 had spoken to her alone about the procedure because she worked alone at the facility during the night shift three times per week. When asked to give specifics regarding what was discussed with her, she stated that she was told how to use the Glutose Gel (an over-the-counter oral glucose gel frequently used by diabetics and those with hypoglycemia to raise their blood sugar when it becomes very low) and to call 911 if the client's BG level was equal to or less than 50 mg/dl, and to identify symptoms of hypoglycemia and hyperglycemia by using forms posted in the facility. DCS 1 could not recall whether RN 3 asked her to sign a document as evidence of their discussion. The employee file for DCS 1, reviewed on 12/20/11, showed there was no documented evidence of training that addressed finger blood sticks or the disease process of DM. The investigation was continued on 12/21/11. On 12/21/11 at 0930 hours, DCS 2 was interviewed. DCS 2 stated her employment at the facility began in July 2011. DCS 2 stated she did not attend any training that addressed Client 1's diagnosis of DM and/or how to monitor the client's BG levels. On 12/21/11 at 0932 hours, DCS 3 was interviewed. DCS 3 stated her employment at the facility began in July 2011. DCS 3 stated she did not attend any training that addressed Client 1's diagnosis of DM and/or how to monitor the client's BG levels. On 12/21/11 at 0940 hours, DCS 4 was interviewed. DCS 4 stated his employment at the facility began in July 2011. DCS 4 stated he did not attend any training that addressed Client 1's diagnosis of DM and/or how to monitor the client's BG levels.On 12/21/11 at 1230 hours, the Licensee informed the surveyor that she located the training record for DCS 1 regarding BG testing. The Licensee presented a document titled, "Specialized Individual Treatment Certificate" dated 3/30/11. The Licensee stated the document was not filed in DCS 1's employee file, and that it was located in one of the training logs. Review of the Specialized Individual Treatment Certificate, dated 3/30/11, showed DCS 1 was the trainee and RNC 2 provided the training. The certificate contained information pertaining to a policy that showed the DCS members could perform "a specific procedure for a client" under the following conditions: - The procedure is ordered by the physician. - Prior to performing the procedure, the staff member shall be trained by the RN to perform the procedure and shall demonstrate proficiency in performing the procedure.- The attendant shall also be trained to recognize the complications which could arise as a result of the procedure and to be knowledgeable in how to respond if a complication arises. - This certification is client specific and shall not be transferred between clients or facilities. - At least every three months the RN shall observe and confirm the attendant's proficiency in performing the approved procedure and shall update the certification. The Specialized Individual Treatment Certificate also showed the training provided for DCS 1 was specific to Client 1's "Accu checks." The teaching method that was used included lecture, return demonstration and a handout for independent study regarding the Accucheck monitor instruction sheet. Review of the documents included with the Specialized Individual Treatment Certificate showed information that described how to use and clean the lancet (a small medical implement used for blood sampling), and how to use the BG monitor and the testing strips. However, the training did not include an overview of the disease process of Type I and Type II Diabetes, recognition of signs and symptoms of hyperglycemia/hypoglycemia, the role of nutrition management in diabetes, and blood glucose control, long term complications of diabetes, proper infection control practices including the disposal of infectious waste, and recording accurate records of blood glucose readings in the clinical record. b. The clinical record for Client 1 was reviewed on 12/20/11. The clinical record showed the client's diagnoses included DM. Review of the physician progress note, dated 8/15/11, showed the endocrinologist documented the client's condition as "Brittle Diabetes." The clinical record showed the client was admitted to the facility on 3/17/11.Further review of the clinical record showed the client required treatment related to complications of DM on the following dates: - On 6/10/11, the client was transferred to the acute hospital for a BG reading "Hi." The client was admitted for "weakness" and discharged on 6/12/11. - On 6/15/11, the client was taken to the Emergency Room (ER) related to a hypoglycemic episode. - On 7/19/11, the client was admitted to the acute hospital for a hypoglycemic episode. The client was readmitted to the facility on 8/14/11. - On 8/31/11, the client was admitted to the acute hospital with a diagnosis of hypoglycemia. The client returned to the facility on 9/3/11. - On 12/13/11, the client was treated by paramedics related to a hypoglycemic episode. On 12/20/11, the Special Incident Report (SIR) form, dated 12/13/11, was reviewed. The SIR showed on 12/12/11 Client 1 experienced an episode of hypoglycemia. The SIR showed the client was moaning, confused, and appeared agitated and lethargic as he ambulated around the room. Documentation showed the nocturnal (NOC) staff, DCS 1, performed a finger blood stick to obtain the client's BG level. The results were 43 mg/dl. The SIR further showed that 911 was called and the paramedics treated the client for hypoglycemia by using "oral glucose." The recapitulated physician's orders for December 2011 were reviewed. An order for Glutose 15 gel 40% (oral glucose), dated 10/21/11, showed the entire contents of the Glutose gel was to be squeezed into the client's mouth if the blood glucose levels were 50 mg/dl or below. The order also showed to check the finger blood stick every 5 minutes. The order showed this procedure could be repeated 2 times, and if the BG level does not rise higher than 50 mg/dl after 10 minutes call 911 or transport to ER for evaluation. On 12/20/11 at 1600 hours, DCS 1 was interviewed. DCS 1 stated on 12/12/11 at 1250 hours, she observed Client 1 in his bedroom. DCS 1 stated the client was walking aimlessly around his room and he was shaking. DCS 1 stated she performed a finger blood stick in order to obtain the client's BG level. DCS 1 stated the client's BG level was 43 mg/dl at that time. DCS 1 stated she gave the client orange juice to drink, called 911, and informed RN 3 of the incident. When asked to explain why she did not give the Glutose gel as ordered by the physician, DCS 1 stated that she forgot. On 12/20/11 at 1643 hours, RNC 1 was questioned regarding DCS 1's training to perform finger blood stick testing. RNC 1 stated she had not provided any training for DCS 1. RNC 1 stated she had not conducted any observations of DCS 1 performing finger sticks. On 12/20/11 at 1800 hours, the Assistant RN (RN 3) was interviewed. RN 3 stated DCS 1 called her on 12/12/11 to inform her that Client 1's BG level was 43 mg/dl. RN 3 stated she advised DCS 1 to call 911. When asked to explain why DCS 1 was instructed to call 911 instead of administering the Glutose gel, RN 3 stated she was not sure if DCS 1 had performed the finger blood stick accurately therefore, she did not want DCS 1 to give the Glutose gel. When asked if she had provided any training that included assuring DCS 1's proficiency in performing finger blood sticks, she stated she had not provided any training to the DCS. The physician's order for the Glutose was reviewed with the RNC at that time and it was confirmed the order was written to administer if the blood sugar level was below 50 mg/dl. An extensive review of the employee files and the in-service log showed no additional trainings were conducted that addressed finger blood sticks or the disease process of DM Type I and Type II. On 12/21/11 at 1200 hours, another interview with RNC 1 was conducted. RNC 1 confirmed she had not performed any staff training regarding finger blood sticks or the disease process of DM Type I and Type II since she was employed as the RNC in September 2011. RNC 1 stated she planned to conduct training, but she did not have an opportunity to do so as of this time. RNC 1 was informed of the concern regarding the staff training in relation to Client 1's diagnoses of DM and the need for training to ensure proficiency in finger blood stick testing. The statute that addressed this concern was reviewed with RNC 1 at that time. On 12/21/11 at 1617 hours, the interview with DCS 1 revealed that DCS 1 had performed finger blood stick checks for Client 1 on other occasions besides 12/12/11. DCS 1 stated she could not remember the dates that she performed the other finger blood sticks. When asked if she had documented the readings of the blood glucose level after she checked the client's BG level, DCS 1 stated she did not document that information in any records kept in the facility. DCS 1 stated she reported the information to the LVN, but there was no documentation of the BG tests or readings that she performed.An extensive review of the clinical record for Client 1 and the Medication Administration Record (MAR) showed there was no documentation to show DCS 1 performed BG checks, and there were no readings of the results obtained from those tests. The facility's failure to ensure that DCS 1 was trained thoroughly to perform BG checks, including the importance of documentation, resulted in incomplete records of the client's health status. c. On 12/21/11, the Licensee was asked to present the facility's policy that addressed finger blood sticks and the direct care staff. Review of the policy and procedure (P&P) titled Diabetic Care Blood Sugar Check-Finger Stick Method showed the policy consisted of information pertaining to the equipment and supplies used to perform the procedure, the steps in the procedure for finger blood sticks, and the reporting and documentation of the procedure performed. The P&P was missing pertinent information that is required to meet the above statute. d. The clinical record for Client 1 was reviewed on 12/20/11. Review of the physician's orders for December 2011 showed an order, dated 10/21/11 to "check finger stick: AC [before] meals and at bedtime/ 6:30 am/11:30 am/4:30 pm/ 9 pm." On 12/20 /11 at 1600 hours, DCS 1 stated she was the only DCS member to be trained to check Client 1's BG levels since she worked during the night when the Licensed Vocational Nurse (LVN) was not working. On 12/20/11 at 1005 hours, the LVN was questioned about the LVN hours. The LVN stated she was the only LVN that was employed by the facility. The LVN stated the DCS did not pass medications and they did not perform the routine BG checks for Client 1. The LVN was asked to present the most recent staff schedule. A review of the schedule was conducted concurrently during the interview with the LVN. Review of the "Home Staff Schedule" showed the LVN hours were as follows: - 6 am to 9 am on Sunday 12/18/11 (three hours). - 6 am to 10 am and 3 pm to 7 pm on Monday 12/19/11 (total of eight hours). - 6 am to 10 am and 3 pm to 7 pm on Tuesday 12/20/11 (total of eight hours). - 6 am to 10 am and 3 pm to 7 pm on Wednesday 12/21/11 (total of eight hours). - 6 am to 10 am on Thursday 12/22/11 (total of four hours). - 6 am to 10 am and 3 pm to 7 pm on Friday 12/23/11 (total of eight hours). - zero hours on Saturday 12/24/11. During the interview on 12/20/11 at 1005 hours, the LVN was asked to explain who performed the nursing duties like passing the medications and performing the BG testing for Client 1 when she was not present at the facility. The LVN was asked to specifically explain how Client 1's healthcare needs would be met on 12/18/11 when her schedule was 6 am to 9 am, and on 12/24/11 when she was not scheduled to work at all. The LVN explained that she came into the facility to perform the finger blood sticks and to administer the medications even though she was not on the schedule. The LVN stated after the treatments were completed she left the facility.On 12/20/11 at 1030 hours, the Licensee was questioned about the LVN hours provided in the facility. The Licensee stated the facility's policy was to have 8 hours of LVN hours of service every day. The Licensee confirmed the facility was not provided with 8 hours of LVN hours of service each day. The Licensee was informed the lack of LVN hours was a concern.On 12/21/11, the Licensee was asked to present the facility's program plan approved by California Department of Developmental Services (DDS).The program plan was reviewed on 12/21/11. The program plan showed the facility was approved by DDS to provide services with the condition that the facility would provide 280 staffing hours with "at least 8 of these hours each day must be LVN or Psych Tech hours." The facility failed to ensure the DCS members were trained to provide necessary monitoring and treatments for Client 1, when the LVN was not present in the facility. The facility failed to ensure the DCS member that was allowed to perform finger blood sticks was thoroughly trained to monitor the client, had an understanding of the disease process afflicting Client 1, and that the DCS was competent to perform the finger blood sticks and to follow the physician's orders regarding hypoglycemic BG levels. Furthermore, the DCS member that was permitted to perform finger blood sticks was not monitored to ensure proficiency. The facility also failed to ensure the necessary LVN hours of service were provided for the facility.The facility's failure to ensure that all of the DCS members were thoroughly trained to provide care for Client 1 was especially egregious since the facility failed to provide appropriate LVN hours of services. This discrepancy resulted in the lack of knowledgeable, trained personnel to meet Client 1's extensive healthcare needs. The facility's multiple failures 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 harm would result. |
| 630012563 |
CRESCENT HOME |
060009354 |
A |
06-Jun-12 |
89ZF11 |
12610 |
Welfare and Institution 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 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 above statute was NOT MET as evidenced by: Based on interview, clinical record review, and document review, the facility failed to ensure Client 1 was monitored adequately after he presented with a change in condition. In addition, the facility failed to ensure the policy and procedure addressing physician notification was implemented. As a result, Client 1 experienced respiratory distress and expired at the facility. Findings: On 1/30/12, the Department of Public Health was notified regarding the death of Client 1. On 1/30/12, an investigation was initiated at the facility.On 1/30/12, the Special Incident Report (SIR) was reviewed. The SIR showed Client 1 presented with lethargy and shallow breathing on 1/29/12 between the hours of 1700 and 1715 hours. The SIR showed the client was in respiratory distress between 1800 and 1805 hours, and 911 was called at that time. The SIR also showed paramedics arrived at the facility between 1805 and 1810 hours and provided "rescue procedures." The SIR showed the paramedics stated, "Nothing else can be done" for the client between 1810 and 1815 hours.On 1/30/12 at 1550 hours, the Direct Care Staff (DCS 1) that was present during the incident on 1/29/12 was interviewed. DCS 1 stated the client received the afternoon feeding while positioned in bed with his head elevated. DCS 1 stated the client looked fine prior to the feeding. DCS 1 stated he checked on the client 15 minutes after the feeding was given and noticed the client was still in an upright position but noticed Client 1 was breathing in a way that made him think something was not right so he notified the Licensed Vocational Nurse (LVN 1). When asked to describe what was strange about the client's breathing, DCS 1 stated the client was breathing in a way that made his chest rise very high.Review of the nurse's notes, dated 1/29/12, showed LVN 1 documented the events that took place on 1/29/12. The documentation showed the following: - At 1640 hours, LVN 1 started the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding for Client 1. Client 1 tolerated the feeding. - Between 1700 and 1715 hours, LVN 1 asked the client a question and the client responded "slowly and appeared lethargic." The client's vital signs were obtained and revealed a respiratory rate of 20 breaths per minute (a normal breathing rate ranges from 12 to 16 breaths per minute). LVN 1 documented the client presented with "shallow breathing" (chest breathing is the drawing of minimal amount of breath into the lungs, usually by drawing air into the chest area using different muscles other than the intended muscle. This causes abnormal and sometimes inefficient air flow). Documentation showed LVN 1 contacted the Registered Nurse Consultant (RNC) and left a voice message informing the RNC of the client's shallow breathing. The note shows LVN 1 repositioned the client in an upright position at 45 degrees and the client's breathing improved.- Between 1730 hours and 1745 hours, LVN 1 documented that he checked Client 1 once again and repositioned the client in an upright position. - Between 1745 hours and 1800 hours, the LVN noticed the client's face and lips appeared cyanotic (the appearance of a blue or purple discoloration of the skin and/or lips due to the tissues near the skin surface being low in oxygen). - Between 1800 and 1805 hours, LVN 1 called 911 and reported the need for assistance for a client in "respiratory distress" (a condition indicating difficulty breathing such as rapid breathing, difficulty catching breath, and bluish or purple changes in skin color). - Between 1800 hours and 1805 hours, paramedics arrived at the facility and started rescue procedures, but the paramedics stated, "Nothing else can be done." - At 1920 hours, the client's primary care physician was informed of the client's death via telephone. Further review of the nurse's notes, dated 1/29/12, showed there was no documented evidence to show LVN 1 listened to the client's breath sounds at any time once the client presented with shallow breathing. There was no documented evidence to show LVN 1 monitored the client's vital signs after the first set was obtained between 1700 hours and 1715 hours when the client initially presented with lethargy and shallow breathing. Furthermore, there was no evidence to show the physician was contacted when the client initially presented with shallow breathing and lethargy between 1700 and 1715 hours.On 1/29/12 at 1655 hours, a policy that addressed steps to be taken during a medical emergency was requested. The policy titled Condition Requiring Notification of the Physician and the policy for signs and symptoms of illness was presented. Review of the policy titled Condition Requiring Notification of the Physician showed difficulty breathing was a condition that should be reported to the physician. Further review of this policy showed it did not include instructions regarding the procedure to be followed if the physician was not available in an attempt to report a concern. On 1/29/12 at 1710, the RNC was informed of this finding. The RNC stated 911 should be called if the physician was unavailable to consult. On 1/31/12 at 0955 hours, the RNC was interviewed. The RNC stated LVN 1 called her on 1/29/12, but she was not exactly sure of the time of the call. The RNC stated LVN 1 reported that Client 1 was breathing shallow, and recited the client's vital signs. The RNC stated the vital signs were fairly normal except for the blood pressure (BP- the force of blood flow against the arterial walls) which was a little high and the temperature which was a little low. The RNC stated she asked LVN 1 to monitor the client by watching him and checking his breath sounds. The RNC stated she would expect the vital signs to be checked at least every 15 minutes. The RNC stated if she was providing care for the client in that situation she would call 911 if the client experienced respiratory distress consisting of a change in the breathing pattern or rate, rapid pulse rate, or a decrease or increase of the BP. On 2/1/12 at 0915 hours, a telephone interview was conducted with LVN 1. The nurse's note, dated 1/29/12, was reviewed with LVN 1 at that time. LVN 1 confirmed that he provided treatment to Client 1 on 1/29/12. LVN 1 stated he noticed the client was behaving differently on 1/29/12 when he was preparing to administer the client's GT feeding. LVN 1 stated when he entered the client's bedroom he noticed the client was quiet. LVN 1 stated the client would usually "say something" when a person entered his room. LVN 1 stated the client was verbal, but the client's speech was echolaic (the repetition of vocalizations made by another person).LVN 1 went on to say that one of the DCS usually helped with the GT feeding by holding the client's arms to prevent the client from disturbing the GT. LVN 1 stated Client 1 would typically flail his arms during the GT feeding. However, on 1/2912, the client's movements were not as strong as usual and the client remained quiet during the feeding. LVN 1 confirmed that he administered the client's GT feeding at 1640 hours as documented in the nurse's note, dated 1/29/12.LVN 1 stated he left the client's bedroom after the feeding was administered and returned to check on the client between 1700 and 1715 hours. LVN 1 stated he described the client as "lethargic" in the nurse's note, dated 1/29/12, because the client was quiet and required prompting to repeat words when he would usually repeat what was being said without needing to be prompted. LVN 1 also stated the client was taking a long time to respond when asked to repeat a word. LVN 1 stated while obtaining vital signs he noticed the client's breathing was shallow as evidenced by the chest not rising very high and the breathing was fast.LVN 1 stated he called the RNC at that time and left a voice message regarding Client 1's status.LVN 1 stated he repositioned the client before leaving the client's bedroom since the client had slid down in the bed causing his head to be elevated at 15 degrees. Therefore, he returned the client to a position in which the head was elevated at a 45 degree angle. LVN 1 was asked to explain how he determined the client's breathing had improved at that time, per the nurse's note, dated 1/29/12. LVN 1 stated the client responded to his request to repeat a word when asked; therefore, he thought the client's breathing had improved. LVN 1 stated the client continued to be slow to respond at that time. LVN 1 stated he left the bedroom once again in order to administer a GT feeding for another client, and returned to check on Client 1 between 1730 and 1740 hours. LVN 1 stated at that time the client was slumped to the right and his breathing "was not that good." LVN 1 stated the client's breathing was shallow and the client was responding "a little bit." LVN 1 stated he wanted to send the client out to the Emergency Department (ED), but he was waiting for the RNC to return his telephone call. So he repositioned the client by sitting him up straight and raising his head to a 90 degree angle.LVN 1 was asked whether he had contacted the client's physician at any time. LVN 1 stated he did not call the physician because it was the weekend and he did not think the physician would respond. LVN 1 stated he left the client's bedroom and returned to the client's bedroom between 1745 and 1800 hours. At that time he noticed the client's face and lips were discolored to a gray color. LVN 1 stated he requested assistance to place the client on the floor and he called 911. LVN 1 was asked if he had listened to the client's respirations at any time during the episode. LVN 1 stated he did not because everything was happening so fast.When asked if he had checked the client's vital signs again after initially taking them between 1700 and 1715 hours, LVN 1 stated he had not taken any additional vital signs. LVN 1 stated prior to calling 911 he had checked the client's chest and noticed it was not rising and falling. LVN 1 further stated he had swiped the client's mouth to clear the airway, but the paramedics arrived before he could initiate rescue breathing or chest compressions. LVN 1 stated when the paramedics arrived they did not do CPR (cardiopulmonary resuscitation), but used the defibrillator instead. After using the defibrillator the paramedics stated there was nothing else that could be done for the client. LVN 1 stated after the client expired he called to leave a message for the physician. On 3/12/12, the paramedics report, dated 1/29/12, was reviewed. The report showed paramedics arrived at the facility at 1827 hours and found the client on the floor with obvious signs of death. It was also documented on the report that at 1829 hours, the client had no heart sounds or lung sounds, and the EKG (electrocardiogram - a simple, painless test that records the heart's electrical activity) report showed the client was asystole (no cardiac electrical activity). Review of the form containing the job description for the LVNs showed LVNs would:- Interpret assessment of client's to medical staff.- Notify the physician immediately of any sudden or marked adverse changes in signs, symptoms or behavior exhibited by the client. The facility's LVN failed to adequately monitor Client 1 and notify the physician immediately when Client 1 presented with lethargy and shallow breathing; thus, delaying the assistance of paramedics.The failure of the facility to adequately monitor Client 1 and to notify the physician immediately when the client presented with lethargy and shallow breathing 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. |
| 060000129 |
Crystal Cove Care Center |
060009572 |
A |
03-Dec-12 |
JKNF11 |
15361 |
72311(a)(1)(2) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care plan shall be based on this plan.72315 (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities 72315 (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement its policies to help heal Patient A's Stage 1 pressure ulcer (intact skin with redness), and to prevent Patient A from developing additional pressure ulcers. Patient A developed three Stage III (full thickness tissue loss extending through the skin to the tissue underneath) pressure ulcers on her sacral area (above the tip of the tailbone) and buttocks, while at the facility, between admission on 11/26/11 and 12/15/11. Interventions recommended on 12/2/11, were not carried out until 12/16/11 to 12/19/11, after the Stage III pressure ulcers already developed. Patient A died on 1/23/12 due to sepsis (a severe systemic infection affecting the body and organs) due to urosepsis (a bacterial infection that spreads to the blood stream from the urinary system) and sacral pressure ulcer.Findings: The facility's policy and procedure, Prevention of Pressure Ulcers (dated 3/2005), read in part, "General Preventive Measures: 1. Identify risk factors for pressure ulcer development...2. For a person in bed: a. Change position at least every two hours or more frequently if needed. b. Use foam, gel or air cushion as indicated to relieve pressure.", and "6. Refer resident to a rehabilitation program, or a restorative nursing program, as indicated. 7. Encourage the resident to participate in active and passive range of motion exercise to improve circulation. 8. Ensure resident drinks plenty of fluids and eats a well-balanced diet...10. Immediately report any signs of a developing pressure ulcer to the supervisor. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of interventions; and to modify the interventions as appropriate." The policy further read, "Choose preventive actions appropriate to individual risk factors and adjust for cognitive impairment of the resident...adjusting for any limitations in resident's understanding of instructions or ability to participate in preventive actions." Per the same Prevention of Pressure Ulcers policy, documentation of wound prevention was to include: "1. The type of skin care given. 2. The date and time skin care was given. 3. The position in which the resident was placed...6. The condition of the resident's skin (i.e., the size and location of any red or tender areas). 7. How the resident tolerated the procedure or his/her ability to participate in the procedure, and resident refusal of care. Refusal of a procedure was also to be reported to a supervisor.On 4/11/12, the medical record for Patient A was initiated and showed Patient A was admitted on 11/26/11. The Nurse's Admission Record dated 11/26/11, showed Patient A was alert, oriented and verbally responsive. The coccyx Weekly Pressure Sore (ulcer) Report dated 11/26/11 through 11/29/11, showed Patient A was admitted with a Stage 1 pressure ulcer to her sacral area, measuring 4.0 cm by 3.0 cm with no necrotic (dead tissue) tissue present. The MDS (Minimum Data Set) dated 12/3/11, showed Patient A required assistance from staff for ADLs (Activities of Daily Living). Patient A's care plan problem dated 11/27/11, for treatment of the Stage I pressure ulcer and for prevention of ulcers showed that the plan was for weekly skin assessment, keeping the skin dry and lubricated, adequate hydration and nutrition, out of bed as tolerated, pressure reducing mattress, assist to turn/reposition, and careful handling. However, the plan omitted some elements that were in the facility policy, such as, referring resident to a rehabilitation program, or a restorative nursing program, as indicated, encouraging Patient A to participate in active and passive range of motion exercise to improve circulation, and immediately report any signs of a developing pressure ulcer to the supervisor.Review of the medical record after 11/26/12, showed Patient A was to have physical (PT) and occupational therapy (OT) evaluation and treatment. However, there was no box checked to indicate OT and PT treatments were given from 11/26/12 through 11/30/12; the boxes were blank.The progress note dated 11/29/11 read in part, "resident is alert but forgetful...appeared that she is incontinent of B & B (bowel and bladder).", and "continue to keep her skin clean/dry to prevent skin breakdown. Q2h (every 2 hours) repositioning, check her depends q2h." No changes to the patient's plans of care were made on 11/29/11, pursuant to the observations of forgetfulness and incontinence. New care plan problems for a confusion and incontinence were not initiated until 12/2/11 and 12/3/11, respectively. The progress note dated 12/1/11 read in part, "Resident was resistive to take medications attempted several times...", and "Resident needs extensive one person assistance with bed mobility." There was no notation that a supervisor was notified that Patient A was becoming resistant to treatment, and no evidence that additional care planning was done due to the need for extensive help with bed mobility.The progress note dated 12/2/11 at 2006 hours, showed Patient A was transported to the acute care hospital for an evaluation due to confusion. The hospital's Emergency Department's Focused Assessment Flowsheet Information notes dated 12/2/11 at 2100 hours, showed Patient A was noted with two Stage II pressure ulcers on her sacral area. The pressure ulcers measured 1.0 cm by 1.5 cm, one on each side of her coccyx (tailbone area) with redness and a small amount of drainage. The notes showed the acute care hospital called the facility to update them to the patient's plan of care and discharged her back to the facility. The note showed the facility was aware of the Patient A's Stage II pressure ulcers. Patient A returned to the facility on 12/3/11 at 0123 hours. However, review of the resident's clinical record from the facility showed no assessment of Patient A's skin upon readmission on 12/3/11, until 12/7/11, eight days after the previous assessment.a. On 12/7/11, the Weekly Pressure Sore (ulcer) Report, for Patient A's sacral area showed a Stage I pressure ulcer had deteriorated to a Stage II pressure ulcer, measuring 2 cm by 2.8 cm with no necrotic tissue present. On 12/15/11, eight days later, staff documented the sacral pressure ulcer deteriorated to a Stage III pressure ulcer, measuring 2 cm by 1.4 cm with an undetermined depth, and 75 % necrotic tissue present. On 12/20/11, the pressure ulcer remained a Stage III; a nurse documented Patient A "understands to reposition q2h", but "prefers" to lie on her back.b. On 12/8/11, the Weekly Pressure Sore (ulcer) Report, for Patient A's left buttocks showed a Stage II pressure ulcer, measuring 1.2 cm by 0.8 cm with a depth of 0.1 cm. On 12/15/11, the pressure ulcer deteriorated to a Stage III ulcer, measuring 1.0 cm by 0.8 cm with an undetermined depth, with 75 % necrotic tissue present. The nurse documented Patient A was "noncompliant with turning schedule". On 12/20/11, the pressure ulcer remained the same. c. On 12/8/11,The Weekly Pressure Sore (ulcer) Report showed Patient A was identified with a Stage II pressure ulcer on her right buttocks, measuring 1.0 cm by 0.5 cm with a depth of 0.1 cm. On 12/15/11, the pressure ulcer deteriorated to a Stage III ulcer, measuring 1.2 cm by 1.0 cm with an undetermined depth with 75 % necrotic tissue present. On 12/15/11, the report showed Patient A was non-compliant with turning and repositioning. On 12/20/11, the report showed the pressure ulcer remained the same, and Patient A had a tendency to stay in one position, and refused to be repositioned at times.There was no documentation a supervisor was notified that Patient A was refusing repositioning, and no changes to care plans to provide for assistive devices, or additional staff to ensure Patient A performed repositioning. Review of the Registered Dietician's (RD) assessment dated 12/2/11, showed Patient A's meal intake percentages ranged from 25% to 75%, and the patient was at risk for decreased oral intake and dehydration due to receiving a mechanically altered diet and fluid restriction. The RD noted the patient's elevated HgbA1c (a test which measures the percentage of blood sugar present in the blood over the last two to three months) indicated inadequate glycemic (sugar level in the blood) control and recommended the patient's diet be changed to an ADA (a diet which helps control blood sugar) diet due to her elevated HgbA1c. The RD made a recommendation for the physician to consider ordering Accuchecks (a test which measures blood sugar) to monitor the patient's blood sugar. The RD recommended the physician adjust the patient's fluid restriction due to indications of inadequate hydration. In addition, the RD noted Patient A had increased nutritional needs to help heal her sacral redness Stage I pressure ulcer. The RD recommended the patient receive a multivitamin tablet daily for supplementation.The Patient Progress Notes dated 12/8/11, showed Patient A's Stage I pressure ulcer on her sacral area progressed to a Stage II pressure ulcer and the patient was developing pressure ulcers on her buttocks. The notes showed Patient A was non-compliant with turning and repositioning and preferred to lie on her back. The RD's progress note dated 12/10/11, showed Patient A had a two pound weight loss and her meal percentage intake ranged from 25% to 75%. The note showed the patient was not receiving an ADA diet and her fluid restriction of 1000 ml daily was still in effect. The RD documented Patient A had developed two Stage II pressure ulcers on her buttocks. The RD noted the patient had increased nutritional needs to help heal her the pressure ulcers. The RD again recommended the patient receive a daily multivitamin, vitamin C 500 mg tablet twice daily and a prealbumin (a test used to check for protein levels to identify possible malnutrition) level to monitor the patient's current nutritional status, and possible need for a protein supplement.The RD's progress note dated 12/22/11, showed Patient A had a six pound weight loss since admission, three Stage III pressure ulcers, one on each buttocks, and one on her sacral area. The patient's HgbA1c level was elevated and her prealbumin level was low. The RD documented Patient A stated she had "a decreased appetite due to increased pain." The RD also documented the patient continued with increased nutritional needs for skin care and she low prealbumin level indicating inadequate protein stores.Review of the MAR (Medication Administration Record) dated December 2011, showed a low air loss mattress (a mattress used to treat and prevent pressure ulcers by redistributing the weight of the patient more evenly) was ordered on 12/15/11(seven days after staff documented Patient A was non-compliant with turning. The daily multivitamin tablet, recommended on 12/2/11, was not ordered until 12/18/11 (16 days later). The adjustment of the fluid, recommended on 12/2/11, was not discontinued until 12/16/11 (14 days later). The diet change recommended on 12/2/11, was not changed until 12/17/11 (15 days later). The vitamin C 500 mg twice daily recommendation on 12/10/11, was not ordered until 12/18/11 (eight days later).On 4/12/12 at 0830 hours, during an interview and medical record review with RN (Registered Nurse) 1, RN 1 stated she did not know why some of the RD's recommendations took two weeks or longer to be carried out.On 4/12/12 at 1040 hours, during an interview with the RD, the RD stated when she makes a recommendation she enters the recommendation in a communication log for the nursing staff to notify the physician. The RD stated the recommendations should be followed up on within 72 hours. On 4/16/12 at 1630 hours, during an interview with the DON (Director of Nursing), the DON stated when a patient returns from the acute care hospital a skin assessment is supposed to be done and documented. When asked if there was a skin assessment documented for Patient A when she returned from the acute care hospital on 12/3/11, the DON was unable to answer. The DON stated she would look for the assessment.On 4/17/12 at 1020 hours, during a follow-up interview with the DON, the DON stated the facility did not do a body check when the patient returned from the acute care hospital. On 4/23/12, a review of additional information received by the facility on 4/19/12 was done. Documentation provided showed Patient A was not provided the low air loss mattress until after her pressure ulcers deteriorated. Review of the Weekly Pressure Sore (ulcer) Report dated 12/7/11, showed Patient A's sacral area pressure ulcer deteriorated from a Stage I pressure ulcer to a Stage II pressure ulcer. The Stage II ulcer was identified in the hospital emergency room on 12/2/11. However, review of the MAR dated December 2011, showed the low air loss mattress was not ordered until 12/15/11 (thirteen days later, when the pressure ulcer was a Stage III).Review of the Resident Progress Notes dated 12/22/11, showed Patient A was transferred to the acute care hospital.Review of the acute care hospital's Emergency Physician Record dated 12/2/11, showed Patient A was admitted with a Stage III pressure ulcer to her sacral area. The Discharge Summary dated 12/28/11, showed Patient A's sacral pressure ulcer was colonized (bacteria is present but not causing illness but could cause illness) with MRSA (Methicillin-resistant Staphylococcus aureus - a highly drug resistant bacteria).The hospital's color photographs dated 12/22/11, showed Patient A had two Stage III pressure areas and one unstageable pressure ulcer clustered together, one on the sacral area, and one on each buttocks. The right buttocks pressure ulcer measured 2 cm by 4 cm. The left buttocks pressure ulcer measured 1 cm by 2 cm. The sacral pressure ulcer measured 2 cm by 1.75 cm and was noted as unstageable (a pressure ulcer that cannot be staged because the depth of the ulcer cannot be determined due to necrotic tissue). Review of the Certificate of Death showed Patient A died on 1/23/12. The cause of death was due to sepsis related to urosepsis (a bacterial infection that spreads to the blood stream from the urinary system) and sacral pressure ulcer. The facility failed to ensure that the policy, Prevention of Pressure Ulcers, was implemented for Patient A, and failed to ensure adequate nutrition was provided to Patient A, resulting in three advanced stage pressure ulcers.The above violation jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physician harm would result. |
| 080001536 |
Carehouse Healthcare Center |
060010885 |
B |
30-Jul-14 |
M9YN11 |
7853 |
483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors.483.60(a),(b) PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in ?483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.The facility must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility.The facility failed to ensure Resident 15 was free of a significant medication error. The facility failed to carry out a physician's order to discontinue Hygroton (a drug used to treat high blood pressure. The drug is also a diuretic, a drug used to reduce fluids in the body). In addition, the facility failed to ensure systems were implemented when the physician wrote the order to discontinue the Hygroton. Resident 15 had a physician's order to discontinue Hygroton 25 mg daily. However, the resident continued to receive the Hygroton 25 mg daily without a physician's order. The facility failed to notify the pharmacy the physician discontinued the order for Hygroton. As a result, the pharmacy continued to dispense the Hygroton to the facility. The licensed nurses failed to ensure the Medication Administration Record (MAR) reflected the most recent physician's orders. This resulted in Resident 15 receiving 27 additional doses of Hygroton. According to Lexi-Comp (a drug reference resource for health professionals), The warnings/precautions show to use with caution in patients with renal (kidney) disease and with diabetes. Medication pass observation was conducted with License Vocational Nurse (LVN) 4 on 6/3/14 at 1000 hours. LVN 4 administered Hygroton 25 mg, one tablet, to Resident 15. Clinical record review for Resident 15 was initiated on 6/3/14. Resident 15 was admitted to the facility on 4/17/14, with diagnoses including acute kidney injury (a disease with rapid loss of kidney function) and diabetes insipidus (a disease characterized by intense thirst and excretion of large amounts of urine). Review of the physician's orders dated 4/17/14, shows an order to start Hygroton 25 mg, one tablet daily.Review of laboratory studies dated 4/21/14, for Resident 15 shows a high BUN (blood urea nitrogen - an indication of kidney function and/or dehydration) of 38 (normal 7-25) and a creatinine (an indication of kidney function and/or dehydration) level of 1.46 (normal 0.60-1.20).Review of a physician's order dated 4/21/14, shows to discontinue the Hygroton 25 mg daily. Another physician's order dated 4/25/14, shows to administer two liters of IV (intravenous) fluids of normal saline (mild salt solution) at 75 ml (milliliters) per hour for dehydration (excessive loss of body fluids).Review of the MAR for April 2014 shows the Hygroton 25 mg is to be administered daily at 0900 hours. The MAR shows Hygroton 25 mg was administered once daily at 0900 hours on 4/18/14, 4/19/14, 4/20/14, and 4/21/14. Review of the MAR for May 2014 shows a handwritten entry to administer Hygroton 25 mg daily at 0900 hours. The MAR shows Hygroton 25 mg was administered from 5/17/14 through 5/31/14. Review of the MAR for June 2014 shows a handwritten entry to administer Hygroton 25 mg daily at 0900 hours. The MAR shows Hygroton 25 mg was administered on 6/1/14, 6/2/14, and 6/3/14. An interview was conducted with the physician on 6/3/14 at 1515 hours. The physician stated she discontinued the Hygroton 25 mg on 4/21/14, because Resident 15's blood creatinine was elevated. She stated there was no indication to continue the Hygroton 25 mg.Review of Resident 15's bubble pack (a card with 31 pills encased in separate plastic blisters) of Hygroton issued on 5/2/14, showed there were four tablets left out of 31 tablets dispensed (the cycle starts every 8th of the month). Review of the facility's policy and procedure (P&P) titled Physician Order Monthly Recap revised date 11/05 shows the licensed nurse will review the administration record for any new orders received after the review and recapitulation and will verify the accuracy of the orders with the physician's order sheet, add, clarify, or delete orders as appropriate. The facility's P&P titled Non-Controlled Medication Order dated 12/12 under Documentation of the Medication Order shows documentation of the medication order is to be transmitted to the pharmacy. Review of the facility's P&P titled Discontinued Medications dated 10/07 shows, if a prescriber discontinues a medication, the medication container is removed from the medication cart immediately. A telephone interview was conducted with the pharmacy technician on 6/3/14 at 1545 hours. The pharmacy technician verified 20 tablets of Hygroton 25 mg was dispensed to the facility on 4/17/14, and 31 tablets on 5/4/14. The pharmacy technician stated they did not receive an order to discontinue the Hygroton on 4/21/14. An interview and pharmacy document review was conducted with the pharmacist on 6/3/14 at 1630 hours. The Medication Disposition Record shows there were 16 tablets of Hygroton 25 mg labeled with Resident 15's name destroyed on 4/28/14. This finding was verified with the pharmacist.An interview and clinical record review was conducted with LVN 4 on 6/4/14 at 1005 hours. LVN 4 stated she wrote the entry for Hygroton 25 mg daily on the MAR for May 2014. She stated she did not know the medication was discontinued on 4/21/14. She stated she remembered the resident was on Hygroton in the past. LVN 4 stated she based the order for the Hygroton on the original order dated 4/17/14, and continued to administer the medication on 5/17/14. LVN 4 verified the MARs for May and June 2014 showed 18 doses were administered; however, 27 doses had been removed from the bubble pack. LVN 4 was unable to explain what happened to the nine doses.An interview was conducted with LVN 5 on 6/4/14 at 1225 hours. LVN 5 verified she wrote the entry for the Hygroton 25 mg on the MAR for 6/1/14, because the medication was in the cart and the previous MAR (May 2014) showed the entry to administer the medication. She stated she looked in the clinical record and was unable to find an order dated 5/17/14, or before for the Hygroton. LVN 5 stated she notified Registered Nurse (RN) 2 and found an order dated 4/17/14, and documented the entry on the MAR. LVN 5 stated she and RN 2 are both aware there was no documentation of doses administered from 5/1/14 through 5/16/14, but she was instructed by RN 2 to continue to administer the medication. LVN 5 was asked what their process is if a medication error is identified. She stated, when a medication error is identified, they report to the RN Supervisor and complete an incident report for their own medication error.LVN 5 was asked their process of informing the pharmacy if medications are discontinued. LVN 5 stated, when medications are discontinued, the licensed nurse who notes the order faxes the order to the pharmacy. The fax confirmation is placed in the Medical Records drawer. An interview was conducted with The Medical Records Director on 6/5/14 at 0930 hours. The Medical Records Director verified there was no fax confirmation received regarding the order dated 4/21/14, to discontinue the Hygroton 25 mg.Failure to implement these requirements, either jointly or separately, had the direct or immediate relationship to the health and safety of Resident 15. |
| 070000038 |
CRESTHAVEN SKILLED NURSING FACILITY, INC. |
070008957 |
B |
14-Feb-12 |
CFPM11 |
3296 |
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 ensure Resident 1 with a known history of elopement (resident who is cognitively or mentally impaired wanders away from the facility) received adequate supervision to prevent an avoidable accident. The facility failed to pick up the resident from an outpatient physical therapy appointment at 2 p.m. The resident waited and wandered away from an unsupervised waiting room after his therapy appointment. The facility failed to discover the resident was missing until 10 p.m. The resident was located at the general acute hospital's emergency room at 10:15 p.m. The emergency room discharged the resident to the facility at 12:30 a.m. with scrapes on his cheek and forehead. Resident 1 was admitted to the facility with diagnoses including encephalopathy (disorder of the brain) with altered mental status. The Minimum Data Set (an assessment tool) dated 9/26/11, indicated the resident had short term memory problems and had a cognitive impairment. Review of the resident's clinical record on 1/24/12 indicated he has a history of elopement. On 10/22/11, Resident 1 eloped from the facility, tripped and fell, and was transported by police to an acute care hospital emergency department. The resident was admitted with orders for outpatient therapy services two times a week. On 1/24/12 at 9 a.m., the facility's administrator stated the resident's friend would pick up the resident and take him to his therapy appointments. The administrator would pick up the resident and bring him back to the facility. The facility's Visitor & Pass Log indicated on 1/3/12, the resident's friend picked up the resident at 10:40 a.m.On 1/3/12 at 10 p.m., the facility's nurses note indicated the resident was discovered missing. The resident's friend was called regarding the status of the resident. The friend stated she took the resident to therapy at 1 p.m. At 10:15 p.m. the resident was located at the general acute hospital's emergency room. On 1/4/12 at 12:35 a.m., the resident returned to the facility with scrapes on the left side of his cheek and forehead. On 1/24/12 at 9:05 a.m., the administrator stated she was supposed to pick up the resident at the outpatient therapy on 1/3/12 at 2 p.m., and she forgot to do so. On 1/24/12 at 12:45 p.m., the day shift licensed nurse (LN A) stated on 1/3/12, she did not report to the evening shift nurse the patient was still gone from the facility. Resident 1, who had a history of elopement, was left unsupervised waiting for someone to pick him up at the outpatient therapy clinic. The resident wandered away from the clinic and fell, scraping his left forehead and cheek. The facility was unaware Resident 1 was missing until 10 p.m. The facility called the emergency room at 10:15 p.m. and located the resident. The resident was returned to the facility from the emergency room at 12:35 a.m. This was an avoidable incident which had the potential for serious harm.The above violation has a direct or immediate relationship to the resident's health, safety or security. |
| 070001089 |
CHILDREN'S RECOVERY CTR OF NORTHERN CAL. D/P SNF |
070010713 |
B |
13-May-14 |
Z92C11 |
3998 |
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 facility failed to implement their bedhold policy by failing to provide a written bedhold notice to Patient 10's representative when Patient 10 was transferred to a general acute care hospital (GACH). The goal of bedhold is to provide a continuous place of residence for the patient by holding the patient's bed for seven days when a patient is transferred to a GACH. Review of Patient 10's clinical record revealed he was a young adolescent who had been admitted to the facility on 3/18/14 with diagnoses that included a head injury, seizure disorder, persistent vegetative state, spasticity (stiff and rigid muscles) and chronic respiratory failure. Resident 10 had a tracheostomy tube (a surgically created opening in the neck leading directly to the trachea, the breathing tube) placed and was on a ventilator (a machine that supports breathing) care. Resident 10 had a gastrostomy tube (a tube inserted through the abdomen that delivered nutrition directly to the stomach) placed.Patient 10's minimum data set (MDS, an assessment tool) dated 3/31/14 indicated Patient 10 required total care from the facility's staff for activities of daily living (ADL) such as dressing, personal hygiene and mobility. Patient 10's Patient Care Transfer Sheet dated 4/28/14 indicated Patient 10 was transferred to a GACH on 4/28/14 at 2:45 p.m. for the medical evaluation and treatment. The progress note dated 4/28/14 at 2:40 p.m., prior to Patient 10's transfer to a GACH, indicated Patient 10's representative and director of nursing (DON) had a telephone conversation regarding Patient 10's transfer. There was no documentation indicating the DON explained to Resident 10's representative the right to have a bedhold.On 5/5/14 at 10:40 a.m., DON was interviewed. She stated the facility did not provide the bedhold notice verbally or in writing to Patient 10's representative when Patient 10 was transferred to a GACH as required by the facility's policy because of several issues between the facility's staff and Patient 10's family members. The facility's 5/03 policy "Bed Holds" indicated the policy was to hold the patient's bed for seven days when a patient was transferred to a GACH. It further indicated upon transfer of the patient of a skilled nursing facility to GACH, the skilled nursing facility shall inform the patient or the patient's representative in writing of the right to exercise the bed hold provision.On 5/6/14 at 1:45 p.m., the social service supervisor (SS) of the GACH was interviewed. SS stated the facility refused Patient 10's readmission to the facility. Due to Patient 10 requiring specialized pediatric health care needs provided at the facility, the facility's failure to implement their bed hold policy and failure to provide a written bed-hold notice to Patient10's representative impacted Patient 10's readmission to the facility. In addition, the facility refused to readmit Patient 10 on 5/5/14 which was in the bed hold period. Therefore, the above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 070000038 |
CRESTHAVEN SKILLED NURSING FACILITY, INC. |
070010740 |
A |
28-May-14 |
SOTI11 |
10490 |
F309 - 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING 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, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure one patient (1) received necessary medical care and services for his change of condition. Patient 1 developed a symptom of a flaccid (soft and limp) right arm and had increased difficulty swallowing on 4/2/14. The facility was unable to reach the patient's physician for any medical interventions. On 4/5/14, Patient 1 was transported to an acute care hospital after an emergency call, with increased blood sugars, decreased oxygen saturation (O2 amount of oxygen carried in the blood), and being unable to swallow his food, fluids or medication. At the acute care hospital, the clinical records indicated he was admitted with acute renal failure (rapid loss of the kidney's ability to remove waste) along with hyperglycemia (high blood sugar level) and a suspected stroke (vessel in the brain ruptures or is blocked by a clot). He was treated with fluid replacement for dehydration (loss of more fluids than taken in) and required a four-day hospitalization after a stroke was ruled out. Patient 1's clinical record was reviewed on 4/17/14. It indicated he was admitted on 9/12/13 with diagnoses including diabetes and dementia. The admission Minimum Data Set (MDS, an assessment tool) indicated Patient 1 was independent in walking, needed supervision with one person physical assist in eating and had full range of motion of his extremities. The quarterly 12/17/14 MDS indicated an increased assistance with transfer, was independent in walking, no longer required assistance to eat, and had full range of motion of his extremities. The quarterly 3/7/14 MDS indicated he was not ambulating, required assistance to eat, still was moving all his extremities and had no swallowing difficulties. Failure to thrive was added as one of the diagnoses. The clinical record also indicated he was a full code. A full code indicates, if a patient has a cardiac or respiratory arrest, medical personnel will be ethically and legally obliged to perform life-saving measures. There was no documentation of any restrictions on any medical interventions, including being sent to an acute care hospital. The nurse's notes from 4/2/14 at 9 a.m., written by the director of nurses (DON), indicated Patient 1 was leaning to the right and had a flaccid right arm. The patient was not able to swallow his morning medication, was drooling and unable to eat his breakfast. During an interview on 4/17/14 at 11 a.m., the DON stated the right arm flaccidity was first noticed on 4/2/14. The DON stated she called the MD and left a message on his voicemail regarding Patient 1's change of condition, but the MD never called back. The DON attempted to call the responsible party, and left a message on her answering machine. She stated she told the family members she suspected the patient had a stroke when she called them on 4/2 and 4/3/14. She stated the facility continued to monitor Patient 1 until 4/5/14. A review of the Stroke Association's website, www.strokeassociation.org, indicated stroke warning signs include arm weakness and loss of balance. It recommends calling 911 when stroke symptoms are suspected. Suspected stroke victims have their best chance at improvement if treated with a medication within three to four and a half hours.The nurse's notes for the same date at 4 p.m., written by licensed nurse A (LN A), indicated the patient had difficulty swallowing. The 6 p.m. note by the same nurse indicated an O2 sat of 92% (normal range is from 95% to 100% on room air according to MedGuidance.com), and a blood sugar of 133 milligrams/deciliters (normal range is 70 to 130 mg/dl according to WebMD.com (2012)/diabetes/blood glucose-control).During a telephone interview on 4/22/14 at 10:40 a.m., LN A stated she had attempted multiple times to call the MD's cell phone and pager numbers on 4/2/14 to have Patient 1's diet changed to pureed (food ground to a thick paste) diet due to the patient's increased difficulty swallowing. LN A stated she left messages after each call but never talked directly with the MD. On 4/3/14 at 12 noon, the nurse's notes written by the DON indicated the O2 sat was down to 88% on room air and O2 was started by nasal cannula (tube which inserts into the nostrils to deliver oxygen) at 2 liters per minute (2 l/min). At 9 p.m., LN C's nurse's notes indicated the patient drank only 10% of the protein shake. On 4/4/13 at 6:30 a.m., LN A's nurse's notes indicated the patient drooled out his medications and protein shake. At 1 p.m., Patient 1 was not taking either food or fluids. During an interview and record review of the patient's clinical record on 4/17/14 at 1:30 p.m., LN C stated on 4/4/14, Patient 1 had refused to eat and had difficulty swallowing when fluid was offered. She stated his blood sugar had increased to 203, which was over his usual blood sugar levels which ranged between 100-150 mg/dl.At 5 p.m., LN C's nurse's notes indicated Patient 1 was still not able to take food, fluids, or medications due to the inability to swallow. On 4/5/14 at 6:30 a.m., LN A's nurse's notes indicated Patient 1 had a fingerstick (blood removed for test by having a finger pricked with a sharp needle) blood sugar of 237 mg/dl. LN A's notes indicated an attempt to notify the MD, DON and owner of the facility regarding the patient's condition.At 12:30 p.m., LN D's nurse's notes indicated vital signs were a heart rate of 107 and a temperature of 101.1 degrees Fahrenheit (F, a measurement of temperature) axillary (taken under the armpit, usually a degree lower that the normal body temperature). At 3 p.m., LN A's nurse's notes indicated Patient 1 remained on oxygen at 3 l/min, had a temperature of 97.9 øF axillary, a heart rate of 101 beats per minute and a fingerstick blood sugar of 297 mg/dl. At 3:30 p.m., LN A's note indicated a discussion with a family member about the patient's condition of not able to take anything by mouth including food, fluids and medications, and change in vital signs including elevated heart rate and fingerstick blood sugar. At 3:45 p.m., 911 was called and the patient was assessed by the paramedics. Patient 1 was sent to an acute care hospital for further evaluation at 4 p.m. During an interview on 4/22/14 at 10:40 a.m., LN A stated on 4/5/14 at 3 p.m., Patient 1 was observed unable to swallow, was drooling and his mouth was stuffed with food. His fingerstick blood sugar was 297 mg/dl. During an interview on 4/18/14 at 1:15 p.m., a family member stated he was informed of the patient's change of condition as a possible stroke by the DON on 4/3/14. On 4/5/14, he came to visit the patient at the facility. LN A discussed Patient 1's condition with him and the decision was reached to send him to an acute care hospital. The family member stated the first time he heard from the MD was on 4/5/14 at approximately 9 p.m., after the patient was in the acute care hospital. The MD informed the family member he was out of the country. During an interview on 4/18/14 at 1:50 p.m., the MD verified he was out of the country when Patient 1 had a change of condition and received all the messages pertaining to Patient 1's condition. He stated he could not recall whether he called the facility about any of the issues pertaining to Patient 1. He also stated he did not sign out to any other physician while he was out of the country. He also stated he did not provide for an on-call physician in his place while he was away because the staff had his cell phone number and e-mail address and he could always be reached. A review of the facility's undated policy, "Protocol for telephone calls for physicians," indicated the only practicing physician listed on the roster was the MD. It also indicated if at any time the patient appears in need of immediate medical intervention to call 911. On 4/18/14, a review of the facility's undated policy, "Physician Services Policy," indicated a physician is available at all times to furnish necessary care to patients. Another physician will supervise the medical care of each patient when his/her attending physician is not available. It also indicated the facility was to provide or arrange for physician services 24 hours per day in case of emergency. Arranging for physician services includes assuring the patient transportation to a hospital emergency room or other medical facility if they are unable to provide emergency medical care.A review of the acute care hospital's 4/5/14, "Emergency Documentation," indicated the facility staff had noticed neurologic deficits of right upper arm flaccidity, right side neglect and dysphagia (difficulty swallowing) such as not being able to take medications or fluids by mouth over the past three days. The note indicated the staff at the facility had been confused when the emergency services had asked them if they understood the concern for a patient with a CVA (stroke) needing emergency services on 4/2/14. In the Reexamination/Reevaluation section of the same document, it stated the diagnosis was severe dehydration, acute renal failure and likely a new CVA. It went on to indicate due to the CVA being three days plus ago, there was likely no treatment available for the CVA.A review of Patient 1's emergency department visit, history and physical at the acute care hospital, dated 4/5/14, indicated the patient required hospitalization with admitting diagnoses including dehydration and acute renal failure. A review of Patient 1's discharge summary from the acute care hospital indicated no acute stroke, but a discharge diagnoses including acute renal insufficiency and dehydration which improved with fluids over the course of his four-day hospitalization. Other primary discharge diagnoses included delirium encephalopathy (a brain disease, damage or malfunction) possibly due to medication effect, Type 2 diabetes, and history of cerebral vascular accident (stroke) with left-sided deficits, hypertension (elevated blood pressure), severe dementia and hypothyroidism (decreased activity of the thyroid glands). 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. |
| 070000023 |
Canyon Springs Post-Acute |
070011143 |
B |
09-Dec-14 |
WM5L11 |
6294 |
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 ensure Resident 3 was provided with adequate supervision when Resident 3 used a bedside commode (a movable toilet which looks like a chair with a toilet seat with a bucket or container underneath). Resident 3 fell to the floor when a certified nurse assistant (CNA) left Resident 3 alone on the bedside commode and sustained an acute subdural hematoma (SDH, a collection of blood on the surface of the brain), intraventricular hemorrhage (IVH, bleeding inside or around the ventricle spaces in the brain) and subarachnoid hemorrhage (SAH, bleeding in the area between the brain and the thin tissues that cover the brain). Resident 3 required one staff member's physical assistance to use the toilet. This failure resulted in brain injuries to the resident and Resident 3 required more assistance with activities of daily living (ADL) after hospitalization.Resident 3's clinical record was reviewed. Resident 3's Minimum Data Set (MDS, an assessment tool) dated 11/5/14, indicated she had short and long term memory problems with diagnosis of dementia (the loss of mental functions such as thinking and reasoning). She had hearing difficulty and her vision was listed as severely impaired. Resident 3 was a non-English speaker and she needed one staff member's physical assistance for ADL such as toileting. The assessment for the balance during moving on and off the toilet indicated Resident 3 was not steady and only able to stabilize with staff assistance.Review of Resident 3's Optometric Consultation dated 2/17/14, indicated Resident 3 was legally blind. (Legal blindness is defined as visual acuity (vision) of 20/200 or less in the better eye with best correction possible. This means a legally blind individual has to stand 20 feet from an object to see it with the same degree of clarity as could a normally sighted person from 200 feet.) Review of Resident 3's Fall Risk Evaluation dated 8/25/14, indicated Resident 3 was at risk of fall with highly or severely impaired vision status, elimination with assistance, ambulation with problems and unsteady balance while standing, sitting and during transitions. It further indicated Resident 3 was only able to stabilize with physical assistance for the balance. Review of Resident 3's Fall Prevention and Safety Care Plan initiated 11/23/12 and revised 8/25/14, indicated not to leave Resident 3 alone in the bathroom due to poor safety awareness, unsteady gait, impaired cognition/communication, visual impairment, attempts to stand/transfer without assistance and fragile skin.Review of Resident 3's SBAR Communication Form (Situation-Background-Assessment-Request, a standardized nursing communication tool) dated 11/10/14, indicated Resident 3 was on her bedside commode and certified nurse assistant A (CNA A) was assisting Resident 3. CNA A heard an alarm sound outside the room and CNA A left the room to check from where the alarm sound came. Resident 3 was left alone on the bedside commode and when CNA A returned to her, Resident 3 was found lying on the floor. It further indicated Resident 3 sustained a cut and a bump on the left eyebrow with moderate amount of blood coming out continuously and Resident 3 was transferred to an emergency room in a general acute care hospital (GACH). Review of Resident 3's History and Physical Report from the GACH dated 11/11/14, indicated Resident 3 sustained an acute subdural hematoma, intraventricular hemorrhage, and subarachnoid hemorrhage from the fall incident. Resident 3 was admitted to an intensive care unit in the GACH. During an interview with the assistant director of nursing (ADON) on 11/24/14 at 1:40 p.m., he stated staff should stay with Resident 3 during her toileting.During a telephone interview with CNA A at 11/24/14 at 3:20 p.m., she stated she was aware Resident 3 was confused and required assistance with toileting because of fall risks. CNA A stated she heard an alarm while she was assisting Resident 3 and left Resident 3 alone on a bedside commode to check the alarm outside the room. When CNA A returned to the room, CNA A found Resident 3 on the floor. CNA A stated she should not have left Resident 3 alone on a bedside commode. CNA A further stated she should have called coworkers for help.During an interview with the director of staff development (DSD) on 11/24/14 at 2:10 p.m., she stated she instructed staff not to leave alone a resident on a toilet who required assistance during toileting. During an interview with restorative nursing assistant C (RNA C) on 11/25/14 at 3:35 p.m., he stated Resident 3 was able to walk with assistance and her gait was unstable. RNA C stated Resident 3 required one staff member's physical assistance for toileting.Review of Resident 3's Admission Evaluation dated 11/17/14, indicated Resident 3 was readmitted to the facility with diagnoses of SDH, IVH, and SAH. Review of Resident 3's Occupational Therapy (OT) Discharge Summary dated 11/19/14, indicated Resident 3's baseline was assessed on 11/18/14. It indicated Resident 3 was unable to stand during ADL (total dependence) and Resident 3 showed total dependence for toilet/commode transfers. Review of Resident 3's ADL Tracking Form dated 11/17/14, indicated Resident 3 was totally dependent with two staff members' physical assistance for most ADL functions and Resident 3 became always incontinent (a loss of control) of bladder.During an interview with Minimum Data Set coordinator (MDSC) on 11/24/14 at 3 p.m., she reviewed Resident 3's ADL Tracking Form and stated Resident 3 had a decline in ADL functions after hospitalization, which was caused by the fall incident. Review of the undated manufacturer's instructions for the bedside commode indicated users with limited physical capabilities should be supervised or assisted when using the commode.Therefore, the facility failed to provide Resident 3 adequate supervision to prevent the fall incident. These violations had a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000031 |
Camden PostAcute Care, Inc. |
070012037 |
B |
23-Feb-16 |
T88511 |
6175 |
F206 - 483.12(b)(3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility failed to implement their written policy to readmit Resident 1 when her readmission was refused after she was transferred to the acute care hospital, failed to provide written notice of the bed hold and readmission policy to the resident and the immediate family member on the day of discharge, and denied her readmission due to behavior issues after her bed hold period expired.Resident 1's clinical record was reviewed and indicated she was admitted with diagnoses including a history of falls, schizoaffective disorder (a condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression). The Minimum Data Set (MDS, an assessment tool), dated 10/19/15, indicated the resident's cognitive function was moderately impaired and she needed assistance with the activities of daily living. She also had behavior episodes of anger outbursts. During a telephone interview on 2/5/16, at 2 p.m., the hospital's case manager (CM) stated on 1/19/16 she called and left a voicemail for the facility's admission coordinator (AC) informing her Resident 1 was ready for discharge to the facility. The CM stated the AC returned her call and advised the CM that the facility would not accept the resident until the resident was re-evaluated by the AC. The CM stated the AC never arrived and did not call. The CM stated she called the facility again on 1/21/16 and the AC returned her call informing her the facility would not take back the resident because the resident's bed hold period had exceeded 30 days. During an interview on 2/8/16, at 9:55 a.m., the AC stated she did not call and did not visit the hospital to re-evaluate Resident 1 because it was a weekend. The AC stated she informed the hospital's discharge planner the facility could not take back the resident because of her behavior problems. The AC also stated Resident 1 exceeded the 30 day bed hold policy and the facility did not have to accept the resident after the bed hold period expired. During a telephone interview on 2/8/16, at 10:15 a.m., the social service director (SSD) stated she discussed Resident 1 with the interdisciplinary team (IDT, a group of healthcare professionals from diverse fields who work in a coordinated fashion toward a common goal for a resident) and the resident would not be permitted to return to the facility because the facility could not provide care to the resident due to her behavior issues of anger outbursts, yelling, refusing medications, and at times refusing care. The SSD acknowledged the IDT had no documentation of the discussion regarding the reason for refusing Resident 1's readmission. The SSD also stated the medical director (MD) was not included in the IDT's decision not to readmit Resident 1. The SSD further stated at the time Resident 1 did not have an RP to assist in the decision making. During interview and record review on 2/8/16, at 12:40 p.m., with the director of nurses (DON), she stated the social service director (SSD) was responsible to provide a written notification of the readmission and the bed hold policy at the time of the transfer. She stated the bed hold was not offered to Resident 1. The DON confirmed there was no documentation in the records indicating the facility had communicated with the hospital's CM regarding the facility's inability to provide care for Resident 1. There was no documentation the facility coordinated with the physician/medical director regarding the team's decision not to readmit Resident 1 due to care issues and the expiration of the bed hold period.The medical director progress notes, dated 11/30/15, indicated Resident 1 refused most nursing care and medications. The plan was to suggest an IDT care conference meeting regarding the matter. During an interview on 2/8/16, at 3 p.m., the facility's medical director (MD) stated he was aware and had discussed with the DON Resident 1's anger outbursts and refusal of care. He stated he suggested a resident care conference meeting in November 2015 to address the resident's care issues and a possible referral. The MD stated he was not aware the resident care conference meeting had not occurred. He was not aware the resident was still in the acute care hospital. The MD stated the transfer and readmission process required the involvement of the IDT. He further stated the team had to start documenting and communicating their protocols/plans regarding refusing readmissions including the justification concerning the facility's inability to meet the needs of the resident.The facility's 4/2005 policy, "Bed Hold", indicated the facility would provide written notification to all residents, family members, and/or legal representatives of the bed hold policy upon admission, and at the time of transfer in accordance with federal and state guidelines. Residents who are absent from the facility at midnight, were on therapeutic leave, were expected to return and have bed hold days through the Medicaid program or if the RP agreed to pay for the bed hold. The facility failed to provide written notice of the bed hold and the readmission policy to Resident 1 and the immediate family member when she was transferred to the acute care hospital, failed to assist the resident in seeking legal guardianship to coordinate her care during the transfer/discharge and readmission process, and denied the resident readmission after she was discharged to the acute care hospital due to her behavior issues and the expiration of her therapeutic leave (bed hold period). These violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000023 |
Canyon Springs Post-Acute |
070012145 |
B |
25-Mar-16 |
JT6911 |
3097 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policy and procedure for Resident 2 when an allegation of abuse was not reported to law enforcement officials, the attending physician, and adult protective services. Resident 2's allegation of abuse was not investigated and reported to the Ombudsman or to the California Department of Public Health (CDPH) within 24 hours after the incident had occurred.Resident 2's Minimum Data Set (MDS, an assessment tool) dated 10/27/15 was reviewed and indicated Resident 2 had no problem with decision making. During a review of the clinical record for Resident 2, the social services note dated 3/7/16, indicated Resident 1 and Resident 2 had a verbal altercation in the facility. The record revealed things were fine until Resident 1's family member (FM) arrived at the facility and started threatening Resident 2.During an interview with licensed vocational nurse 1 (LVN 1), on 3/16/16, at 3:08 p.m., she stated she saw the FM talking to Resident 2 in a loud voice asking her to stay away from Resident 1. She immediately intervened and redirected the FM to Resident 1's room. LVN 1 later reported the incident by telephone to the facility administrator (ADM). She thought the incident was a simple misunderstanding and she decided not to document the incident or monitor Resident 2.A review of Resident 2's clinical record on 3/16/16 indicated no nurses notes or care plan were initiated until 3/15/16. There was no documentation that Resident 2's attending physician, adult protective services, and law enforcement were notified. During an interview with the ADM, on 3/16/16 at 4:25 p.m., he stated he spoke to the FM informing the FM of the inappropriate nature of what he said. The ADM confirmed based on the information he gathered, that law enforcement and adult protective services were not needed. During an interview with the ADM, on 3/21/16 at 10:35 a.m., he stated he was aware of Resident 2's abuse allegation on 3/5/16 but did not begin an investigation and did not report the allegation to the ombudsman and to the CDPH until 3/7/16.The facility policy and procedure titled "Reporting Abuse to State Agencies and other Entities/Individual", dated August 2011, indicated should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source or abuse be reported, the facility administrator will promptly notify the persons or agencies: State licensing, Ombudsman, Adult Protective Services, Law enforcement officials, Attending Physician and facility Medical Director. Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone. The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000031 |
Camden PostAcute Care, Inc. |
070012250 |
B |
27-May-16 |
YYH011 |
5262 |
Title 22 72541 Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to report two incidents of unusual occurrences to the California Department of Public Health (CDPH) when a water heater serving the facility's kitchen broke, and when a patient with decision-making problems, eloped on the same day the staff were instructed to stay in the facility because of a gas line leak.1. Patient 1's clinical record was reviewed. His Minimum Data Set (MDS, an assessment tool), dated 3/10/16, indicated he had severe difficulty in daily decision-making skills. His care plan, dated 2/22/16, indicated he had a potential for verbal aggression related to poor impulse control and a care plan, dated 2/25/16, indicated he was at moderate risk for falls related to poor safety awareness.Patient 1's nurses note, dated 4/7/16, at 2:01 p.m., indicated at about 1:15 p.m. he was nowhere to be found, and the local police were notified and arrived at the facility.A note written by a physical therapy assistant (PTA), dated 4/7/16, indicated she told Patient 1 he was doing really well and should no longer need supervision when he went to the store. The statement further indicated when the PTA was about to report Patient 1 was leaving, he had already left and the police were notified. During an observation on 4/20/15, at 10:10 a.m., Patient 1 was walking independently in the hallway without any assistive devices such as a cane.During an interview on 4/13/16, at 10 a.m., the director of nurses (DON) stated Patient 1 was missing from the facility the day of the gas leak. During an interview on 4/13/16, at 10:30 a.m., a maintenance staff member (MS) stated he was outside painting a wall on an unknown date when a police officer told him to go inside. A few minutes later, a local gas utility staff member informed him there was a gas leak outside and no one was to leave the facility. During an interview on 4/13/16, at 11:10 a.m., the administrator (ADM) stated on the day of the gas disruption, there were yellow barriers placed on the sidewalk and someone from the local gas company gave instructions to stay in the building. The ADM did not notify the CDPH because there was no danger to the patients.During an interview on 4/13/16, at 1:35 p.m., the MS stated on the day of the gas leak, someone took down a portion of the fence and did not inform the staff. He stated a patient who was missing on the same day might have left the facility when the fence was taken down. During an interview on 4/20/16, at 10:30 a.m., the housekeeping staff (HS) stated after going off duty on the day of the gas leak at 4 p.m., he saw Patient 1 with a lady outside of a restaurant located 15 minutes away from the facility by car. 2. A review of a hardware store receipt indicated a 48-gallon water heater was purchased on 4/12/16 at 1:49 p.m. During an interview on 4/12/16 at 6:10 p.m., the maintenance staff (MS) stated on 4/11/16, at approximately 8:30 a.m., he was notified the heater supplying hot water to the kitchen was broken. When he could not repair the heater, he informed the ADM on 4/11/16, at 3 p.m. After obtaining permission, a new heater was purchased and replaced on 4/12/16 at 3 p.m. During an interview on 4/12/16 at 6:15 p.m., the ADM stated he was notified the hot water heater was broken the afternoon of 4/11/16. The ADM did not report the incident to the CDPH because he did not consider it an unusual occurrence. During an interview on 4/13/16, at 8:35 a.m., the dietary manager (DM) stated she reported to the ADM on 4/11/16 at 7:30 a.m. there was no hot water in the kitchen. The kitchen staff did not use the dishwasher because the water temperature was not hot enough to sanitize the dishes.The facility's 11/8/95 policy, "Unusual Occurrences," indicated the facility should assume responsibility for reporting unusual occurrences to the proper authority and all unusual occurrences should be reported to the "Department of Licensing" (CDPH) by telephone and confirmed in writing within 24 hours. The facility failed to report two incidents of unusual occurrences to the California Department of Public Health (CDPH) when a patient having decision-making problems eloped on the same day the staff were instructed to stay in the facility because there a gas line leak and when a water heater serving the facility's kitchen broke.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of the patients. |
| 070000031 |
Camden PostAcute Care, Inc. |
070012252 |
B |
15-Jun-16 |
1V8D11 |
2108 |
F226--483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Resident 1's clinical record was reviewed. His progress notes, dated 5/3/16, indicated there was an allegation of abuse on 4/27/16 when family member C (FM C) forced him to eat and slapped him. Form SOC 341, California Report of Suspected Dependent Adult/Elder Abuse, was filed on 4/27/16 with the Long Term Care (LTC) Ombudsman (organization that investigates elder abuse complaints in LTC facilities), and local law enforcement was contacted by telephone on 5/3/16. There was no documentation indicating the incident was reported to the CDPH. During an interview on 5/5/16 at 12 p.m., licensed vocational nurse A (LVN A) stated she saw FM C slap Resident 1 during lunch on 4/26/16 while he was eating. LVN A reported the incident to the director of staff development (DSD) on the morning of 4/27/16. During an interview on 5/5/16, at 3 p.m., the social service designee (SSD) stated the DSD informed her of the incident on 4/27/16 and on the same day, she filed Form SOC 341 with the ombudsman but she did not report the incident to the CDPH. During an interview with the administrator (ADM) on 5/5/16, at 4:30 p.m., he stated he reported the alleged abuse to the local law enforcement on 5/3/16. He gave instructions to the staff to file a SOC 341 with the ombudsman and the CDPH. He was not aware the staff did not file the SOC 341 with the CDPH. He stated an allegation of abuse needed to be reported to the ombudsman, law enforcement, and the CDPH. Review of the facility's 7/2015 policy, "Abuse Policy," indicated the facility will prohibit abuse for all patients. The incident should be reported to law enforcement agency, the ombudsman, and the CDPH within 24 hours utilizing the SOC 341. The facility failed to report an allegation of abuse to the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000027 |
CARMEL HILLS CARE CENTER |
070012390 |
B |
14-Jul-16 |
PXZB11 |
3159 |
F226--483.13(C) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Review of Resident 7's Minimum Data Set (MDS, an assessment tool) dated 3/25/16, indicated the resident had diagnoses including encephalopathy (disease of the brain), dementia with behavioral disorder (mental deficiency or impairment), quadriplegia (paralysis of both arms and legs), and was cognitively impaired. The resident was unable to make medical decisions for himself and was totally dependent on nursing staff for bathing, dressing, and transferring. Review of Resident 7's nursing notes dated 6/21/16, indicated an incident of "potential abuse" occurred on 6/19/16. It stated certified nurse assistant E (CNA E) increased the hot water temperature during Resident 7's shower and sprayed his face. It further indicated the resident was abused resulting in skin tears on the left lower extremity and excoriations/lacerations to his coccyx (tail bone) area from CNA E's inappropriate care. Review of Resident 7's progress notes dated 6/19/16 at 14:52 a.m., indicated the resident had two lacerations to his coccyx area with bleeding which was caused by the use of the transfer sling. During an interview with CNA F on 6/29/16 at 9:58 a.m., she stated CNA E told her on 6/19/16, CNA E had increased the hot water temperature, sprayed on Resident 7's face, and it was burning hot when CNA E gave the resident a shower. CNA F stated CNA E told her she did that because Resident 7 allegedly said he would hang CNA E's mother. CNA F stated she was aware of the incident and did not report the 6/19/16 incident to anyone. During an interview with the director of nursing (DON) on 6/29/16 at 2:55 p.m., the DON confirmed the incident happened on 6/19/16 at around 10:30 a.m. She stated she heard of the incident and started the investigation on 6/20/16. During an interview on 6/27/16 at 8:30 a.m., with the administrator (ADM), who was an abuse coordinator, he stated the facility's investigation determined CNA A abused Resident 7 on 6/19/16. The ADM further stated he reported it to the ombudsman and the CDPH on 6/21/16 at 2 p.m. Review of the facility's 7/2005 policy "Abuse" indicated when abuse, mistreatment, neglect or misappropriation of resident's property is observed by, reported to, or suspected of any employee of the facility, the individual who first identifies such a concern must immediately notify the supervisor on duty who will advise the administrator and director of nursing. The administrator or DON will notify the ombudsman and the CDPH of suspected abuse immediately by telephone and a written report will be provide no later than 24 hours following the telephone notification of the ombudsman for all incidences of suspected abuse. Therefore, the facility failed to ensure staff members followed the facility abuse policy to notify the CDPH and the ombudsman of an allegation of abuse. This violation had a direct of immediate relationship to the health, safety, or security of the residents. |
| 070000027 |
CARMEL HILLS CARE CENTER |
070012391 |
B |
14-Jul-16 |
PXZB11 |
2902 |
F223--483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION 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. Review of Resident 7's Minimum Data Set (MDS, an assessment tool) dated 3/25/16, indicated the resident had diagnoses including encephalopathy (disease of the brain), dementia with behavioral disorder (mental deficiency or impairment), quadriplegia (paralysis of both arms and legs), and was cognitively impaired. The resident was unable to make medical decisions for himself and was totally dependent on nursing staff for bathing, dressing, and transferring. Review of Resident 7's nursing notes dated 6/21/16, indicated an incident of "potential abuse" occurred on 6/19/16. It indicated certified nurse assistant E (CNA E) increased the hot water temperature during Resident 7's shower and sprayed his face. It indicated the resident was abused resulting in skin tears on the left lower extremity and excoriations/lacerations to his coccyx (tail bone) area from CNA E's inappropriate care. Review of Resident 7's progress notes dated 6/19/16 at 2:52 p.m., indicated the resident had two lacerations to his coccyx area with bleeding and it was caused by the use of a transfer sling. During an interview with CNA F on 6/29/16 at 9:58 a.m., she stated CNA E told her on 6/19/16, she had increased the hot water temperature, sprayed on Resident 7's face, and it was burning hot when CNA E gave the resident a shower. CNA F stated CNA E told her she did that because Resident 7 allegedly said he would hang CNA E's mother. During an interview on 6/29/16 at 10:30 a.m. with CNA G, she stated CNA E was rough in adjusting Resident 7's sling during a transfer from a shower chair to his bed on 6/19/16. CNA G stated when CNA E pulled the sling roughly Resident 7 started bleeding on his coccyx area and his upper back area. During an interview on 6/29/16 at 10:40 a.m. with CNA H, she stated after Resident 7's shower, CNA E moved Resident 7 to his bed using a lift machine, did not align him properly, so his legs were partially hanging off the bed, and flopped his legs on the bed. CNA H stated she was annoyed by the care provided to Resident 7 by CNA E. During an interview with the administrator on 6/27/16 at 8:30 a.m., he stated the facility's investigation determined CNA E abused Resident 7. Review of the facility's 7/2005 policy "Abuse" indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm. Therefore, the facility failed to ensure the resident was free from physical abuse. This violation had a direct of immediate relationship to the health, safety, or security of the residents. |
| 070000074 |
CYPRESS RIDGE CARE CENTER |
070012423 |
B |
20-Jul-16 |
QSJS11 |
2827 |
F226--483.13(c) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policy and procedures in reporting an injury of unknown origin for Resident 1 when the resident had a bruise on her right eyebrow. Resident 1's bruise of unknown origin was not reported to the California Department of Public Health (CDPH) and the ombudsman within twenty four hours of it being observed. Resident 1's clinical record was reviewed. The resident's progress notes dated 7/2/16 at 6:43 a.m., indicated a staff noticed a bruise on the resident's right eyebrow. Review of Resident 1's progress notes dated 7/4/16 at 10:56 a.m., indicated the resident's bruise was measured 2 centimeters (cm, a unit of length) by 4 cm. It indicated licensed vocational nurse B (LVN B) reported Resident 1's bruise to the CDPH and the ombudsman. Review of the facility's Summary of Incident indicated the origin of Resident 1's bruise was unknown. During an observation on 7/8/16, at 10:20 a.m., Resident 1 had a purplish and greenish bruise on her right eyebrow. During an interview with certified nursing assistant A (CNA A) on 7/11/16, at 2:10 p.m., he stated on 7/2/16 at 5:30 a.m., he noticed Resident 1's bruise on the resident's right eyebrow. During concurrent interview with LVN B, he stated on 7/4/16 which was 2 days after the resident's bruise was noticed, he reported Resident 1's bruise to the CDPH and the Ombudsman. LVN B stated Resident 1's bruise should be reported within 24 hours to the CDPH and the ombudsman. During interview with the administrator (AD) on 7/8/16, at 1:30 p.m., he stated the facility reported Resident 1's bruise to the CDPH and the ombudsman on 7/4/16. AD stated any injury of unknown origin should be reported within 24 hours to the CDPH and the ombudsman, and Resident 1's bruise was not reported in a timely manner. The facility policy "Reporting Abuse to State Agencies and Other Entities/Individuals" dated 8/2011, indicated a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be reported to the State licensing/certification and to the local Ombudsman within twenty four hours of the occurrence of such incident. Therefore, the facility failed to implement their policy and procedures in reporting an injury of unknown origin, when Resident 1 had a bruise on top of the right eyebrow which was not reported to the California Department of Public Health (CDPH) and to the Ombudsman within twenty-four hours of its occurrence. This violation of this regulation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000074 |
CYPRESS RIDGE CARE CENTER |
070012424 |
B |
26-Jul-16 |
O7Q811 |
3475 |
F204--483.12(a)(7) PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHARGE A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency the State LTC ombudsman, residents of the facility, and the legal representatives of the residents or other responsible parties, as well as the plan for the transfer and adequate relocation of the residents, as required at ?483.75(r). Resident 1's facility failed to ensure safe discharge from the facility when they did not assist him to enter his home in a proper manner when he did not have a key to his door, so they placed the resident through a window onto a couch. This failure had the potential to result in the endangerment of Resident 1's health and well-being. The clinical record for Resident 1 was reviewed on 6/1/16. Resident 1 had diagnoses of dementia (involves a decline in thinking and memory skills), lung disease, and dependence on supplemental oxygen. Resident 1 was listed as his own responsible party (ability to make legal decisions about healthcare and finances). The signed discharge physician order, dated 5/23/16, indicated Resident 1 was discharged to home. The nurses note dated 5/20/2016, at 4:30 p.m., indicated Resident 1 was discharged home in a wheelchair by way of the facility van with continuous oxygen at 2 liters per minute, medication list, and instructions for taking medications. The social service note dated 5/20/16, at 12:15 p.m. indicated Resident 1 was discharged because his health had improved sufficiently for the resident to no longer need the services provided by the facility. The social service note further indicated Resident 1 was to receive home health nursing (nursing care in his home after discharge). During an interview with the director of social services (DSS) on 6/1/16, at 12:25 p.m., she stated she accompanied the resident to his home on 5/20/2016 and when the resident did not have a key to enter his home, Resident 1 asked the van driver to lift him into his living room and onto a couch. This was done via a window which they were able to open. The DSS stated the resident was upset at the time and stated he would break into his backdoor if they did not help him in through the window. The DSS stated the van driver then assisted Resident 1 through the window and placed the resident onto the couch. The DSS stated Resident 1 then let them into his home via a door. The discharge summary (DS) from an acute care hospital, dated 6/20/16 indicated Resident 1 was admitted on 5/22/16 from his home, two days after discharge from the facility. The DS indicated Resident 1 was discharged from the acute care hospital on 6/20/16 and assisted into his home via a locksmith for safe entry into his home. The facility failed to ensure safe discharge from the facility for Resident (1) when they did not assist him to enter his home in a proper manner when he did not have a key to his door. This failure had the potential to result in the endangerment of Resident 1's health and well-being, so they placed the resident through a window and onto a couch. The facility therefore failed to provide Resident 1 with a safe discharge to home. This violation had a direct relationship to the health and safety of the resident. |
| 070001089 |
CHILDREN'S RECOVERY CTR OF NORTHERN CAL. D/P SNF |
070012510 |
B |
16-Aug-16 |
IKET11 |
2656 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their abuse policy for Resident 1 when licensed vocational nurse A (LVN A) noticed a bruise on the resident's left cheek on 7/16/16 at 7:30 a.m. The bruise was not reported to the administrator or designee in a timely manner and to the California Department of Public Heath (CDPH) within 24 hours. This had the potential for continued abuse and harm to residents by an unreported abuser. Review of Resident 1's Progress Notes dated 7/22/16, indicated on 7/16/16, LVN A reported the resident's bruise of unknown origin to registered nurse B (RN B). During an interview with RN B on 8/4/16 at 11:50 a.m., she stated on 7/16/16 at 7:30 a.m., LVN B informed her of bruising on Resident 1's left cheek. RN B stated she did not notify the administrator (ADM) and director of nursing of Resident 1's bruise. During an interview with director of nurses (DON) on 8/4/16 at 12:15 p.m., she was aware of the incident on 7/20/16 and notified the administrator (ADM) of the incident on 7/20/16. During an interview with the ADM on 8/4/16 at 12:25 p.m., she confirmed the facility did not report the incident to CDPH within 24 hours. During an interview with the DON on 8/8/16 at 8:05 a.m., she stated the facility did not report to the CDPH within 24 hours Resident 1's bruising of unknown origin which was identified on 7/16/16. Review of the facility's 12/19/2012 policy "Bruise/Skin tear of Unknown Origin" indicated upon observation of a new bruise or skin tear for which there is no witnessed, documented cause, the staff member who first notices the lesion will complete the Bruise/Skin Tear of Unknown Origin Worksheet. The completed form shall be turned in to the facility administrator or designee (DON, ADON) who will review the form and follow up as needed to determine if any reportable even has occurred. If indicated, reporting to CDPH will be done within 24 hours. Review of the facility's 5/2012 policy "Abuse Prevention, Intervention, Reporting and Investigation" indicated the facility administrator or designee will notify the California Department of Public Health of an alleged abuse situation upon a child within 24 hours. Therefore, the facility failed to ensure staff members followed their abuse policy to notify the CDPH and the ombudsman of the allegation of abuse. This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000023 |
Canyon Springs Post-Acute |
070012773 |
B |
22-Nov-16 |
CG1611 |
3255 |
F226--483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their abuse policy when the alleged abuse of one of three residents (1) was not reported to facility management, the California Department of Public Health (CDPH), local ombudsman, and law enforcement in a timely manner. This failure had the potential for continued abuse and harm to residents. Review of Resident 1's clinical record indicated she had diagnoses including dementia. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/9/16 indicated the resident was cognitively impaired. Review of Resident 1's progress notes, dated 9/25/16, indicated the resident complained that someone hit her on the face and buttock. There was no documented evidence facility management, CDPH, local ombudsman, or law enforcement were informed on 9/25/16. On 9/28/16, the Department received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated Resident 1 claimed a female certified nursing assistant lightly slapped her on the face. It indicated the facility contacted law enforcement and the local ombudsman by telephone on 9/27/16 regarding the alleged abuse. It indicated the facility faxed a report on 9/27/16 regarding the alleged abuse to CDPH and Adult Protective Services (APS). During an interview, on 10/25/16 at 10:15 a.m., licensed vocational nurse A (LVN A) stated Resident 1 reported to her that someone hit her. LVN A stated she documented the alleged abuse and reported it to the oncoming nurse of the next shift. LVN A stated she made a mistake and should have reported the alleged abuse right away to the administrator (ADM), who was the abuse coordinator. During an interview, on 10/25/16 at 10:30 a.m., the director of staff development (DSD) stated on 9/27/16, a certified nursing assistant brought to her attention the alleged abuse of Resident 1. The DSD stated she then reported the alleged abuse to the ADM. During an interview, on 11/15/16 at 8:15 a.m., the ADM stated LVN A did not report the allegation of abuse to him timely, and the allegation of abuse was reported to the appropriate agencies a little late. Review of the facility's revised 12/2013 policy, "Reporting Abuse to Facility Management," indicated employees must immediately report any suspected abuse to the administrator or director of nursing services. Review of the facility's revised 4/29/16 policy, "Abuse Reporting to Agencies/Entities," indicated when suspected abuse is reported, the administrator or designee should promptly notify law enforcement by telephone within 24 hours and APS, ombudsman, law enforcement and licensing agency by written report within 24 hours. The facility therefore failed to follow their abuse policy when an allegation of abuse was not reported to facility management, the California Department of Public Health (CDPH), local ombudsman, and law enforcement in a timely manner. The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000074 |
CYPRESS RIDGE CARE CENTER |
070012806 |
B |
12-Dec-16 |
1UV411 |
7025 |
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. The facility failed to provide the necessary care and services for Resident 1 who had a change in condition. A charge nurse (CN) failed to respond to and timely notify the physician when Resident 1, who was at risk for bleeding, had a change in condition when she vomited several times during the night. This failure led to a delay in transfer to the acute care hospital placing her at risk for health complications. Review of Resident 1's record indicated she had diagnoses including disseminated intravascular coagulation (DIC, a condition that prevents control of blood clotting and bleeding), history of nausea and vomiting, ulcerative colitis (inflammation with ulcer formation in the lining of large intestine) with rectal bleeding and chronic atrial fibrillation (abnormal and irregular heart rhythm). The Minimum Data Set (MDS, an assessment tool), dated 8/20/16, indicated Resident 1 did not have problems with memory and with daily decision making skill. The Medication Administration History Record indicated from 9/3/16 to 9/19/16, Resident 1 received Warfarin (a blood thinning medication also known as Coumadin) 10 mg (mg, a metric unit of measurement) at bedtime to treat atrial fibrillation. On 8/15/16 a care plan was developed indicating Resident 1 was "at risk" for bleeding and or bruising from warfarin use. A nursing progress note dated 9/19/16 at 11:14 a.m. indicated a physician was notified regarding Resident 1's high PT/INR (prothrombin time and international normalized ratio) test results of 34.6 and 3.64 respectively. An elevated PT/INR test result means a person's blood is clotting too slowly, there was at risk for bleeding, and the dose of warfarin was too high. During an interview on 11/7/16 at 9:20 a.m., Resident 1 stated she "vomited blood" for six hours and filled two emesis basins (kidney shaped shallow container to contain medical waste) before she was transferred to the hospital. She kept telling nursing staff she was feeling sick but "they would not listen" to her. During an interview on 11/8/16 at 2 p.m., certified nurse assistant A (CNA A) stated she was assigned to provide care for Resident 1 on 9/20/16. She recalled around midnight Resident 1 had a "spit" amount of chocolate colored emesis (vomit) and she reported to the charge nurse (CN). Before 3 a.m., Resident 1 vomited a "large" amount of dark brown emesis, soiling her bed and gown. CNA A stated the resident looked pale and she took vital signs (temperature, pulse, respiration, and blood pressure). After reporting to the CN the CN asked the resident, and the resident denied eating chocolate or chocolate pudding. During an interview on 11/8/16 at 3:20 p.m., CNA B stated she was not assigned to Resident 1 but was on duty the night she vomited. She stated around 3 a.m., CNA A reported to the CN that Resident 1 was throwing up. The CN then asked CNA A the color of the vomit and said, "How bad was it?" Thirty minutes later, Resident 1 threw up again and between 3 to 7 a.m. she threw up three to four times. During an interview on 11/8/16 at 2:10 p.m., the CN stated Resident 1 vomited twice and described the vomit as "coffee ground" (particular appearance of vomit and a sign of upper gastrointestinal bleeding (GIB)). The first vomit was a "smear" amount and occurred around midnight. At 6 a.m. the resident vomited maroon colored emesis and it was "a lot," staining the whole towel. The resident was placed on continuous oxygen. The CN denied knowledge of Resident 1 having any other episodes of vomiting on 9/20/16. Further review of a nursing progress note dated 9/20/16 at 7:51 a.m. indicated the resident vomited dark-chocolate fluids 100 ml (milliliter, a metric unit of measurement, 28 ml is one ounce) at 6:45 a.m. and a physician assistant was notified. An order was obtained to transfer the resident to a hospital emergency department and the resident was transferred at 7:25 a.m. On 9/20/16, there was one set of vital signs documented at 1:08 a.m. There was no other entry indicating Resident 1 had vomited, no assessment determining potential cause of vomiting, no intake and output record of vomiting and no physician order and documentation for oxygen use. During an interview on 11/10/16 at 3:10 p.m., the director of nurses, who reviewed the record, stated when a resident vomits, licensed nurses needed to see the vomit and document it. Documentation by licensed nurses should contain a head-to-toe assessment including palpating (examine by feeling and pressing with the palms of the hands and fingers) the abdomen for pain, checking the mouth, doing medication review such as to see if the resident was on a blood thinning medication, find out what the resident ate, and review the vital signs. If a resident may be vomiting blood, a physician should be immediately notified. The policy, "Change in a Resident's Condition or Status," revised April 2011, indicated the facility was to promptly notify the attending physician of changes in the resident's medical condition. The nurse/supervisor/charge nurse was to notify the attending physician or on-call physician when there had been a reaction to medication, a significant change in the resident's condition, and/or a need to transfer the resident to a hospital/treatment center. Lexi-Comp online (www.lexi.com), a nationally recognized drug information resource, indicated warfarin is a "Black Box Warning" (type of warning appearing on a prescription drug label and is designed to call attention to serious life-threatening risks) medication with potential side effects including massive hemorrhage involving the GI tract. The facility's undated "Charge Nurse Job Description," indicated an essential job function included to complete required documentation of care and services delivered including subjective findings, objective symptoms, interventions and resident responses to interventions and to complete required documentation of special circumstances. Review of Resident 1's acute care hospital discharge summary dated 9/28/16, indicated she was admitted on xxxxxxx with a diagnosis including acute GIB and she presented with supratherapeutic (above therapeutic level) INR. The facility failed to provide the necessary care and services for Resident 1 who had a change in condition. A charge nurse (CN) failed to respond to and timely notify the physician when Resident 1, who was at risk for bleeding, had a change in condition when she vomited several times during the night. This failure led to a delay in the resident's transfer to the acute care hospital placing her at risk for health complications. The above violations had a direct or immediate relationship to the health, safety or security of residents. |
| 070001089 |
CHILDREN'S RECOVERY CTR OF NORTHERN CAL. D/P SNF |
070012807 |
B |
9-Dec-16 |
ZJYN11 |
2689 |
F281 483.21(b)(3)(i) Services Provided Meet Professional Standards (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. The facility failed to implement a physician's order to increase the dosages of two medications and discontinue one medication for Resident 1. This failure could result in the resident not receiving medication at the appropriate therapeutic level. Resident 1 was admitted to the facility on xxxxxxx with diagnoses including pulmonary hypertension (an increase in blood pressure in the vessels of the lungs), chronic respiratory failure and was ventilator dependent. Record review on 12/6/16 at 11:30 a.m. of the medication administration record (MAR) indicated Resident 1 had been receiving sildenafil six mg (milligrams, unit of measure) every eight hours, furosemide six mg every 12 hours, and spirolactone six mg two times a day. Sildenafil is a medication used to open blood vessels in the lungs to allow blood to flow more freely. Furosemide and Spirolactone are medications used to treat fluid retention. Record review at 11:40 a.m. of a physician's order dated 9/7/16 indicated to discontinue the previous sildenafil dosage and increase it to eight mg every eight hours, discontinue the previous furosemide dosage and increase it to eight mg every 12 hours, and discontinue the spirolactone. During an interview at 11:45 a.m. the director of nursing (DON) stated the order had not been implemented until 9/22/16 when during a weekly chart audit it was discovered the changes in dosage had not been transcribed on to the MAR. The DON stated Resident 1 stayed on the previous dosage of the medication until 9/22/16 when the new order was implemented. The DON stated Resident 1 remained stable until he was transferred to the acute care hospital on 10/8/16 for a condition unrelated to the medication dosage. Record review on 12/6/16 at 12:30 p.m. of the facility policy, "Medication Administration" dated 06/12 indicated: "Noting or Implementation of the Medication Order a) The licensed nurse noting or posting the order will check off each order and sign her first initial and last name and date and time the order (am/pm). b) The nurse or her designate enters the order into the MAR." The facility failed to implement a physician's order to increase the dosages of two medications and discontinue one medication for Resident 1. This failure could result in the resident not receiving medication at the appropriate therapeutic level. The violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 220001009 |
Cupertino Healthcare & Wellness Center |
070012938 |
B |
3-Feb-17 |
MEE911 |
8068 |
F323-483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to ensure adequate assistance to prevent accidents and injuries for Resident 19. The facility failed to assist the resident to the bedside commode, and failed to implement a different kind of intervention in response to Resident 19's frequent falls. These failures resulted in Resident 19 sustaining a bump on the left side of her eye and a left clavicle fracture.
Review of Resident 19's clinical record indicated the resident was admitted on XXXXXXX11 with diagnoses including hepatic failure (liver failure), convulsions (seizure) and dementia (memory problem). Her minimum data set (MDS, an assessment tool) dated 7/6/16, indicated the resident had impaired cognition (mental process), required assistance for bed mobility, transfer, and toileting. There were no MDS's in 10/2016 and 1/2017.
Review of Resident 19's Fall Risk Assessment dated 9/19/16, indicated she had a score of 14. A score of 10 or above represents a high risk for falls.
Review of Resident 19's Fall Risk Prevention and Management care plan dated 5/19/16, indicated Resident 19 had a risk for fall related to her history of falls and unsteady gait (abnormal walking). The interventions to prevent falls included placing the call light within reach, remind the resident to use the call light, provide an environment which minimized hazards over which the facility has control, and encourage the use of a front wheel walker.
Review of Resident 19's cognitive loss care plan dated 5/19/16 indicated Resident 19 had a period of forgetfulness, short term memory loss and poor judgment.
Review of Resident 19's situation background assessment recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) dated 9/19/16, indicated the resident had an unwitnessed fall when she was found on the floor next to her bed. This resulted in a skin tear on the back of the head and a skin tear on her right hand.
Review of Resident 19's post fall short term care plan dated 9/19/16, indicated the incident occurred when Resident 19 wanted to use the bedside commode. The intervention to prevent falls was to place the resident on bladder assistance (assist to the bathroom) every two to three hours. There was no evidence Resident 19 was placed on bladder assistance every two to three hours.
Review of Resident 19's bowel and bladder assessment and interventions dated 7/6/16, indicated the resident would proceed with a retraining program. There was no bowel and bladder assessment in 10/2016.
Review of Resident 19's post fall interdisciplinary (team members from different department involved in a resident's care) assessment dated 9/19/16, indicated the resident lost her balance during transfer. The intervention to prevent falls was to remind the resident to use the call light for needs, and encourage her to move slowly when changing position.
Review of Resident 19's SBAR dated 10/22/16, indicated the resident had an unwitnessed fall when the resident used the bedside commode, lost her balance and fell. Resident 19 complained of pain, dizziness, a lump was noted on the back of the head, and the resident was sent to an acute hospital.
Review of Resident 19's Fall Risk Assessment dated 10/22/16, indicated she had a score of 14. A score of 10 or above represents a high risk for falls.
Review of Resident 19's acute hospital diagnosis dated 10/22/16, indicated the resident had a diagnosis of a hematoma (a collection of blood outside of blood vessels) of the scalp.
Review of Resident 19's post fall interdisciplinary assessment dated 10/24/16, indicated the resident tried to use the bedside commode, lost her balance and fell. The intervention to prevent a fall included to monitor orthostatic hypotension (decrease in blood pressure) upon return from the acute hospital. There was no evidence the resident was monitored for orthostatic hypotension.
Review of Resident 19's SBAR dated 10/25/16, indicated the resident had an unwitnessed fall. When the resident fell, the resident complained of dizziness, and a bump on the left side of her left eye. The resident was sent to an acute hospital. Resident 19's acute hospital diagnosis dated 10/25/16 indicated the resident had a left clavicle fracture.
Review of Resident 19's post fall interdisciplinary assessment dated 10/24/16, indicated the resident got up from bed, forgot to use the call light, tried to use her bedside commode but lost her balance and fell. The intervention to prevent a fall included to remind the resident with each contact to call for assistance, educate regarding the risk, and consequence of doing an independent transfer.
Review of Resident 19's SBAR dated 1/9/17, indicated the resident had an unwitnessed fall when she was found sitting on the floor with a right shin (lower extremities) abrasion (scrape).
Review of Resident 19's post fall interdisciplinary assessment dated 1/9/17, indicated the resident rolled off the edge of the bed. The intervention to prevent a fall was to put a floor mat at the resident's bedside.
Review of Resident 19's Fall Risk Prevention and Management care plan dated 11/30/16, indicated Resident 19 had a risk for fall related to history of falls, decreased endurance and medications, e.g., Propranolol (blood pressure medication), Dilantin (for seizure), and Melatonin (medication to control the sleep and wake cycle).
During an observation and interview with licensed vocational nurse J (LVN J) on 1/20/17 at 8:05 a.m., Resident 9 was lying on her bed, with the bedside commode nearby. The call light was bent to the other side of the bedside table. LVN J confirmed Resident 19's call light was not within reach and she could not call for assistance. LVN J also stated Resident 19 had no floor mat.
During an interview with the director of nursing (DON) on 1/20/17 at 2:35 p.m., she stated Resident 19 was a high risk for falls related to her confusion, and forgetfulness. The resident required assistance for transfer and toileting. The DON stated the interventions should have been implemented and new interventions should have been developed to prevent falls. She also stated Resident 19 should have been referred to therapy related to her frequent falls. The DON acknowledged there was no bowel and bladder training every two to three hours, there was no weekly summary from 9/21/16 to 10/26/16, no monitoring for orthostatic hypotension, no floor mat and the call light should have been within reach.
Review of the facility's 11/7/2016 policy, "Fall Management Program", indicated the facility will implement a fall management program which supports and provide an environment free from hazards. The licensed nurse and interdisciplinary team (IDT, team members from different department involved in a resident's care) will develop a plan of care according to the identified risk factors and root cause. The licensed nurse will evaluate the resident's response to the plan of care during weekly summary evaluation and will update the care plan as necessary.
This failure had a direct relationship to the health, safety, or security of residents. |
| 220001009 |
Cupertino Healthcare & Wellness Center |
070012939 |
B |
3-Feb-17 |
MEE911 |
5871 |
F314 - 483.25(b)(1)TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES
(b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
The facility failed to ensure Resident 9 received appropriate care to prevent a pressure ulcer (skin injury caused by unrelieved pressure that results in damage to the underlying tissues). The facility failed to update Resident 9's Braden scale (a tool to predict pressure ulcer risk) and failed to implement a different kind of intervention to prevent a pressure ulcer. This failure resulted in Resident 9's left inner heel with a stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough).
A review of Resident 9's clinical record indicated he was admitted onXXXXXXX16 with diagnoses including dementia (memory problem), muscle weakness and cognitive communication deficit. Resident 9's Minimum Data Set (MDS, an assessment tool) dated 10/9/16, indicated the resident had impaired cognition, required assistance with bed mobility, transfer, hygiene and bathing. The MDS also noted he was at risk for the development of a pressure ulcer. Resident 9's MDS for 12/2016 was not completed.
During an interview with the MDS Coordinator (MDSC) on 1/17/17 at 1:40 p.m., she stated Resident 9's quarterly assessment was scheduled on 12/15/16 and it was not completed.
A review of Resident 9's admission assessment dated 9/11/16 indicated under skin integrity he had skin discoloration on the left hand and left forearm, multiple skin rashes on the right and left forearms, and skin redness on the resident's buttocks. Resident 9 had no pressure ulcer on the left inner heel upon admission.
A review of Resident 9's Braden scale dated 9/11/16 indicated he was at mild risk for developing a pressure ulcer. Resident 9's Braden Scale for 12/2016 was not updated.
A review of Resident 9's skin care plan dated 9/11/16 indicated the resident was at risk for a pressure ulcer related to impaired mobility, cognitive impairment, and fragile skin. The interventions to prevent pressure ulcer included repositioning with care rounds and referral to the registered dietitian (RD) if needed.
A review of Resident 9's weekly pressure ulcer progress report dated 1/9/17, indicated he had developed a blister (it was raised on the skin which contains clear liquid and that was caused by injury or rubbing against something) on his left inner heel, which measured approximately three centimeters (cm, unit in measurement) length and three cm in length. The interventions for preventing pressure ulcer were floating heel (the heels were off the bed) and heel protector.
During an observations on 1/17/17 at 3 p.m., 1/18/17 at 3:35 p.m., and 1/19/17 at 8:00 a.m., Resident 9 was lying on his back and his left inner heel rested on his bed with no heel protector.
During an interview with licensed vocational nurse A (LVN A) on 1/18/17, at 3:30 p.m., she stated she was the assigned charge nurse when Resident 9 developed a blister on his left heel with a stage II pressure ulcer on 1/9/17. LVN A stated Resident 9 was always in bed and got his blister from his bed.
During an observation and interview with LVN B on 1/18/17, at 3:35 p.m., she confirmed Resident 9 was lying on his back. The left inner heel pressure ulcer rested on the bed with yellowish color around the dressing, and Resident 9's bed linen had yellow circle color drainage from his left inner heel pressure ulcer. She stated Resident 9 should have been repositioned and the left inner heel stage II pressure ulcer should have been floating when he was in bed.
During an interview and record review with the assistant director of nursing (ADON) on 1/18/17, at 3:45 p.m., she stated she was not aware of Resident 9's left inner heel pressure ulcer. She stated Resident 9 developed his left inner heel stage II pressure ulcer from his bed and nursing staff should have repositioned Resident 9 when he was in bed. The ADON confirmed Resident 9 was a high risk for developing a pressure ulcer, he was immobile, and it was an avoidable pressure ulcer. She also stated there was no interdisciplinary (IDT, team members from different departments involved in a resident's care) notes, the Braden scale was not updated, and no RD referral.
During wound care observation and interview with treatment nurse I (TN I) on 1/18/17, at 8:50 a.m., Resident 9's left inner heel pressure ulcer was observed with slough and dry black blood in the wound bed area. TN I stated Resident 9's left inner heel pressure ulcer had increased in size, and measured approximately 5.5 cm in length and 4.8 cm in width. TN I confirmed Resident 9 had no heel protector and he should have it.
A Review of the facility's policy titled, "Pressure Injury Prevention" dated 8/12/16, indicated to provide interventions for residents identified as high risk for developing a pressure ulcer. A risk assessment (Braden Scale) for a developing pressure ulcer will be completed in a timely manner. The nursing staff will implement interventions identified in the care plan based on individual risk factors. Nursing staff will observe for any signs of potential or active pressure injury daily while providing nursing care.
This failure had a direct relationship to the health, safety, or security of residents. |
| 070000023 |
Canyon Springs Post-Acute |
070013054 |
B |
16-Mar-17 |
OQB711 |
5454 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to conduct Resident 10's quarterly fall risk assessment (a tool used to identify risk factors for fall and formulate action plan), and failed to implement the intervention of placing the bed in a low position. These failures resulted in a fall and a right hip fracture.
Review of Resident 10's facesheet on 2/28/17, indicated the resident was admitted XXXXXXX 15 with diagnoses including history of falling, difficulty in walking, muscle weakness, dementia (memory problem), unsteadiness on feet, and age related osteoporosis (a medical condition in which the bones become brittle and fragile) without current pathological fracture (a fracture caused by disease which led to weakness of the bone structure). Her minimum data set (MDS, an assessment tool) dated 6/10/16 indicated the resident had severe impaired cognition (the activities of thinking, understanding, learning, and remembering), required assistance in bed movements, transfers, walking, and toileting.
Review of Resident 10's fall risk assessment dated 6/17/16, indicated under fall risk summary score Resident 10 had a score of 19 which indicated she was at risk for falls. There was no quarterly fall risk assessment done for 9/2016.
During an interview and record review with the assistant director of nursing (ADON) on 3/1/17 at 11 a.m., he stated Resident 10 was at high risk for falls, and there should be a quarterly fall risk assessment in 9/2016.
Review of Resident 10's care plan for fall risk dated 9/17/16, indicated to keep the bed in the lowest position with the brakes locked.
Review of Resident 10's event report dated 11/22/16, indicated the resident had an unwitnessed fall at 3:30 p.m., and was found on the floor. Per the body assessment it was suspected there was a fracture or an actual fracture.
Review of Resident 10's progress note dated 11/22/16 at 11 p.m., indicated at 3:30 p.m., "a CNA assisting across the hall noted the resident was on the floor with the bed elevated, and was calling for help. [Resident 10] was unable to state what she was doing prior to fall".
Review of Resident 10's progress note dated 11/23/16 at 8:19 a.m., indicated receipt of the results of the X-ray (an imaging test used to produce photograph of bones which can be checked for fractures). Results were acute right hip fracture. Resident 10 had an old fracture involving right rami (part of a pubic bone) with modest healing. Resident 10's primary physician was called to report the X-ray result, and he ordered to transfer Resident 10 to the acute hospital.
Review of Resident 10's acute hospital discharge summary dated 12/1/16 and the admission dated 11/23/16, indicated Resident 10's discharge diagnoses were right hip fracture with status post (had the procedure) right hip gamma nail fixation (a surgical procedure to stabilize severe fracture of the bone), postoperative (after surgical procedure) anemia (a medical condition in which the red blood cell count is less than normal), status post blood transfusion (a process to replace blood lost), history of osteoporosis, mechanical falls (means slipped, tripped or lost your balance), and high risk for falls.
Review of Resident 10's care plan for falls dated 12/2/16, indicated to keep the bed in a low position with an alarm, landing pad, and hip protector. Review of Resident 10's event report dated 12/23/16, indicated the resident had an unwitnessed fall when she was found on the floor while she transferred from the wheelchair to her bed, and lost her balance.
During an observation on 2/28/17 at 7:40 a.m. and 3/1/ 17 at 8:30 a.m., Resident 10 was lying in her bed with her eyes closed. The bed was elevated and was not in a low position.
During an observation and interview with licensed vocational nurse C (LVN C) on 3/1/17 at 8:35 a.m., Resident 10 was lying in bed. The bed was not in a low position, and the bed alarm was turned off. LVN C confirmed the bed should have been in a low position and the bed alarm should not be turned off.
A review of the facility's 2001 policy, "Fall and Fall Risk, Managing", indicated the staff identify interventions and implement relevant interventions to try to minimize serious consequences of falling
Therefore, the facility failed to conduct Resident 10's quarterly fall risk assessment (a tool used to identify risk factors for fall and formulate action plan), and failed to implement the intervention of placing the bed in a low position.
These failures had a direct relationship to the health, safety, or security of residents. |
| 070000031 |
Camden PostAcute Care, Inc. |
070013106 |
B |
12-Apr-17 |
6PX411 |
4207 |
F226 -- 483.12(b) (1)-(3), 483.95(c) (1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC. POLICIES
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 facility failed to implement their abuse policy for Resident 1 when:
1. the alleged abuse incident was not reported to the Department within 24 hours,
2. the alleged abuser was not immediately removed from duty, and
3. the completed investigation was not reported to the Department within five working days of the incident.
These failures had the potential for continued abuse and harm to the resident by the suspected abuser.
Resident 1 was admitted to the facility on XXXXXXX17 with diagnoses included cerebral infarction, unsteadiness on feet, muscle weakness, atrial fibrillation, anxiety and major depressive disorder.
1. Review of Resident 1's Activity Progress Notes dated 3/24/17 at 1:38 p.m., indicated Resident 1 reported to registered nurse A (RN A) and activity director (AD) that certified nursing assistant A (CNA A) stuck his fingers in her rectum during a shower.
During an interview with the director of nursing (DON) on 4/3/17 at 1:20 p.m., she stated RN A did not report the incident to anyone because Resident 1 was a frequent complainer and fabricated stories.
Review of Resident 1's Nursing Progress Notes dated 3/25/17 at 10:55 a.m., indicated Resident 1 reported to licensed vocational nurse A (LVN A) that on 3/24/17 CNA A put his three fingers in her rectum during a shower.
During an interview with LVN A on 4/3/17 at 2:55 p.m., she stated she only called the Ombudsman about the incident on 3/25/17.
Review of the facility's form SOC 341 (form used to report an incident of suspected abuse or neglect) indicated the incident took place on 3/24/17, and the form was completed on 3/27/17.
The Department received the SOC 341 via fax on 3/27/17.
The facility policy and procedure titled "Abuse Policy" dated 07/2015, indicated "... If no serious bodily injury: ... Provide a written report to the local Ombudsman, the L&C Program District Office, and the local law enforcement agency within 24 hours utilizing California Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341)."
2. During an interview with the director of staff development (DSD) on 4/3/17 at 1:30 p.m., she stated CNA A worked in the facility on 3/25/17 and 3/26/17, but he was not assigned to provide care for Resident 1.
Review of the facility's "CNA Nursing Assignments - Afternoon Shift" dated 3/25/17 and 3/26/17, indicated CNA A continued working in the facility after Resident 1 reported the incident on 3/24/17.
The facility policy and procedure titled "Abuse Policy" dated 07/2015, indicated "The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation."
3. During an interview with the social services director (SSD) on 4/3/17 at 12:05 p.m., she stated the facility's investigation report was not ready.
The facility policy and procedure titled "Abuse Policy" dated 07/2015, indicated "The Administrator or designee will report findings of all completed investigations to the L&C Program District Office via fax and other officials in accordance with state law within five working days of the incident...."
These violations had direct relationship to the health, safety, or security of patients. |
| 070000023 |
Canyon Springs Post-Acute |
070013229 |
AA |
14-Jun-17 |
WON711 |
2999 |
F323 -- 483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to provide adequate supervision to prevent an accident for Resident 1. Resident 1 was allowed to smoke unsupervised after Resident 1 demonstrated unsafe smoking behavior.
Review of the facility's undated "SMOKING POLICY," indicated smoking was not allowed inside the facility. Unsafe /dangerous behavior was defined as smoking in areas that were not designated, smoking with oxygen tank in close proximity, improper extinguishing and disposal of cigarette buds, etc. The only designated smoking area in the facility was the outside Gazebo. For residents who demonstrate unsafe/dangerous smoking behavior, smoking was only allowed in the Gazebo, at designated times and under the supervision of a facility staff member, smoking paraphernalia was to be kept locked at the nursing station.
The facility staff was aware of Resident l's unsafe smoking behaviors, including smoking in her room with oxygen in use (Resident 1 was given supplemental oxygen per physician's order.) Yet, it did not revise her plan of care to require supervised smoking and storage of smoking paraphernalia at the nurse's station, as mandated by the facility's own smoking policy for residents with unsafe smoking behaviors. This failure resulted in a fire that engulfed Resident 1 in her room, causing extensive thermal (burn) injuries and death.
Review of Resident 1's record indicated she was admitted to the facility on XXXXXXX 11 with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that causes coughing, wheezing, shortness of breath, and other symptoms) and emphysema (condition in which the air sacs of the lungs are damaged and enlarged, causing difficult breathing).
Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 2/10/17, indicated she had severe impairment in memory and in daily decision-making skills. Resident 1 had a cognitive loss/dementia care plan dated 3/14/13, indicating she had changes in short and long term memory recall and was moderately impaired in daily decision making skills. |
| 070000074 |
CYPRESS RIDGE CARE CENTER |
070013241 |
B |
1-Jun-17 |
N35911 |
22070 |
F203 -- 483.15(c)(3)-(6)(8) NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE
(c) (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (b)(5) of this section.
(c) (4) Timing of the notice.
(i) Except as specified in paragraphs (b)(4)(ii) and (b)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (b)(1)(ii)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (b)(1)(ii)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (b)(1)(ii)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (b)(1)(ii)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
(c) (5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
(c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at ? 483.70(l).
The facility improperly transferred Residents 1, 2, and 3 to another long term care facility even though the residents' needs could be met at the transferring facility, the residents continued to need the services provided by the transferring facility, the safety of the transferred residents and the other residents was not endangered, and the residents had resided in the transferring facility for more than 30 days. In addition, the facility failed to notify the residents in writing at least 30 days prior to the transfer and failed to advise the residents of their rights to appeal.
1. Resident 1's clinical record was reviewed and indicated he was admitted to the transferring facility from a hospital in XXXXXXX 2013 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness) affecting his left side. His Face Sheet (a document providing a patient's information at a glance) indicated he was his own responsible party (RP, person responsible for making medical decisions). Resident 1's Progress Notes, dated 8/6/13 and 9/5/13, indicated he would need long term care in a nursing facility. His Minimum Data Set (MDS, an assessment tool), dated 3/24/17, indicated he was cognitively intact.
Resident 1's physician order, dated 4/25/17, indicated he was to be transferred to another facility located over 200 miles away for continued physical and occupational therapy. There was no documentation in his clinical record indicating the transfer had been discussed with the resident prior to the transfer on XXXXXXX17. There was no written notice of the transfer and there was no documentation indicating the resident had been advised of his rights to appeal.
Resident 1's Progress Note from the receiving facility, dated 4/25/17, indicated he was upset regarding the transfer and refused to be completely assessed at the time of his admission. His Progress Note, dated 4/26/17, indicated he did not know why he was forced to leave the transferring facility. His Progress Note, dated 4/27/17, indicated he did not think he was in the right facility, and he needed to "get out of this place."
During an observation and interview on 5/22/17, at 11:15 a.m., Resident 1 stated he was told about the transfer a few hours prior to his departure. He stated he did not want to leave the transferring facility, but he was told if he did not accept the transfer, he would be taken to a hotel where he could stay for a few days at the facility's expense and then he would be out on the street. Resident 1 also stated he was told he was being transferred to a different facility than the one where he is currently located. He stated he is very unhappy and he wants to return to the transferring facility.
2. Resident 2's clinical record was reviewed and indicated he was admitted to the transferring facility in 10/2016 with diagnoses including hemiplegia and hemiparesis affecting his left side and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). His Face Sheet indicated he was his own RP. Resident 2's Progress Notes, dated 10/25/16 and 2/1/17, indicated he was considering a transfer to a VA (Veterans Affairs) facility (facility provided by the federal government as part of the provision of benefits for veterans). His MDS, dated 1/28/17, indicated he was cognitively intact. Resident 2's Physical Therapy Notes indicated he was actively participating in physical therapy and he had just been provided with a custom-made leg brace necessitating additional treatment.
Resident 2's physician order, dated 4/25/17, indicated he was to be transferred to another facility located over 200 miles away for continued physical and occupational therapy. There was no documentation in his clinical record indicating the transfer had been discussed with the resident prior to 4/22/17. There was no written notice of the transfer and there was no documentation indicating the resident had been advised of his rights to appeal.
Resident 2's Progress Notes from the receiving facility, dated 4/25/17, indicated he was upset about the transfer. His Progress Note, dated 4/26/17, indicated he did not know why he was transferred, he had been "dropped off without his permission", he thought he had been tricked into transferring by the social service director (SSD) at the transferring facility, he had only been given two days notice of the transfer, and he had been told he was being transferred to a different facility than the one where he is currently located. He also was uncooperative, kicked the treatment nurse, and refused to participate in anything.
Resident 2's Progress Notes, dated 4/27/17, indicated he thought his rights had been violated, he had been lied to, and he was mistreated. His Progress Note, dated 5/5/17, indicated he complained about everything, was unable to relax, did not trust the facility, refused a change in medication, and refused physical and occupational therapy.
During an observation and interview on 5/22/17, at 10:30 a.m., Resident 2 stated he was told about the transfer two days before it occurred. He stated the SSD told him he had to leave because there were no long term beds available at the transferring facility and because the transferring facility was going to be a nonsmoking facility and he was a smoker. He stated he was not given anything in writing and was not advised he had any rights to appeal.
Resident 2 also stated when he asked to see the pictures of the proposed new facility, he was shown a different facility than the one where he is currently located. He stated he was told the transfer would occur at 6 a.m. However, he stated the van did not leave for another four and a half hours because the facility could not find his medications and Resident 3's wallet. Resident 2 stated he and Resident 3 were crying when they left.
Resident 2 also stated he had just gotten a new custom-made leg brace right before he left. The final fittings and adjustments and training regarding the use of the brace had not been completed before his departure.
Resident 2 stated when he arrived at the new facility, he noticed the facility was not the facility he had seen in the pictures and he advised the driver. He stated the driver told him the receiving facility had changed its name. He also stated Resident 1 refused to get out of the van and Residents 1, 2, and 3 stated they did not want to be there.
Resident 2 stated when he got into the new facility, the staff put a name band on his arm with the incorrect name. He stated the receiving facility said they were not expecting him. He stated the new facility would not give him the medications the transferring facility sent with him because they needed to get new orders and new medications from the receiving facility's pharmacy. He said he finally got them to take some medications out of their emergency kit.
Resident 2 stated he called ADM A at the transferring facility the next day and told him the three transferred residents wanted to come back. He stated he was advised there were no beds available. He stated he also called the SSD who told him he was instigating trouble.
Resident 2 stated he has been unhappy and depressed since he arrived at the new facility. He stated he feels bad and he feels like he was "pushed to the curb." He stated he is so depressed he does not participate in many activities or any rehabilitation. He also stated the weather where the new facility is located is too hot, the food, care, and decor were better at the transferring facility, and there is a lady at the new facility who sits in the hall all day and screams. He stated is very unhappy and he wants to return to the transferring facility.
3. Resident 3's clinical record was reviewed and indicated he was admitted to the transferring facility from a hospital in XXXXXXX 2017 with diagnoses including chronic heart disease (a chronic condition in which the heart does not pump as well as it should), cardiomyopathy (disease of the heart muscle), mitral valve disorder (a backflow of blood caused by a failure of the heart's mitral valve to close tightly), a pacemaker (a small device placed in the chest or abdomen to help control abnormal heart rhythms), and chronic kidney disease. His Face Sheet indicated he was his own RP. His MDS indicated he had moderately impaired cognition. Resident 3's Physical Therapy Notes indicated he was actively participating in physical therapy.
Resident 3's physician order, dated 4/25/17, indicated he was to be transferred to another facility located over 200 miles away for continued physical and occupational therapy. There was no documentation in his clinical record indicating the transfer had been discussed with the resident prior to 4/22/17 when the Progress Notes indicated he was reluctant to transfer. There was no written notice of the transfer and there was no documentation indicating the resident had been advised of his rights to appeal.
Resident 3's Progress Note from the receiving facility, dated 4/25/17, indicated he did not want to stay at the receiving facility and he would not participate in rehabilitation. His Progress Note, dated 4/26/17, indicated he was transferred for some unknown reason, he was upset about the transfer and depressed, no one told him why he had to leave the transferring facility, and he will do anything to leave the new facility. His Progress Note, dated 4/27/17 indicated he had only been given two days notice of the transfer, the SSD at the transferring facility had lied to him, he had not been given the option to stay, he had been told if he did not transfer, he would be out on the street, and he felt like he had been dumped. Later the same day, he complained of severe chest pain and was transferred to the emergency room.
Resident 3's Progress Note, dated 4/29/17, indicated he was readmitted from the hospital with new medication orders. His Progress Note, dated 5/1/17, indicated he was sent back to the hospital for abdominal pain and diagnosed with inflammation of the duodenum (the first part of the small intestine immediately beyond the stomach). After he returned later the same day, his Progress Note indicated he and Resident 2 met with the discharge planner and the ombudsman regarding the recent transfers and were advised referrals back to the transferring facility would be made.
Resident 3's Progress Note, dated 5/8/17, indicated he was transferred to the hospital again for abdominal pain where a hematoma (solid swelling of clotted blood within the tissues) in his abdominal wall and fluid were found. He returned two days later and was treated with medication and fluid restriction.
Resident 3's Progress Notes, dated 5/12/17, indicated he was transferred to the hospital for pain and shortness of breath. An ultrasound (sound or other vibrations having an ultrasonic frequency used in medical imaging) revealed cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) and bilateral renal cysts (lesions on both kidneys).
Resident 3's Progress Note, dated 5/17/17, indicated he does not like the new facility and he will not comply with medical orders until he is sent back. Later the same day, he signed himself out against medical advice, called emergency services, and went to the hospital. When he returned to the facility the next day, his Progress Note indicated he will continue to call emergency services until he is sent back to the transferring facility.
During an observation and interview 5/22/17, at 10:30 a.m., Resident 3 stated shortly after he was admitted to the transferring facility in 1/2017, he was told he could stay as a long term resident. He stated he was told about the transfer two days before it occurred. He stated the SSD told him he had to leave because there were no long term beds available at the transferring facility. He stated he was not given anything in writing and was not advised he had any rights to appeal. He also stated when he asked to see the pictures of the proposed new facility, he was shown a different facility than the one where he is currently located. He stated he was told the transfer would occur at 6 a.m. However, he stated the van did not leave for another four and a half hours because the facility could not find his wallet and Resident 2's medications. Resident 3 stated he and Resident 2 were crying when they left.
Resident 3 stated on the trip to the new facility, the van driver stopped at a fast food restaurant for lunch. He stated he and Resident 1 could not eat the food because they were on special diets. He also stated shortly before his arrival at the new facility, the van went over a bump and he wet his pants and was very embarrassed.
Resident 3 stated when he arrived at the new facility, he noticed the facility was not the facility he had seen in the pictures. He stated the van driver told him the receiving facility had changed its name. He also stated Resident 1 refused to get out of the van and Residents 1, 2, and 3 stated they did not want to be there.
Resident 3 stated he has been unhappy, depressed, and anxious since he arrived at the new facility. He stated the day after he arrived he was so anxious he thought he was having a heart attack so he went to the hospital. He stated he feels bad and he feels like he was "pushed to the curb." He also stated he has never been treated so badly in his life.
During an interview with the SSD, from the transferring facility, on XXXXXXX 17, at 9:15 a.m., she stated Resident 1 wanted a change of scenery and agreed to go. She stated Resident 2 was a smoker and when the facility became nonsmoking he was told he had to go. She stated the three residents knew each other and were transferred to a sister facility over 200 miles away because none of the other local facilities were accepting long term residents. She also stated the social services assistant (SSA) mistakenly told the three residents they were going to a different smaller facility.
During an interview with the SSA, from the transferring facility, on XXXXXXX 17, at 11:40 a.m., she stated Resident 2 asked her to show him pictures of the proposed new facility. She mistakenly showed him pictures of the wrong facility. The pictures she showed him were of a facility with 100 residents. The facility the residents were actually transferred to had 200 residents including psychiatric patients.
During an interview on 5/16/17, at 12:30 p.m., administrator A (ADM A), from the transferring facility, and the SSD reviewed the three residents' clinical records and stated they could not find any documentation indicated the residents consented to the transfers other than their signatures on the transferring documents signed at the time of discharge. ADM A also stated the facility has no policies regarding transfers.
During an interview on 5/22/17, at 2:40 p.m., licensed vocational nurse E (LVN E) stated he performed the admission assessment at the receiving facility on Resident 3. He stated he was helping another LVN who was performing the admission assessment on Resident 2. He stated both residents were assigned to the same room and were very upset about the transfer. LVN E stated both residents thought they were transferred to the wrong facility and both residents were surprised they were transferred at all. He also stated once a resident was transferred, new orders need to be obtained and medications need to be ordered from the receiving facility's pharmacy.
During an interview on 5/23/17, at 8:45 a.m., director of admissions C (DA C), from the receiving facility, stated she first received a request for transfer from the transferring facility on XXXXXXX 17. She stated the transferring facility wanted to transfer four residents but she told them the receiving facility could only accept three residents. She stated the receiving facility thought Residents 1 and 3 and another resident were being transferred. She stated the transferring facility actually transferred Residents 1, 2, and 3.
During an interview on 5/23/17, at 9:10 a.m., ADM B, from the receiving facility, stated he talked to the three transferred residents shortly after their arrival. He stated they were very upset they were transferred and they wanted to go back to the transferring facility or go to the other facility they had seen in the pictures. ADM B stated he told them the facility in the pictures knew nothing about them because all of the communication had occurred between the transferring facility and the receiving facility. He stated he told the residents he would speak to the transferring facility about a return transfer. ADM B stated when he last spoke to the transferring facility they were attempting to get enough staff so they could accept the three residents back.
During an interview on 5/23/17, at 12:35 p.m., with the activities director (AD)/discharge planner (DP), from the receiving facility, she stated the three transferred residents do not participate in many activities. She stated they primarily keep to themselves. She stated she called the transferring facility's DA D and she agreed to take Residents 2 and 3 back. The AD/DP stated she expects the two residents to be transferred back on XXXXXXX 17 and she will call DA D about the potential transfer of Resident 1. She also stated she told DA D the transfers of the three residents to the receiving facility were not appropriate since the transfers violated the residents' rights. She stated she also called the local ombudsman and told him the transfers were not appropriate. The AD/DP stated DA D asked her to have Resident 2 sign a "no smoking" agreement but he refused.
The facility improperly transferred three residents to another long term care facility, failed to notify the residents in writing at least 30 days prior to the transfer, and failed to advise the residents of their rights to appeal.
These violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000074 |
CYPRESS RIDGE CARE CENTER |
070013408 |
B |
7-Aug-17 |
20P111 |
3847 |
F226, 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES
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 facility failed to implement their abuse policy when Resident 1 had an emotional abuse allegation which was not reported to the California Department of Public Health (CDPH).
During an interview with Resident 1, on 7/27/17 at 1:25 p.m., he stated he felt he was mentally abused when he heard staff was laughing about his bowel movement (BM). Resident 1 stated he talked to the admission coordinator (AC) the next day after the incident happened. Resident 1 stated he was in the hallway when he heard staff saying, "Oh my God! Look at the size of that."
During an interview with the AC, on 7/26/17 at 1:30 p.m., she stated when Resident 1 talked to her, he was upset, mad, and alleged certified nursing assistant A (CNA) A purposely did not clean up the BM to make fun of it. The AC stated, Resident 1 said, "I did not like anybody laughing at me."
During an interview with CNA A on 7/26/17 at 11:20 a.m., he stated Resident 1 had a big BM on 7/19/17. CNA A stated he forgot to clean the BM right away.
Resident 1's clinical record was reviewed. The resident was admitted to the facility on XXXXXXX10 with diagnoses of paraplegia (paralysis of the legs and lower body) and neurogenic bowel (lack of control which prevents the bowel from functioning correctly resulting in fecal incontinence, chronic constipation, or both).
Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/5/17, indicated he was cognitively intact.
Review of Resident 1's Progress Notes, dated 7/20/17 indicated Resident 1 was upset because CNA A did not clean his BM right away. The resident was very angry.
Resident 1's clinical record was reviewed and there was no documented evidence the incident was reported to the CDPH.
During an interview with the administrator (AD) on 7/31/17 at 10:05 p.m., he stated the AC did not report Resident 1 was upset because staff was laughing about the size of the BM. The AD acknowledged it was not reported to the CDPH. The AD stated all allegations of abuse should be reported to the state agency.
During a concurrent interview with the AC, she stated she reported the incident to the AD on 7/20/17 and did not report the incident to the CDPH.
Review of the facility's policy, "Reporting Abuse to State Agencies and Other Entities/Individuals", dated 12/2009, indicated a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be reported to the State licensing/certification and to the local Ombudsman within twenty-four hours of the occurrence of such incident.
Therefore, the facility failed to implement their abuse policy when Resident 1 had an emotional abuse allegation which was not reported to the CDPH.
The violation of this regulation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000032 |
CANTERBURY WOODS |
070013425 |
A |
15-Aug-17 |
F5T611 |
15209 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to ensure Resident 1 received adequate supervision and was free from accident hazards while riding in the facility's bus. On 7/11/17 at approximately 12:30 p.m., Resident 1 did not have a seatbelt and shoulder harness in place and fell out of her wheelchair onto the floor when the driver was making a left hand turn. She sustained a laceration to her right knee requiring sutures, and abrasions to the right side of her head and her right shoulder. On 7/19/17, Resident 1 was placed under Hospice care (end of life) to control her pain. During a telephone interview on 7/25/17 at 8 a.m., Resident 1's family member stated Resident 1 expired in the evening on XXXXXXX 17.
Review of the facility's job description titled "Driver II" dated 9/20/15, indicated the driver is responsible for the scheduling and safe transportation of residents. One of the primary responsibilities listed was to "inform residents that they must wear seatbelts during transportation."
Review of the facility's Policy and Procedure dated 7/14/17 indicated the bus driver will attach the shoulder and lap seatbelt harness extension (Sure-Lok) to the seatbelt harness anchored to the passenger bus and the attendant will apply the safety belt harness so that the lap portion of the safety belt rests over the hips before the bus is in motion.
http://sure-lok.com/products/occupant-restraints (Web based Internet site) indicated a warning: occupant restraints are not wheelchair securements. Always secure the occupant in the vehicle with a complete occupant restraint system, consisting of lap and shoulder belts.
https://www.transit.dot.gov/regulations-and-guidance (Web based Internet site) Section 38.23(d) of the Department of Transportation (DOT) American Disabilities Act (ADA) regulations requires all ADA-compliant buses and vans to have a two-part securement system, one to secure the wheelchair, and a seatbelt and shoulder harness for the wheelchair user. (On 7/21/17 at 11 a.m., an observation of the facility's bus was conducted, accompanied by the driver. A shoulder/lap extension was visible attached to the wall on the left side of the bus.)
Clinical record review for Resident 1 was initiated on 7/21/17. Resident 1 was admitted to the facility on XXXXXXX 14 with diagnoses including muscle weakness, osteoporosis (brittle bones) and Parkinson's disease (a disease that includes symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking, and impaired balance and posture).
Review of Resident 1's Clinical Psychologist note dated 1/18/17 indicated Resident 1 was oriented to name, place, and time and was looking forward to celebrating her 100th birthday. Resident 1 was very involved in the current news reports.
Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 4/22/17 indicated she was alert and oriented (able to make herself understood) and required assistance from one to two staff members for all her activities of daily living (ADL).
Review of Resident 1's care plan problems indicated a "current" problem (not dated) to address her self care deficit in ADL care related to decreased mobility, involuntary movement, functional impairment, joint stiffness, and generalized weakness.
Review of the administrator's summary note dated 7/14/17 indicated "[Resident 1's] wheelchair had been safely secured onto the passenger bus floor; however [Resident 1] was not fastened onto the wheelchair using the shoulder and lap seatbelt harness extension... It appears [Resident 1] slipped forward, out of her wheelchair and onto the bus floor while the bus was in motion making a left turn... From interviewing the driver, the shoulder and lap seatbelt harness extension that was supposed to be used to fasten [Resident 1] onto her wheelchair was not fastened because the driver believed that the bus did not have the appropriate extension [a device used to secure the resident in her wheelchair during transportation]." When the director of administrative services tested the shoulder and lap seatbelt harness extension (Sure-Lok Lap Belt, Type-1 FE200842-2) (after the incident) on 7/11/17, he was able to ensure the buckle would remain locked and secured.
Review of the attendant's written interview statement dated 7/11/17 indicated she was watching Resident 1 several times (in the bus) to make sure she was comfortable. During one of her visual checks, she saw the resident on the floor. She stated the bus was moving when the incident occurred and "there was no seatbelt on the way to there but we put the seatbelt on the way back home (back to the facility)." The attendant seating diagram indicated Resident 1 was seated on the left side in the back of the bus and she was seated a few seats in front of Resident 1 on the right side of the bus, away from the resident.
Review of Resident 1's Emergency Physician Record dated 7/11/17 indicated Resident 1 sustained a five centimeter laceration to her right knee that required nine sutures, and abrasions and pain to her right shoulder and right forehead. Her X-ray report of her right knee dated 7/11/17 indicated her bones were osteoporotic (brittle bones) and the X-ray was limited due to the resident's inability to straighten her leg out (contracted: bent). Resident 1's X-ray results on 7/11/17 of her right shoulder indicated a possible fracture of the shoulder bone socket and to consider a computerized tomography (CT: a more detailed X-ray) scan. (Review of Resident 1's Care Plan Conference Summary dated 7/18/17, indicated Resident 1's family member did not want to put her mother through any further tests and declined to have the follow-up CT scan completed.)
Review of the Resident 1's Physician notes dated 7/14/17 showed after the resident slid out of her wheelchair on 7/11/17, she had marked decreased range of motion to her right shoulder and required the use of Tramadol to control her pain. A note dated 7/21/17 indicated the resident was "now comfortable with Roxanol (a form of Morphine), does not respond today and was on hospice care at the family's request for pain control." He documented the family was notified Resident 1's condition was unlikely to improve.
Review of a letter regarding the fall incident in the facility's bus on 7/11/17 from the administrator to Resident 1's family members dated 7/20/17, indicated, "I apologize for this oversight in our operations... I am sorry it took this accident for us to become aware of this shortcoming in our transportation practices. While we went to great efforts to safely lock and secure wheelchairs into place, we did not provide a shoulder and lap belt [extension]."
During an interview on 7/21/17 at 9:10 a.m., Resident 1's family member stated prior to the incident on 7/11/17, Resident 1 was wheelchair bound, had a good memory and was able to converse. A concurrent observation of Resident 1 was conducted during the interview. Resident 1 was in bed, lying on her left side. Her head was slightly elevated and she was receiving oxygen via a nasal cannula. Resident 1 did not respond to verbal commands and showed no voluntary movements.
On 7/21/17 at 9:20 a.m., an observation was conducted when licensed vocational nurse (LVN) A and the director of nurses (DON) removed Resident 1's right knee dressing. Sutures and steristrips (thin, adhesive strips used to hold wounds closed) were visible on the knee cap. A small amount of bright red blood was oozing from the center of the wound. Resident 1's legs were contracted (bent). Further observation showed slight bruising on Resident 1's right shoulder and outer forearm.
During an interview on 7/21/17 at 10:05 a.m., Resident 1's primary care physician (PCP) stated prior to Resident 1's fall on 7/11/17, the resident was alert and oriented and "sharp as a tack." He stated Resident 1 had a change in her condition after the fall on 7/11/17, it was the family's decision to place her on hospice (end of life comfort measures) to ensure the resident was pain free after the fall. The PCP stated today (7/24/17) the resident was unresponsive, and "snowed" (heavily sedated) to keep her as comfortable as possible and pain free.
During an interview 7/21/17 at 10:30 a.m., the bus driver stated the facility's bus had the capacity to transport 22 passengers without a wheelchair and 18 passengers if a resident is in a wheelchair. She stated on 7/11/17 while making a complete turn to the left, the attendant told her to stop the bus because Resident 1 fell out of her wheelchair. The driver stated Resident 1 was found in a fetal position (head facing down and the knees bent) on her right side. She stated the attendant and her lifted the resident back into the wheelchair, grabbed the first aid kit and placed a dressing onto the resident's right knee.
On 7/21/17 at 11 a.m., an observation of the facility's bus was conducted, accompanied by the driver. The passenger seats had the capability to apply seatbelts. The rear of the bus had the back seats folded up to make an area available for two residents in wheelchairs. A shoulder/lap extension was visible attached to the wall on the left side of the bus. A concurrent interview was conducted with the driver. She stated the shoulder extension was to be pulled across the wheelchair and attached to the back seatbelt buckle. The driver stated she did not put the shoulder/seatbelt extension on during Resident 1's trip on 7/11/17 because she was unable to locate the shoulder and lap extensions. She stated (after Resident 1's incident) she "looked and looked for the shoulder/seatbelt extension, she finally found it." She confirmed the bus equipment and safety of the residents are the responsibility of the driver.
During an interview on 7/21/17 at 11:10 a.m. the attendant stated she had accompanied Resident 1 in the bus on 7/11/17. She stated she hooked Resident 1's wheelchair to the floor board in the bus per the driver's request. The attendant stated there was a shoulder/seatbelt strap in the bus but she was told by the driver the strap was not to be used. She stated on 7/11/17, she sat on the right side of the bus in front of Resident 1 and kept turning around to check on the resident. The attendant stated when the bus was making a turn, she turned around and she saw Resident 1 on the floor. She did not hear any noise prior to seeing the resident on the floor. The attendant stated she removed her own seatbelt and told the driver to stop the bus so they could help the resident. She said the driver and her lifted Resident 1 back into her wheelchair and then applied the shoulder strap extension.
On 7/25/17 at 10:30 a.m., a telephone interview was conducted with the director of administrative services. He stated after Resident 1's fall out of her wheelchair in the bus on 7/11/17, he located the shoulder and lap seat harness extension (Sure-Lok) inside a bag in the back of the bus. The director of administrative services stated he was able to buckle the harness extension safely and securely. He stated the driver was aware of the location of the shoulder and lap seat harness extension.
During an interview on 7/21/17 at 11:30 a.m., Resident 1's family member was interviewed. He stated Resident 1 was placed under hospice care after the accident on 7/11/17 because the resident was in excruciating pain and the family felt if the resident was under hospice care she could receive the appropriate amount of pain medication to keep the resident pain free.
Review of Resident 1's Weekly Summary reports dated 6/28/17 and 7/5/17, indicated she was in no pain; however on 7/12/17 her pain level was a score of three (on a scale of 0 -10 with 0 having no pain to a 10 being the worst) and on 7/19/17 she had frequent pain at a moderate level in her shoulder.
Review of Resident 1's July 2017 Physician Order Sheet indicated the following medication orders:
a. on 6/17/15: administer Tylenol (pain medication) 325 milligrams (mg) two tablets by mouth every six hours as needed for general discomfort;
b. on 2/10/17: administer Tylenol 325 mg two tablets by mouth twice a day for pain;
c. on 7/13/17: administer Tramadol (a narcotic pain medication) 25 mg by mouth every four hours as needed for moderate pain and 50 mg by mouth for severe pain; and
d. on 7/19/17: administer Morphine (a narcotic pain medication) five mg every hour by mouth or sublingual (under the tongue) as needed for mild pain, 10 mg every hour by mouth or sublingual for moderate pain and 20 mg every hour by mouth or sublingual for severe pain.
Review of Resident 1's July 2017 Medication Administration Record (MAR) indicated after her fall on 7/11/17, she required stronger and frequent pain medication. The following pain medication was administered:
a. Routine Tylenol 325 mg two tablets by mouth twice a day from 7/1-7/21/17;
b. As needed Tylenol 325 mg two tablets by mouth on 7/13/17, 7/17/17 and 7/19/17;
c. Tramadol 25 mg by mouth: 10 doses from 7/13-7/17/17
d. Tramadol 50 mg by mouth: 10 doses from 7/13-7/19/17;
e. Tramadol 100 mg by mouth: 3 doses from 7/17-7/19/17;
f. Morphine 5 mg by mouth: 2 doses from 7/19-7/20/17;
g. Morphine 10 mg by mouth: 5 doses from 7/19-7/21/17; and
h. Morphine 20 mg by mouth: 11 doses from 7/20-7/21/17.
Review of Resident 1's Nurses Notes indicated:
a. On 7/13/17 at 12 p.m., Resident 1 was put back to bed due to complaining of pain. DON documented the pain medication (Tylenol) was not covering the pain and the physician was contacted and ordered Tramadol 25 mg every four hours for moderate pain and 50 mg every four hours for severe pain;
b. On 7/17/17 at 12 p.m., Resident 1's pain level was a nine. The DON notified the physician and an order was obtained to increase the administration of Tramadol to 100 mg; and
c. On 7/18/17 at 11:45 a.m., Resident 1 told the DON she wanted to be under hospice care because, "I do not want to be in any pain."
The facility's failure to adequately supervise the resident and/or provide a resident environment as free from accident hazards as possible, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080009159 |
B |
20-Mar-12 |
B6Q311 |
2394 |
Health and Safety Code 1418.91 (a) (a) A long term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report a known allegation of abuse to the Department within 24 hours, in accordance with the facility's policy and procedures, and in accordance with California Health and Safety Code 1418.91 (a). On 1/4/12, the Department received an anonymous report of alleged abuse to Resident A by a Certified Nurses Aide (CNA). An investigation was initiated on 1/5/12, and the resident record was reviewed.Resident A was a 73 year old female admitted to the facility on 2/12/11, according to the Record of Admission.According to the nurses notes dated 1/2/12, at approximately 7 P.M., CNA 2, reported to the licensed nurse (LN 1) that Resident A had "swelling and bruising" to the middle fingers of her right hand. Per the same notes, LN 1 documented that she spoke to Resident A, who stated that CNA 1, "Grabbed my [Resident A] hand and popped my fingers." On 1/5/12, at 2:15 P.M., an interview with Resident A was conducted in her room. Resident A identified CNA 1 as the nurse who, "Popped my fingers." Resident A then held up her right hand. The resident's two middle fingers of her right hand were dark blue from the base of her palm to the tips of her fingers, and the two middle fingers were swollen.On 1/5/12 at 3 P.M., LN 1 was interviewed. LN 1 stated that on 1/2/12, immediately after speaking with Resident A about the allegation, she reported the allegation to the Director of Nursing (DON) and Administrator, according to the facility policy. When asked why she had not reported the incident immediately to the Department, she stated that she believed the DON would follow up.On 1/5/12 at 3:15 P.M., a joint interview with the DON and Administrator was conducted. According to the DON, he received notification of the abuse allegations from LN 1 on 1/2/12, but failed to report it to the Department in accordance with the facility's policy because he, "Had not investigated it."According to the facility's undated abuse policy, the facility will, "Ensure all residents will not be subjected to intentional acts of abuse... and reporting will be telephoned immediately to the appropriate agencies or as soon as 'practically possible', not to exceed 24 hours." |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011255 |
B |
06-Feb-15 |
5FO411 |
4050 |
F-206 ?483.12(b)(3) Permitting Resident to Return to Facility A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident- (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services. The facility failed to re-admit 1 of 24 sampled residents (40) to the facility.As a result, Resident 40 had no behavior issues during his stay in the Emergency Room and was admitted to the hospital due to the facility's refusal to accept the resident for re-admission. Findings: Resident 40 was re-admitted to the facility on 7/17/14, with diagnoses to include metabolic encephalopathy (a temporary or permanent damage to the brain), according to the facility's Face Sheet. On 9/10/14 at approximately 5:40 P.M., Resident 40 was transferred to the emergency room for the evaluation of his behavior and adjustment of his medications, per the Resident Transfer Record. On 9/11/14 at approximately 8 A.M., the Ombudsman handed a note to the survey team that he received a call from the acute hospital regarding the facility's refusal to re-admit Resident 40. On 9/11/14 at 3 P.M., an interview with the acute hospital staff was conducted. EDRN 3 stated Resident 40 was admitted to the Emergency Room for behavior issues. EDRN 3 stated throughout Resident 40's 18 hour stay in the Emergency Room, the resident demonstrated no behavior issues. The EDRN said, "He calls for attention and he's not thrashing." The EDRN 3 further stated, that Resident 40 would be admitted to the acute hospital. EDRN3 also stated, that the nursing home would not accept the resident back. On 9/12/14 at 4 P.M., a record review of the Emergency Records was conducted.EDRN 1 documented on 9/10/14 at 9:15 P.M., that a call was made to the facility requesting to send Resident 40 back. EDRN 1 documented, "...AIT...unwilling to take back patient due to his behavior." EDRN 1 further documented the AIT was informed Resident 40's current behavior was cleared by the hospital's psychiatrist and that the psychiatrist cleared Resident 40 for discharge back to the facility." On 9/12/14 at 9:25 P.M., EDRN 2 documented he spoke to LN 6. EDRN 2 informed LN 6 that Resident 40 was medically and psychiatrically discharged from the Emergency Room. EDRN 2 documented LN 6, "Stated, we are not accepting the patient back to our facility I have spoken to the administrator and we are aware of the penalties and fines for patient dumping and do not care." On 9/18/14 at 3:11 P.M., LN 6 was interviewed. LN 6 recalls the telephone conversation with an EDRN and confirmed she informed the EDRN that the facility would not re-admit Resident 40. LN 6 stated "they" told me they would not accept Resident 40. When asked who "they" were , LN 6 stated, "The AIT, ADM and VPCS were in the room." LN 6 recalled that it was the AIT who responded first. On 9/18/14 at 3:29 P.M., a telephone interview with the AIT was conducted. The AIT recalled the telephone conversation with the ED staff. The AIT stated the facility conducted an Interdisciplinary Team Meeting on 9/9/14 at 2:30 P.M., to transfer the resident to the Emergency Room due Resident 40 "...posed a danger towards others." The AIT was informed that there was no documentation of the Interdisciplinary Team Meeting in Resident 40's clinical record. The AIT stated, "I prefer not to make a comment on this case." According to the facility's undated policy and procedure entitled, Bed Hold, "In the event that the resident...meets the standards for skilled nursing care...the Facility will readmit the resident to the first available bed in a semi-private room." The ADM was aware of the complaint lodged by the hospital regarding the refusal to readmit Resident 40 on 9/10/14. The violations had a direct relationship to the health, safety, or security of patients. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011257 |
B |
06-Feb-15 |
K4YL11 |
25400 |
The citation narrative for this penalty will not fully display due to narrative length limitations. Please send a request toÿÿCHCQdata@cdph.ca.govÿto obtain a full copy of this citation narrative.ÿ
F 325
?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.
The facility failed to implement a comprehensive systematic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for 5 of 20 sampled residents (80, 45, 30, 82, 20) and 2 of 4 extended sampled residents (42, 35).
The facility failed to ensure two residents identified as nutritionally high risk at the time of admission was assessed by and/or Registered Dietitian recommendations were communicated to the physician timely to meet the assessed nutritional needs (Resident 80, 42).
The facility failed to identify and address unplanned, gradual, progressive weight loss prior to becoming an unplanned significant weight loss. In addition, the facility failed to notify the physician of the unplanned, significant weight loss which had the potential for delayed nutrition intervention to address the weight loss by the practitioner responsible for the care of the resident (Resident 45).
The facility failed to ensure an effective monitoring system of parameters of nutritional status in order for facility staff, the Registered Dietitian, and/or the Interdisciplinary team to identify and determine underlying causes of a slow progressive weight loss (Resident 30).
The facility failed to ensure care staff was knowledgeable on how to implement a physician's order for "nourishment" (Resident 82, Resident 35). Lacked an effective system to ensure timely Registered Dietitian (RD) assessments and/or follow up, a system to ensure RD recommendations were communicated to the physician in a consistent and timely manner. In addition, the facility failed to have a system to document the percentage consumed of a planned nutrition intervention for an identified concern as related to evaluating and nutrition assessment and compared to assessed needs. (Resident 82, 20, 35)
The above cited systems failures had the potential to negatively impact and compromise the medical status of all residents residing in the facility.
Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4)
Findings:
1. On 9/11/14 at 8:05 A.M., Resident 80's medical record was reviewed. Resident 80 was re admitted to the facility on 7/23/14 with diagnoses that included protein calorie malnutrition, dysphagia (difficulty swallowing) and fed via a G tube (a tube inserted to the stomach that delivers nutrition), and multiple pressure ulcer's (a lesion that results in damage to the underlying tissue) including stage IV (full thickness tissue loss with exposed bone, tendon or muscle).
On 7/23/14 Resident 80's physician prescribed Fibersource HN (a liquid nutrition formula) at 50 cc [cubic centimeter]/HR [hour] x 20 hrs. to provide 1000cc/1200 kcal (calories) via Peg tube (a tube inserted through the wall of the abdomen directly into the stomach) and enteral pump (a device that controls the amount of nutrition delivered). Start at 9 PM off at 5 pm until dose completed. Flush [infuse water] GT w/165 ml [milliliters] H20 [water] q [every] 4 h [hour].
On 7/30/14, 7 days after admission, a registered dietitian (RD) completed an "Enteral Feeding Assessment", dated 7/30/14 for Resident 80. The RD noted Resident 80 was 56" (inches) tall and weighed 71 pounds (lbs.). Per the RD, Resident 80's ideal body weight was "81 lbs.90 lbs.99 lbs.". The RD noted the current formula prescription had not met Resident 80's estimated caloric needs. The RD noted the formula prescription provided 1,200 calories, and 54 grams of protein. The RD had assessed Resident 80's calorie needs at 1,307 1,745 calories a day, 39 47 grams of protein a day. The RD recommended changing the formula to Jevity 1.5 at 50 ml x 20 hr. to provide 1,500 calories a day.
On 8/4/14 there was a physician's order to carry out the RDs recommendations of Jevity 1.5 at 50 ml x 20 hours to provide 1,500 calories a day, 4 days after the RD identified Resident 30 had not been receiving sufficient calories for 7 days, compared to assessed needs.
According to the August medication administration record (MAR), Resident 80 received the above formula prescription at 1, 500 calories per day from 8/4/14 to 8/19/14. On 8/19/14, the physician order changed back to the original admission tube feeding order that provided 1,200 calories and 54 grams of protein a day.
The RD had not followed up from 7/30/14, until almost a month later, on 8/28/14. On 8/28/14, RD 2 noted that the formula changed back to 1200 calories a day since 8/19/14, 9 days earlier. Per the Weekly/Monthly Weight Trend Assessment (initiated on 7/24/14), Resident 80 who was under her ideal body weight dropped two pounds from 71 lbs. to 69 lbs., as of 8/11/14.
On 8/28/14, RD 2 noted, "goal gradual wt. [weight] gain to at least 90# (pounds; lbs.)/ 1 2 #/week and heal pressure sore. Increase Fibersource HN = 70 ml x 20 hr. to provide 1, 680 calories a day, and 74.2 grams of protein a day."
The RD noted the recommendation in the dietary/nursing communication log book on 8/28/14.
On 9/9/14, eleven days later, after the RD was aware that Resident 80 had not been receiving sufficient caloric intake, compared to assessed needs per RD 2, and lost two pounds, RD 3 conducted a follow up nutrition assessment.
RD 3's 9/9/14 note indicated, "Recommend Prostat [a protein supplement] 30 ml q day ...".RD 3 logged the Prostat recommendation in the dietary/nursing communication log.
On 9/11/14 at 11:03 A.M, RD 3 stated, "I recommended the Prostat because the resident has multiple wounds and the Prostat will help with wound healing."
On 9/11/14 at 11:15 A.M., the Assistant Director of Nurses (ADON) reviewed the dietary/nursing communication log. ADON observed nurses' initials and date of 8/4/14 next to the RD recommendation, and stated, "That means that is the day the nurse communicated the recommendation to the doctor."
Concurrently, ADON reviewed the RD recommendations located in the communication log dated 8/28/14 (a recommendation to modify the formula again for further increase in calories), and on 9/9/14 (for Prostat to increase protein), and stated, "These were not communicated to the physician because there is not a nursing initial." ADON stated it was a charge nurse's responsibility to ensure the RD recommendations were communicated to the physician.
On 9/12/14 at 7:40 A.M, the current Director of Nursing (CDON) reviewed the RD recommendations which were logged in the dietary/nursing communication log on 8/28/14, and 9/9/14, and acknowledged that there was no documentation to indicate they were communicated to the physician. The CDON verified that the RD recommendation made on 7/30/14, and communicated to the physician on 8/4/14 to address insufficient calories from the formula was not timely. The CDON stated she was employed at the facility since mid august 2014 and was not aware of the facility's expectations in terms of timeliness for communicating RD recommendations to the physician. The CDON stated it would be her expectation as a nurse to have the recommendations communicated immediately, at least by the end of every shift.
Resident 80 had worsening pressure sores since her re admission to the facility on 7/23/14. A record review of the wound care physician's documentation, from 7/30/14 through 9/2/14, indicated the progress of the following pressure ulcers:
1. Left big toe UTD [unable to determine the depth/stage of the wound], which measured 1.5 x 1 cm [centimeter; 2.54 cm equals 1 inch]
2. Right plantar [sole of the foot] healing scab, which measured 1 x 1.5 cm
3. Right ankle lateral [sides], which measure 1 x 1 x 0.1 x 0.2, slough 20% and debrided [surgical removal of dead tissue]
4. Left hip/trochanter [area for attachment of muscles to the thigh bone] stage 4, which measured 0.5 x 0.5 x 0.3 .x 0.5 and debrided;
5. Sacrum [triangular bone in the lower back] Stage 4, which measured 0.8 x 0.8 x 0.1 x 0.2, not healed, but improving
6. Right Buttock/trochanter Stage 4, which measured 3.5x4. x 1.0 x 1.2, not healed, but improving.
On 8/5/14 the wound care physician re assessed Resident 80's pressure ulcers:
1. Right ankle lateral, 0.5 x 1 x 0.1 x 0.2, 20% slough
2. Right lateral trochanter 2 x 2.5 x 1 x 1.2, 30% slough
3. Right trochanter foot healing 1.5 x 1.5
4. UTD sacrum stage 4/5
5. Left ankle healing;
6. Right hip lateral 0.7 x 1 x 0.2 x 0.3 30%;
On 8/25/14:
1. Sacrum Stage 4, measured 3 x 0.5 x 0.1 x 0.2, not healed
2. Right trochanter Stage 4 2.5 x 1.5 x 0.8 x 1.0 (increased in size and stage)
3. Right big toe 1x0.5x.1x0.2
4. Right ankle 1 x 1 x 0.1 x 0.2
5. Left big toe 0.5 x 0.5 x 0.1 healing
6. Right 2nd toe 0.5 x 0.5 x 0.1 scab, healing (new)
9/2/14
1. Right ankle 0.3 x 0.3
2. Right foot plantar 1 x 1 x 0.1
3. Right trochanter stage 4, 2 x 3 x 1 x 1.5
4. Sacrum Stage 4 measured at 3 x 4 x 0.1 x 0.2
On 9/15/14 at 8:32 A.M., Resident 80's medical record was reviewed from a re admission to the facility which occurred on 6/26/14.
According to the nutrition care plan which was developed on 6/26/14, and was effective through 9/26/14, Resident 80's goal was for a weight gain of 1 2 pounds a week to reach 100 pounds.
In a physician's order, dated 6/26/14, "Fibersource HN @ 40 cc/ x 20 hr. till RD eval [evaluates]..."
On 9/15/14 at 8:48 A.M., RD 2 reviewed the above order, and Resident 80's medical record, and stated that the physician consult order was not addressed by a RD.
According to physician orders, dated 7/14/14, the physician repeated the order for an RD consult, "Dietary Consult."
On 9/15/14 at 8:48 A.M., RD 2 reviewed the above order and stated that the physician consult order was not addressed by an RD. RD 2 stated that the RD was not informed that there was a physician's order for a dietary consult. The following note was observed in the Licensed Personnel Weekly Progress Notes, dated 7/14/14, "Dietary consult ordered & carried out; low protein and albumin." RD 2 verified that the dietary consult was not completed and addressed by a registered dietitian.
A Licensed Personnel Weekly Progress Notes, dated 7/18/14 at 1100, indicated Resident 80 was transferred to a hospital due to vomiting and temperature for further evaluation.
Resident 80 was re admitted to the facility on 7/23/14. Per physician progress notes, dated 7/25/14, "...readmit from [name of hospital] ...recent bacteremia [bacteria in the blood], and has MRSA [infection is caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used] wound infection..."
The facility's policy and procedure entitled, "Nutritional Screening/Assessments/Resident Care Planning," (undated) indicated, "Policy: The resident's nutritional status and his nutritional needs will be assessed. A nutritional program specific to his needs will be planned and implemented, and then reassessed periodically for progress..."
2. On 9/9/14 at 9:33 A.M., Resident 45's medical record was reviewed. Resident 45 was admitted to the facility on 5/10/13 with diagnoses that included Alzheimer's Disease (brain disease), high blood pressure, and psychosis (a severe mental disorder) per the Face Sheet.
On 5/10/13 the physician ordered a mechanical soft, chopped meat diet.
According to the weights documented on Resident 45's Weekly/Monthly Weight Trend Assessment;
1/1/14149.2 lbs.
2/2/14151 lbs.
3/2/14151 lbs.
4/1/14146.6 lbs.
5/1/14143 lbs.
6/1/14142 lbs.
7/1/14139 lbs.
8/1/14135 lbs.
8/11/14136 lbs.
8/18/14135 lbs.
9/1/14136 lbs.
9/8/14135 lbs.
An interdisciplinary meeting (IDT) note indicated, dated 8/4/14, "IDT met today to discuss weight loss ...weight loss of 16 lbs. 10.6% x 6 months ..." The same IDT note documented an intervention to add fortified (adding calories to food) to the diet order, and to change the monitoring of weight from monthly to weekly. RD 1 verified that the IDT had not documented possible underlying causes for the weight loss.
On 9/9/14 at 10:53 A.M., the facility's consultant registered dietitian (RD 1) stated that Resident 45 was not on a physician prescribed weight loss regimen. RD 1 verified that the kitchen was providing Resident 45 a fortified diet since 8/4/14 as a result of the IDT meeting. RD 1 verified that 8/4/14 was the first intervention by the facility in regard to weight loss since January 2014.
RD 1 stated that it was the facility's process to obtain a physician's order for a fortified diet, but was unable to find a physician's order.
Concurrently, RD 1 reviewed Resident 45's nutrition care plan and verified that it had not been updated and revised to reflect the status of significant weight loss, the intervention of a fortified diet, and had not included a root cause analysis for the significant change in condition, and should have.
On 9/9/14 at 1:43 P.M., a licensed nurse (LN 2) verified that there was no physician's order for the fortified diet, and stated, "There should be a physician order [for fortified diet]."
On 9/10/14 at 8:34 A.M., LN 11 reviewed Resident 45's medical record which included the IDT note from 8/4/14, and a quarterly nutrition assessment dated 8/12/14 which noted a 11.8 % significant weight loss in 6 months. LN 11 verified there was no documentation that the physician had been notified of the significant weight loss.
On 9/15/14 at 9:26 A.M., RD 2 reviewed Resident 45's Weekly/Monthly Weight Trend Assessment (beginning on 1/1/14), and stated, "An RD should have seen the resident at the beginning of June because she had three consecutive months of slow weight loss."
On 9/8/14 at 5:31 P.M., the Administrator stated that the facility had not had Registered Dietitian services available at the facility from 6/1/14 to 6/25/14.
The facility failed to identify and address an unplanned slow weight loss prior to becoming a significant weight loss. The facility failed to notify the physician once there was significant weight loss. The facility failed to update and revise the nutrition care plan to include an analysis of the underlying cause of the change in condition (significant weight loss), and failed to document a planned nutrition intervention of the addition of "fortified" to the diet with measurable time frames to monitor for effectiveness of the nutrition plan of care.
The facility's policy and procedure (P & P) entitled, "Nutrition Care; Subject: Weight Variance Policy and Procedure," (undated) indicated, "6. Charge nurses will notify the physicians...of significant weight changes via fax/phone ...with responses documented in the resident's/patient's medical record/computer and necessary disciplines notified of any new changes, 7. ...Discussion of possible causes for the weight changes...will be documented in the medical record with the heading of Weight Variance Committee..., recommendations requiring a physician order will be initiated by the responsible discipline, followed up by nursing, and the care plan updated to reflect interventions..."
The facility's P & P entitled, "Diet Orders" (undated) indicated, "Policy: Diet orders as prescribed by the Physician will be provided by the dietary department..."
The facility's P & P entitled, "Diet Record Maintenance" (undated) indicated, "Purpose: To ensure that the Facility provides residents with meals that meet the nutritional and consistency requirements per physician orders..., Policy;
The dietary department will maintain a system to record dietary information necessary to use on the resident's tray care ..., Procedure; I. The diet record system will contain the following information to be reflected on the resident's tray card: F. Physician ordered supplemental feeding or extra nourishments provided to the resident beyond those listed on the therapeutic diet extension sheet..."
3. On 9/9/14 at 3:15 P.M., Resident 30's medical record was reviewed. Resident 30 was re admitted to the facility on 3/6/12, with diagnoses that included Alzheimer's Disease (brain disease), esophageal reflux (stomach contents back up into the esophagus), and an allergy to nuts per the Face Sheet.
According to Resident 45's Weekly/Monthly Weight Trend Assessment the following were the documented weights;
1/1/14122.4 lbs.
2/2/14123.2 lbs.
3/2/14118.6 lbs.
4/1/14118.4 lbs.
5/1/14115 lbs.
6/3/14114 lbs.
7/1/14113 lbs.
8/1/14112 lbs.
9/2/14113 lbs.
On 9/10/14 at 8:30 A.M., a licensed nurse (LN 11) reviewed the above weights and stated that as of 5/1/14 the weight was a concern because it met one of the facility's criteria which was a three month consecutive slow weight loss, and should have been identified and referred to a weight variance committee by the interdisciplinary team (IDT). LN 11 reviewed the medical record and verified that there had not been an IDT meeting to determine, and address underlying causes for the slow progressive weight loss.
On 9/10/14 at 9:18 A.M., the facility's registered dietitian (RD 2) reviewed the above weights and stated that the facility should have identified and referred the slow progressive weight loss to a RD or the IDT beginning 5/1/14.
RD 2 reviewed the dietary notes and stated that there had not been a dietary follow up by either an RD, or dietary services supervisor (DSS), since 12/31/13. RD 2 verified that per the annual nutrition assessment, dated 12/17/13, the resident was noted as receiving a puree fortified diet, and the goal was to maintain weight at 121 pounds.
Concurrently, RD 2 stated that it would have been the facility's expectations for a DSS to have conducted a dietary quarterly follow up during March 2014, and June 2014, which were not done. RD 2 acknowledged that the purpose of the dietary quarterly reviews were to monitor for changes which could impact nutrition such as a decrease in diet intake and/or weight loss which would have resulted in a referral to the RD. RD 2 confirmed that a RD was unaware of Resident 30's unplanned, slow, progressive weight loss.
RD 2 was asked to review a label which was located on the front of Resident 30's medical record which indicated an allergy to nuts. RD 2 was then asked to review the dietary meal tray card for Resident 30, which was observed to not have indicated a nut allergy. RD 2 reviewed the meal tray card and stated, "The food allergy to nuts should be listed on the meal ticket." RD 2 reviewed the nutritional screening form completed by a DSS on 12/11/13 under the pre printed category of "Food Allergies", and acknowledged the DSS inaccurately documented "NKFA" (no known food allergy).
Concurrently, RD 2 reviewed the nutrition care plan which had an initial date of 3/6/12, with a date of "9/14" under the last re evaluated date of the nutrition care plan. The nutrition care plan which was currently in effect as of 9/9/14 at 3:15 P.M., noted under the approach column that Resident 30 was receiving a 2 cal med pass (oral nourishment for calories/protein) 60 cc BID (two times a day), as of 12/19/12. RD 2 acknowledged the nutrition care plan had not reflected the current nutritional status for Resident 30 as it had not reflected the resident's slow, progressive weight loss, and failed to note that the 2 cal med pass 60 cc BID was not a current intervention.
RD 2 stated, "Last evening I reviewed Resident 30's medical record and revised the nutrition care plan."
A review of the revised nutrition care plan indicated, "Resident goal; Maintenance Weight 108118 # [pounds]." There was no indication on the nutrition care plan that there was physician involvement, and/or conservator involvement in determining a weight maintenance goal of 108118 #, which would have been a potential 5 pound additional weight loss. A review of the physician's progress notes indicated the following, "6/23/14...weight loss of 8.4 pounds since 1/14 ..., 7/26/14 ...the nursing staff have not reported any acute problems. She is losing weight..., 8/19/14...the nursing staff are not aware of any new problems. She is not eating very well and since 01/01/14 she has had a weight loss of 10.4 pounds...plan:...monitor weight..."
The facility failed to implement policies and procedures (P & P) that would have involved a monitoring mechanism for facility staff to have identified the slow weight loss, and would have resulted in a referral to the RD and/or IDT meeting to determine potential underlying causes for the change in nutritional parameters, prior to becoming an unplanned significant weight loss. In addition, the facility failed to ensure the kitchen staff was aware of Resident 30's nut allergy.
According to the facility's P & P entitled, "Nutritional Screening/Assessment/Resident Care Planning", (undated), "Policy: The resident's nutritional status and his nutritional needs will be assessed. A nutrition program specific to his needs will be planned and implemented, and then reassess periodically for progress. Procedure:...All residents will be reviewed quarterly. The Dietary Services Supervisor [DSS] will also chart on any resident with changes in weight, eating habits ...as these problems arise. Change in eating habits..., weight and other problems will be recorded in the dietary progress notes and resident care plan. The [DSS] will complete the "Dietitian Assessment & Monitoring Sheet" on a daily basis and give this sheet to the Dietitian on each visit. This way the Dietitian will be aware of all dietary changes, weight changes..., The Dietary Service Supervisor and/or Dietitian will participate in resident care planning to contribute pertinent nutritional information to the medical and nursing team ..."
The facility's P & P entitled, "Diet Record Maintenance", (undated) indicated, "Policy: The dietary department will maintain a system to record dietary information necessary to use on the resident's tray cart. Procedure; 1. The diet record system will contain the following information to be reflected on the resident's tray card: G. Allergies..."
The facility's P & P entitled, "Tray Card System", (undated) indicated, "Policy: Each meal tray at breakfast, lunch and dinner will have a tray card which designates the resident's name, diet, food dislikes, food requests, allergies, beverage preference and portion size."
4. On 9/12/14 at 9:33 A.M., Resident 82's medical record was reviewed. Resident 82 was re admitted to the facility on 7/6/14 with diagnoses that included urinary tract infection and diabetes (elevated sugar in the blood).
Physician orders, dated 7/6/14, included an order for "nourishment."
On 9/16/14 at 11:00 A.M., RD 2 was asked what the physician's order for "nourishment" meant and she stated, "I don't know what that means. Means nothing."
On 9/16/14 at 1:47 P.M., LN 11 was asked how the physician order for "nourishment" was implemented. LN 11 stated, "Our nourishment is usually a healthshake." LN 11 then stated, "Nourishment means snacks. The kitchen will be implementing as snacks." LN 11 was asked to show the documentation to show a physician's order was implemented related to the "nourishment", and was unable to provide the documentation. RD 2 stated that an order for "nourishment" had not been communicated to the dietary staff/kitchen.
On 7/11/14, an RD completed a nutritional assessment for Resident 82. The RD noted that Resident 82's admission weight was 175 pounds, and the ideal body weight was "112 125 138" pounds. The RD assessed daily caloric needs based on a weight of 138 pounds for this 98 year old resident who weighed 175 pounds.
On 9/12/14 at 3:27 P.M., RD 2 (who had the contract with the facility) stated, "I teach them not to use ABW [adjusted body weight]."
On 9/15/14 at 2:44 P.M., RD 2 stated that healthshakes was started on 9/11/14 due to weight loss for Resident 82. RD 2 was asked how the facility monitored percentage consumed of a planned nutrition intervention which was provided for a specific identified problem (weight loss). RD 2 stated, "I usually just ask the resident and/or staff, but let me go check."
On 9/15/14 at 2:53 P.M., the resident's certified nursing assistant (CNA 10) stated that she documents the overall cc consumption of fluid from the tray, and enters it on a column under "cc" on a CNA form. CNA 10 reviewed the form under 9/15/15, for Resident 82, which indicated 360 cc for lunch. CNA 10 stated, "That could be any fluid on the tray including water or the health shake." A review of the form utilized by the CNA had an area for "% [percent]", "Sup" [supplement], and "cc [cubic centimeter]". The column under "sup" was blank. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011258 |
B |
06-Feb-15 |
K4YL11 |
6098 |
F-520 483.75(o) Quality Assessment and Assurance (1) A facility must maintain a quality assessment and assurance committee consisting of - (i) The director of nursing services; (ii) A physician designated by the facility; and (iii) At least 3 other members of the facility's staff. (2) The quality assessment and assurance committee - (i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develops and implements appropriate plans of action to correct identified quality deficiencies. (3) State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. (4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.The facility failed to provide evidence of a viable, ongoing, and comprehensive Quality Assurance Program which evaluated the facility's ability to provide continuous assessment of issues, related to quality of care, quality of life and facility practices. As a result, the facility was unable to identify system issues, develop and implement plans to address areas of concern and opportunities for improvement in a timely manner.Due to the facility's failure to: 1. Identify and discuss on going activities within the facility; 2. Identify system issues related to Resident Behavior and Facility Practices, Quality of Care, and Quality of Life, the survey team called an Immediate Jeopardy for QA. On 9/18/14 at 12:35 P.M., the survey team called an Immediate Jeopardy and informed the ADM. The team requested the ADM provide the survey team with immediate measure that would ensure a QAC was implemented. As of survey exit on 9/19/14 at 3:30 P.M., the Immediate Jeopardy had not been abated. On 10/3/14 at 4:20 PM, the survey team accepted the Allegation of Removal of Immediate Jeopardy (POC) and informed the ADM the Immediate Jeopardy was abated. Findings: 1. On 9/10/14 an Immediate Jeopardy was called related to the facility's lack of a comprehensive Infection Control Program. On 9/11/14 at 9:40 A.M., an interview with the ICC was conducted. She confirmed that she had not received any surveillance of infections for "Months", from the facility. She further stated, she was not kept, "In the loop", regarding infection control in the facility.While the ICC attended the quarterly QAC meetings, she acknowledged that no discussions or decisions were made regarding Infection Control Practices. Due to the facility's lack of surveillance, the facility was unable to identify infection control trends. On 9/15/14 at 9:45 A.M., the Pharmacy Consultant was interviewed. He stated, "I have never given them any reports on antibiotic use. I have told them we could, but [they] do not come to us, (regarding QA)."2. On 9/15/14 at 9:30 A.M., the MD was interviewed. He stated his services as Medical Director of the facility would no longer be needed, effective 9/30/14. He further stated, that they [ADM] may have mentioned the Immediate Jeopardy related to Infection Control and stated, he was not aware of the second Immediate Jeopardy related to abuse. According to the MD, he used to be involved in QA with the previous ADM. He stated that when the new ADM started in January 2014, she [ADM] did not include him and further stated he was not involved with QA and that the committee was "Passive, just the paperwork." On 9/18/14 at 9:26 A.M., the MD was re-interviewed. The MD stated, he did not participate at all in the meetings. He stated, "Just a formality [Quarterly QA meeting], maybe 30 to 40 minutes, it was just, you sign [here]; no discussion, superficial and sign here and there." He acknowledged that he attended the quarterly meetings and signed as directed by the ADM. The MD further acknowledged he was not involve in nor informed of any QA related issues since "January 2014, when the new Administrator came." 3. On 9/18/14 at 10:31 A.M., the ADM was interviewed. She stated the QAC met on a quarterly basis throughout the calendar year. During the April 2014 QAC meeting, which reflected the QA issues for January through March 2014, the ADM stated the previous nursing department heads presented a report that did not meet her standards. She graded the report as an "F." She then met with the previous nursing department heads "around April, May-ish" to review their revised reports. Again, the ADM stated, there was no data collection by the previous nursing department heads. During the July 2014 QAC meeting, which reflected the QA issues for April through June 2014. The ADM stated, the PDON reported limited information regarding falls, nothing was reported on restraints, weight loss, skin issues, or abuse. The ADM further stated, that the IC surveillance was not accurately reported. Also, the DSD/ICN was not present during the July meeting. The ADM confirmed she accepted the ICC report related to urine cultures and infection rates, but stated the ICC shared she obtained the cultures and infection rates based on the lab results only and did not receive any input related to the cultures and infection rates from the DON or DSD/ICN. The ADM acknowledged, the information form the ICN was not accurate. A review of the July 2014 agenda and sign-in sheet was conducted. Each department head signed the sign-in sheet, but no agenda item was noted for each department head. When asked what decisions were made during the July 2014 QAC meeting, the ADM was unable to locate the minutes in the binder. The ADM acknowledged, that with the inaccurate data from the ICN reports, the absence of data collection of resident care issues from the previous DON, ADON and DSD/ICN, there was no QAC program for the facility. In addition, the ADM stated, there was no Bioethics Committee agenda item on the QAC and was not aware of any bioethics committee until she received a complaint. The violations had a direct relationship to the health, safety, or security of patients. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011259 |
B |
06-Feb-15 |
K4YL11 |
17052 |
F-441?483.65 Infection Control The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. ?483.65(a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. ?483.65(b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. ?483.65(c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. The facility failed to ensure an Infection Control Program was in place.As a result, staff was not following infection control practices, which placed all residents at risk for acquiring the transmission of disease and infection. An Immediate Jeopardy was called on 9/10/14 at 6 P.M., related to the facility's nonexistent infection control program. The team accepted the Allegation of Removal of Immediate Jeopardy (POC) and informed the ADM on 9/16/14 at 9:10 A.M., that the Immediate Jeopardy was abated. Findings: 1. On 9/8/14 at 3 P.M., during the initial tour, it was observed in Room 28, non-sampled Resident 51 had 3 urinals on his bedside table. One urinal was 1/4 full (approximately 100 cc) of dark yellow fluid. On 9/9/14 at 7:30 A.M., Resident 51 was observed with 3 urinals on his bedside table. One urinal was 1/4 full (approximately 100 cc) of yellow fluid and the other 2 urinals were empty. Resident 51 was asked how often the staff emptied his urinals, he stated, "They empty it." On 9/9/14 at 11 A.M., Resident 51 was observed with 3 urinals on his bedside table. All 3 urinals were empty. On 9/9/14 at 12:30 P.M., Resident 51 was observed eating his lunch tray which was placed on his bedside table. The 3 urinals were placed hanging on the top right side rail of his bed.On 9/9/14 at 1:30 P.M., CNA 1 stated, "He's not assigned to me", when asked how often the urinals are emptied. On 9/9/14 at 2 P.M., Resident 51 was observed with 3 urinals on his bedside table. One urinal was 1/4 full (approximately 100 cc), of yellow fluid. It was unknown how long the urinal with urine had been sitting on the bedside table. On 9/9/14 at 2:31 P.M., the ICN was interviewed. A request was made to review the infection control binder for policies and procedures. She stated she was newly employed at the facility and acknowledged there was no infection control binder, "There's nothing." She further confirmed, she initiated the infection surveillance for the facility on 9/8/14. On 9/10/14 at 8:30 A.M., Resident 51 was observed with 3 urinals on his bedside table. One urinal was approximately 100 cc's filled with dark yellow urine.2 a. During a medication pass observation, 3 LNs did not sanitize the blood pressure (BP) cuff (inflatable cuff that wraps around the arm, used to measure blood pressure), which was used for multiple residents, before and after use.During a medication pass observation on 9/9/14 at 9:40 A.M., LN 8 was observed taking the BP cuff from the medication cart and did not sanitize the cuff. She proceeded to take Resident 53's BP. After LN 8 finished, she placed the cuff back into the medication cart and did not sanitize the BP cuff. On 9/9/14 at 9:50 A.M., LN 8 confirmed she did not sanitize the BP cuff before and after use for Resident 53. When asked she said, "I should have done it." During a medication pass observation on 9/9/14 at 10 A.M., LN 11 was observed taking Resident 24's BP before administering the medications. LN 11 did not clean/sanitize the BP cuff before and after use. At 11:20 A.M., she confirmed she did not clean/sanitize the BP cuff before and after use. During a medication pass observation on 9/9/14 at 10:30 A.M., LN 2 was observed using the BP cuff to measure BP for Resident 40 without sanitizing it before and after use. At 11:10 A.M., LN 2 said she did not know she was supposed to clean it before and after use. On 9/9/14 at 2:45 P.M., the DON said nursing staff are expected to sanitize the BP cuff before and after taking BP for each resident. The facility's policy and procedures entitled "Cleaning & Disinfection of Resident Care Equipment," undated, indicated: "Reusable items are cleaned and disinfected or sterilized between residents." The reusable items included BP cuffs. 2 b. During a medication pass observation, a nursing staff did not use the appropriate disinfectant to disinfect the glucometer as per manufacturer's recommendation. On 9/9/14 at 2 P.M., LN 12 was observed obtaining a finger stick (blood sample obtained from a finger and placed on a test strip which is inserted in a glucometer, to get a blood sugar reading) from Resident 86. After finished, LN 12 sanitized the glucometer (Assure Platinum Brand) with a Procure Hand Sanitizing wipe. This wipe contained only 65.9% of alcohol and had no disinfecting action against E. Coli bacteria, Salmonella bacteria, HIV, Hepatitis B Virus, Hepatitis C Virus, different types of fungi, etc.On 9/9/14 at 3:40 P.M., the ADON provided the facility's undated policy and procedures entitled "CLEANING AND DISINFECTION OF GLUCOMETER." It indicated: "Disinfect after cleaning the exterior surfaces following the manufacturer's directions..." A review of the manufacturer's recommendation for Assure Platinum glucometers, provided by the DON on 9/10/14, read: "Disinfecting can be accomplished with an EPA [Environmental Protection Agency] registered disinfectant detergent or germicide that is approved for healthcare settings or a solution of 1 part to 10 parts concentration of sodium hypochlorite (bleach)." On 9/10/14 at 9:30 A.M., the ADON said the Procure Hand Sanitizing wipe was not appropriate for disinfecting the glucometers. She said the facility just brought in a new sanitizing wipe called Clorox Healthcare Bleach Germicidal Wipes, which the facility will use to disinfect all resident care equipment. 2 c. During a medication pass observation, a nursing staff did not appropriately disposed of potentially contaminated IV medication bag and IV tubing to prevent the transmission of disease within the facility. Resident 21 was admitted to the facility with diagnoses including an infection of a colon by the bacterium Clostridium difficile (C. diff). According to the CDC, symptoms of C. diff include: watery diarrhea, fever, loss of appetite, nausea, and abdominal pain. Residents can get sick from C. difficile picked up from contaminated surfaces or spread from a health care provider's hands. (http://www.cdc.gov/hai/organisms/cdiff/Cdiff-patient.html) On 9/10/14 at 11:10 A.M., the ADON said Resident 21 was placed on contact isolation precautions due to C. difficile. Contact precautions are measures put in place to prevent transmission of microorganisms in healthcare setting. The measures include proper hand hygiene, personal protective equipment, isolation of resident care equipment, etc. These measures are designed to protect residents, staff, and visitors from contact with infectious diseases. On 9/10/14 at 11:15 A.M., the ADON was observed hanging a new IV medication (Teflaro, an IV antibiotic to treat various infections) bag at Resident 21's bedside. She then removed the empty IV Teflaro bag and its tubing (which had been hanging on the IV pole from the night before) and brought them out of the resident's room. ADON then cut sharp end of the tubing and placed it in the sharps container hung outside of a medication cart. She then threw the rest of the IV tubing and the empty IV medication bag in the trash bin located on the side of that same medication cart. During this observation, when asked if that was a proper disposal of the potentially contaminated IV bag and IV tubing, ADON did not respond but quickly retrieved the IV bag and tubing from the trash bin, and discarded them in a large unlabeled black trash container located in a room adjacent to the nursing station. She said that black trash container was a "biohazard bin" although it did not have any signs indicating it was a biohazard bin. When asked what was the proper way to handle potentially contaminated materials, ADON said, "You are right. We should dispose of those in the room. We should have the designated trash bin and sharps container in the patient's room." ADON acknowledged that bringing potentially contaminated materials outside of the contact isolation room had the potential for spreading infections in the facility. In the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, the CDC recommended:"Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set" and "Equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents." 3. On 9/8/14 at 4:15 P.M., during the initial tour jointly with LN 1, shower room 1 was observed. The shower curtain had brown substance spots at the bottom of the curtain, 4 x 4 tiles were coated with black substance. The corners of the shower stall floor had black substance.In addition, on the wall of shower room 1, was a sharp disposal container, which was filled to the top with disposal razors and other disposable sharps. At the top of the sharp disposal container was 13 used disposal razors which were stacked on top of the sharp disposal container. On 9/8/14 at 5 P.M., LN 1 was stated, "It is overflowed and should have been changed." On 9/18/14 at 8:30 A.M., the DON stated she expected CNAs' or central supply staff for a new container, to replace the filled sharp disposable container. According to the facility's undated and unsigned policy and procedure, entitled Sharps Precautions, "B. Such containers shall be easily accessible to personnel needing them...and will not spill their contents if knocked over and will not themselves allow injuries when handled." 4. On 9/9/14 at 7:30 A.M., it was observed that an isolation cart in the hallway at the entrance of the door for Room 11.Resident 21 was admitted to the facility on 9/8/14, with diagnoses to include Clostridium Difficile, (A bacterial infection which is contagious), according to the Physician's Orders. On 9/9/14 at 3:12 P.M., CNA 2 was observed. CNA 2 put on a yellow gown, gloves and a mask that was obtained from Resident 21's isolation cart. CNA 2 entered Resident 21's room, and greeted the resident. CNA 2 raised Resident 21's head of bed higher and assisted the resident in comfort. CNA 2 disposed of the yellow gown, gloves and mask in the garbage can located inside Room 11 then, walked out of the room without washing her hands and proceeded to walk down the hallway. CNA 2, after leaving Resident 21's room, was about to enter another resident's room. CNA 2 was stopped for an interview before entering another resident's room. CNA 2 was asked, the process when a resident is on isolation precautions. She hesitated in her response then stated, "I should wash my hands, after I take off my gown and gloves. I did not wash my hands after leaving Resident 21's room." CNA 2 stated she was trained on infection control procedures, "I think a couple of months ago." On 9/10/14 at 7:25 A.M., during breakfast observation, the CDON was observed sitting and feeding a resident. She stood up and went to a second resident and assisted the resident with her meal tray. The CDON walked over to a third resident. She repositioned his wheelchair and went to a fourth resident, to touch the resident's shoulder. The CDON moved the fourth resident's meal tray to another table and pushed the resident to another table. The CDON picked up the fourth resident's 4 ounce glass of white fluid and proceeded to assist her with her meal. The CDON then leaned against a fifth resident's wheelchair and placed her hand on his wheelchair and began to feed the resident. The CDON went back and forth between 5 residents and assisted them with their meals. The CDON did not wash her hands nor sanitize her hands between each resident contact. On 9/10/14 at 7:51 A.M., CNA 2 was observed feeding a male resident. The CNA stood up and poured coffee for another resident. The CNA left the main dining room to go to the kitchen and entered the kitchen to obtain more coffee and cups. CNA 2 returned with the coffee and cups. She assisted another resident with his meal. The CNA did not wash her hands between residents and did not wash her hands upon her return to the main dining room. CNA 2 sat between 2 different residents and assisted the residents with their meal. A different resident at the same table started to cough and the CNA attended to the resident and wiped her mouth. She returned to the 2 residents and resumed feeding the residents. CNA 2 did not wash her hands after she assisted the resident who had coughed. On 9/10/14 at 12:45 P.M., CNA 3 was observed at the doorway of Resident 21, who was on isolation precautions. CNA 3 put on a yellow isolation gown, and gloves and obtained a lunch tray from the meal cart. She delivered the tray to Resident 21 and assisted the resident with his meal tray. The CNA removed the yellow isolation gown and her gloves at the trash can inside Resident 21's room. She left the room and proceeded to the meal cart and obtained another meal tray. CNA 3 did not wash her hands when she exited Resident 21's room. CNA 3 stated she forgot to wash her hands after leaving his room.On 9/10/14 at 1:25 P.M., CNA 4 was observed standing at Resident 21's doorway. CNA 3 handed Resident 21's consumed meal tray to CNA 4. CNA 4 accepted the meal tray and placed the tray on the meal cart. CNA 4 then entered another resident's room and did not wash her hands after she handled Resident 21's meal tray. CNA 4 stated, she forgot to wash her hands. On 9/10/14 at 2:10 P.M., the team coordinator called a team meeting to discuss the infection control issues observed. The team agreed to obtain additional interviews. On 9/10/14 at 3:55 P.M., the CDON was interviewed. She stated that was the first time she had assisted in the main dining room for meals. She further stated she did not monitor the staff on hand washing. She further stated, she had not conducted in services for hand washing to the staff. On 9/10/14 at 4:10 P.M., the ICN was interviewed. She acknowledged there was no infection control program throughout the facility, "No program yet." Due to the facility's failure to: 1. Ensure the staff practiced proper hand washing techniques; 2. Ensure the staff were in-serviced on infection control prevention; and 3. Ensure the facility monitored and tracked infection control issues within the facility. On 9/10/14 at 6 P.M., the survey team called the Immediate Jeopardy and informed the ADM and the VPCS. The team requested the ADM provide the survey team with immediate measures that would be taken to ensure the safety of each resident to prevent the spread of infectious disease and implement an Infection Control Program. On 9/16/14 at 9:10 A.M., the survey team reviewed an Allegation of Removal of Immediate Jeopardy (POC) presented by the facility. According to the POC: 1. The staff were in serviced on hand washing techniques; 2. The staff were in serviced on contact isolation; 3. The facility installed 11 automatic hand sanitizers which were placed in hallways and common areas throughout the facility; 4. An infection control checklist for rounds was developed; 5. The department heads were in serviced on hand washing and cleaning of medical equipment; 6. An Infection Control Committee was developed, the Infection Control Consultant made rounds throughout the facility; 7. The facility re-instituted the infection control surveillance logs and committed to a monthly monitoring process; 8. An infection control manual was reviewed and accepted by the Infection Control Committee. The team accepted the Allegation of Removal of Immediate Jeopardy (POC) and informed the ADM on 9/16/14 at 9:10 A.M., that the Immediate Jeopardy was abated. The violations had a direct relationship to the health, safety, or security of patients. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011260 |
B |
06-Feb-15 |
K4YL11 |
20403 |
F431 ?483.60(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. ?483.60(d) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (e) Storage of Drugs and Biologicals (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. The facility failed to ensure controlled substance (CS) medications (drug tightly regulated by the Federal government for its abuse or risk potential) were accurately accounted for as evidenced by: 1. A review of controlled substance records for 8 residents (sampled and non-sampled) reflected 126 tablets of CS medications were not accurately accounted for five residents (Residents 38, 48, 63, and 80, and one non-sampled resident, 39) since August 1, 2014, as follows: - 65 tablets of Percocet (a combination of oxycodone 5 milligrams (mg) & Tylenol 325 mg; is a Schedule II (high potential for abuse) narcotic for pain) for Resident 48 from 8/17/14 to 9/17/14 (a one-month period); - 11 tablets of oxycodone 10 mg (a Schedule II narcotic for severe pain) for Resident 63; - 24 tablets of Norco (hydrocodone 5 mg & acetaminophen 325 mg, a potent narcotic for moderate to severe pain) for Resident 38, - 18 tablets of Norco 5/325 mg for Resident 80; and - 8 tablets of Norco 5/325 mg for Resident 39; were signed of the Controlled Drug Record (CDR) without subsequent documentation on the medication administration record (MAR) and/or pain assessment flow sheet (PAF) as given in accordance with the facility procedures. It was undeterminable what happened to these medications. Also, for 2 of 5 residents (Residents 48 and 80) with identified CS drug unaccountability, the facility could not provide controlled drug records prior to 8/17/14 for Resident 48 and prior to 8/19/14 for Resident 80. The frequent and repeated failures to document CS medication administration on the MAR and/or on the PAF, and the failure to account for all CS medications, had the potential to result in CS medication overdose (such as when the medication is given too soon before due time) for a universe of 32 residents who were receiving CS medications; and misuse/diversion of controlled substances in the facility. Overdosing of CS narcotic medication could lead to adverse effects such as respiratory depression (a condition of having a breathing rate that becomes too low to ventilate the lung), extreme sedation, muscle weakness, slow heart rhythms, low blood pressure, loss of consciousness, and death.2. The facility could not provide controlled drug disposition records to account for all discontinued/discharged controlled drugs from 5/5/14 to 8/11/14. Federal regulations require that the facility have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. CDR (a.k.a. count sheet) is an inventory sheet that includes the resident's name, medication, and direction for use. The form contains entries for staff to enter date, time, doses present, and the signature of staff signing out the number of doses.The PAF is a form used by the facility to evaluate the safety and effectiveness of pain medications. It is individually filled out for each resident, to document the date, time, location of pain, pre-analgesia pain rating, medication and dose given, date and time of re-assessment, post-analgesia pain rating, sedation level, the non-drug interventions taken, and the signature of the licensed staff who gave the medication and performed the pain assessment. As a result, an Immediate Jeopardy was declared on 9/17/14 at 12:05 P.M. with the Administrator and the Vice President of Clinical Service. As of survey exit on 9/19/14 at 3:30 P.M., the Immediate Jeopardy had not been abated. On 10/3/14 at 4:20 PM, the survey team accepted the Allegation of Removal of Immediate Jeopardy (POC) and informed the ADM the Immediate Jeopardy was abated. Findings: 1. On 9/11/14 at 2:25 P.M., an inspection of the CS medication accountability records at the North Station Medication Cart #2 was conducted with LN2 revealed Resident 80 had a physician order, dated 7/23/14, for Norco 5/325 mg to take 1 tablet every 4 hours as needed for moderate pain and 2 tablets every 4 hours as needed for severe pain. The record showed 2 tablets were signed out of the controlled drug record (CDR) at 3 A.M. on 9/11/14, but the nursing staff did not document the administration on the MAR or on the pain assessment flow sheet (PAF). LN2 said every time a CS medication was signed out, the nurse had to document on the MAR after the medication was administered, and document on the PAF the pain assessment and the interventions taken. LN2 acknowledged 2 tablets of Norco for Resident 80 were not accounted for.On 9/12/14 at 3:05 P.M. an inspection the CS medication accountability for 3 residents at the South Station Medication Cart #2 with LN3 revealed the following: - 16 tablets of Percocet 5/325 mg for Resident 48 were unaccounted for in a 7-day period from 9/5/14 to 9/12/14. They were signed out the CDR at various times as given but not documented on the MAR (front or back) or on the PAF. For example, on 9/6/14, 10 tablets of Percocet were signed out on the CDR as given, 2 tablets each, at 1 A.M., 8:55 A.M., 3 P.M., 4 P.M., and 9 P.M. None of these were documented on the MAR under 9/6/14 entry. The PAF only had one entry, dated and timed 9/6/14 at 9 A.M., that accounted for the 8:55 A.M. dose. The other 4 doses (8 tablets) were not documented anywhere else on the MAR (such as the back of the MAR where staff occasionally entered PRN medication administration) to account for them. Again, on 9/7/14 at 6 P.M., 2 tablets were signed out on the CDR as given. This administration was not documented anywhere on the MAR or the PAF. This happened again on 9/9/14, 9/10/14, and 9/11/14. - 2 tablets of Norco 5/325 mg for Resident 38 were unaccounted for. They were signed out of the CDR on 9/5/14 and 9/8/14 as administered without subsequently documented on the MAR (front or back) or on the PAF as given. - 1 tablet of Norco 5/325 mg for Resident 39 was not accounted for on 9/12/14, when it was signed out the CDR but not subsequently documented on the MAR (front or back) or on the PAF as being given. During this inspection, LN3 acknowledged CS medications for three of three residents (Residents 38, 39, and 48) were not accurately accounted for, and staff was not consistently documenting CS medication administration on the MAR and/or on the PAF. When asked to explain what happened to the unaccounted medications, LN3 shrugged and said, "I don't know." She stated CS medications signed out of the CDR must be documented on the MAR after given to the resident and then on the PAF to document nursing assessment and interventions.During an interview with Resident 48 on 9/12/14 at 3:40 P.M., he said had pain "all over the place" as he pointed to his left shoulder, arms, and legs, and said he asked for pain medication "all the time." He stated he received medication every time he asked and often got pain relief after the medication given.On 9/12/14, a review of Resident 48's medical record revealed he was admitted to the facility with diagnoses including general muscle weakness and lung cancer. He had a physician order, dated 5/25/13, for Percocet 5/325 mg 1 tablet every 4 hours as needed for moderate pain, and 2 tablets every 4 hours as needed for severe pain.During an interview on 9/15/14 at 1:50 P.M., the director of nursing (DON) confirmed CS medications signed out of the CDR must be documented on the MAR after given, then on the PAF to document the pain assessment and interventions. She was presented with documents showing CS medications for 4 residents (38, 39, 48, and 80) not accurately accounted for. The DON agreed that without documentation on the MAR or on the PAF (or on the back of the MAR), there was no telling of what happened to the medications. The DON said she could not provide an explanation, and said that there was a failure of staff to document. During this interview, a review of Patient 48's Percocet CDR with the DON showed on 9/6/14 at 3 P.M., a nursing staff signed out 2 tablets of Percocet 5/325 mg but did not document on the MAR (front or back) or on the PAF. One hour later, at 4 P.M. (after shift change, which took place at 3 P.M.), another nursing staff (LN4) signed out 2 tablets for the resident, and again this administration was not documented. Thus, within 1 hour period, the resident was reportedly given 4 tablets of Percocet 5/325 mg. The DON acknowledged the lack of documentation on the MAR and on the PAF could potentially lead to nursing staff administering the medication too close together or too soon before due time (due to the lack of documentation of the medication given from the previous shift), which would lead to overdose for residents.LN4 was interviewed on 9/15/14 at 2:50 P.M. She said she could not recall what happened on 9/6/14 when she signed out 2 tablets of Percocet at 4 P.M. for Resident 48. She acknowledged she did not document that Percocet administration on the MAR and on the PAF. She stated she did not realize 4 tablets were signed out just one hour apart. On 9/15/14 at 2 P.M., the Percocet CDRs from 8/1/14 to 9/5/14 for Resident 48 were requested from the medical record director (MRD). At 2:50 P.M., the MRD said she could only find CDRs for Resident 48 dating back to 8/17/14; she could not find CDRs from 8/1/14 to 8/17/14. A review of the provided CDRs for Resident 48, from 8/17/14 to 9/5/14, revealed 120 tablets of Percocet were signed out on the CDR, but the medication administration recorded on the MAR, PAF, and the back of the MAR, only accounted for 79 tablets, leaving 41 tablets unaccounted for. Thus, in a period of 27-day period from 8/17/14 to 9/12/14, a total of 57 tablets (16+ 41) of Percocet for Resident 48 were unaccounted for. On 9/15/14 at 4 P.M., the DON was informed of the additional finding related to Resident 48's unaccounted Percocet. Again, DON stated she could not provide an explanation but insisted it "was a documentation problem," and that staff failed to document CS medication administration on the MAR and on the PAF to account for medications given.On 9/16/14 at 8:40 A.M., the CDRs for Resident 48's Percocet and Resident 80's Norco were requested from the MRD. At 9:30 A.M., the MDSN said the facility could only find CDRs dating back to 8/19/14 for Resident 80. She said the facility was still looking for the "missing" CDRs for Resident 48 (they were not provided by the end of the survey). On 9/16/14 at 10:30 A.M., the MRD confirmed she could not find CDRs for Resident 80 prior to 8/19/14. A review of the provided CDR (from 8/19/14 to 9/7/14) revealed additional 16 tablets of Norco unaccounted for. Thus, adding the data from 9/11/14, a total of 18 tablets (16+2) of Norco for Resident 80 were unaccounted for, in a period of 23 days. She had diagnoses including general muscle weakness, pressure ulcer, and rheumatoid arthritis. Resident 80 was not available for interview. On 9/16/14 at 11:15 A.M., Residents 38's CDRs for Norco from 8/1/14 to 9/10/14 was reviewed. It reflected a total of 24 tablets of unaccounted Norco, as they were signed out from the CDRs but not subsequently documented on the MAR (front or back) or on the PAF. Resident 38 had a physician order, dated 7/3/14, for Norco 5/325 mg 1 tablet every 4 hours as needed for moderate pain or 2 tablets as needed for severe pain. She had diagnoses including general muscle weakness. Resident 38 was not available for interview.Similarly, on 9/16/14 at 11:40 A.M., a review of Resident 39's CDRs for Norco from 8/1/14 to 9/12/14 reflected 8 tablets were unaccounted for. Resident 39 had physician order, dated 7/7/14, for Norco 5/325 mg 1 tablet every 6 hours as needed for moderate pain. He had diagnoses including general muscle weakness, difficulty walking, and history of bone fracture.The above findings were verified with the DON on 9/16/14 at 2 P.M. She acknowledged the unaccounted for CS medications for 4 residents (38, 39, 48, and 80) and that staff were not consistently documenting on the MAR and on the PAF as required, in accordance with the facility procedures. On 9/16/14 at 3:40 P.M., an interview was conducted with LN5, who signed out 2 tablets of Percocet for Resident 48 on 9/10/14 without documenting on the MAR. She acknowledged and said, "I missed it."On 9/16/14 at 3:50 P.M., an interview was conducted with LN6. The CDR of Norco for Resident 38 showed LN6 signed out 1 tablet of Norco each day for Resident 38 from 8/1/14 to 8/4/14 (4 tablets) without documenting on the MAR (front or back), or on the PAF. When shown that there was no documentation of Norco administration from 8/1/14 to 8/4/14, LN6 said, "I forgot." She said she was supposed to document on the MAR after the medication given to the resident and on the PAF to document pain assessment and interventions. On 9/16/14 at 4:25 P.M., the DON provided the facility's procedure, undated, entitled "Medication - Administration " Nursing Manual - General. It indicated: "PRN [as needed] Medication Documentation A. When a PRN medication is given, it will be charted on the Medication Administration Record. The Nurse will document the reason given, reason for the drug, route of administration, date, and time. B. The result of the PRN medication will be charted by the responsible Nurse on the back of the MAR. C. If the PRN is for complaint of pain, the Nurse will document the pain score prior to given the medication and after the administration of the pain medication." The DON also presented the PAF. She said the nursing staff were to use the PAF to document the pain assessments and interventions (as it was a tool to evaluate the safety and effectiveness of pain medication interventions), instead of on the back of the MAR. On 9/17/14, a review of the facility's policy and procedures, entitled "PAIN MANAGEMENT," undated, indicated: "I. Pain Assessment: ... D. Resident given PRN pain medication, after intervention/medication are implemented, resident [sic] will re-evaluate the resident's level of pain within one hour.... II. Pain Management: ... B. The Licensed Nurse will administer pain medication as ordered and document all medication administered on Medication Administration Record (MAR)." On 9/17/14 at 8:45 A.M., further review of the Percocet CDR, the MAR, and PAF for Resident 48 since 9/12/14 (the day CS unaccountability was identified) was conducted at the Medication Cart with LN3. The records showed: - On 9/14/14, 10 tablets of Percocet were signed out of CDR, but the MAR and the PAF only accounted for 6 tablets (4 tablets unaccounted for) - On 9/15/14, 8 tablets of Percocet were signed out of the CDR, but the MAR and the PAF only accounted for 4 tablets (4 tablets unaccounted for) LN3 verified the finding. Thus, the concern of unaccounted CS medications continued even after it was brought up with the licensed staff on 9/12/14. Therefore, in a 31-day period from 8/17/14 to 9/17/14, a total of 65 (57 + 8) tablets of Percocet for Resident 48 were unaccounted for. On 9/17/14 at 9 A.M., a review of Resident 63's medical record reflected she had diagnoses including muscle weakness, end-stage renal disease (last stage of kidney disease), and history left knee replacement. She had a physician order, dated 7/7/14, for oxycodone 10 mg 1 tablet every 6 hours as needed for moderate or severe pain.On 9/17/14 at 9:15 A.M., a review of Resident 63's CDRs, MARs, and PAFs from 8/1/14 to 9/17/14 with LN7 revealed a total of 33 tablets were signed out of the CDRs, but the MAR and the PAF (and the back of the MAR) only accounted for 22 tablets, leaving 11 tablets unaccounted for. For example, on 9/15/14, 4 tablets of oxycodone 10 mg were signed out as given, but the MAR only accounted for 2 tablets. LN7 verified the finding. During an interview with Resident 63 on 9/17/14 at 10:15 A.M., she said she " usually hurt all the time. " She said she received pain medication when she asked for them. When asked if she had sufficient pain relief after pain medication given, she stated, "Sometimes it does, sometimes it doesn't'."Resident 63 also had order, dated 8/9/14, for Tramadol (a pain medication for mild-moderate pain) 25 mg three times daily. On 9/17/14 at 12:05 P.M., a declaration of Immediate Jeopardy was called with the Administrator and the Vice President of Clinical Service due to CS medication unaccountability and potential for CS drug overdose due to the lack of medication administration documentation on the MAR and/or on the PAF. To date, the manufacturer for oxycodone indicates: "Acute overdose with oxycodone hydrochloride tablets can be manifested by respiratory depression, somnolence [sleepiness], progressing to stupor or coma, skeletal muscle flaccidity [soft and weak], cold and clammy skin, constricted pupils, bradycardia [slow heart rhythms], hypotension [low blood pressure], and death." (http://dailymed.nlm.nih.gov/dailymed/index.cfm, accessed 9/19/14) For Norco, the manufacturer indicates overdose with hydrocodone (a component of Norco) is "characterized by respiratory depression, extreme somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and hypotension." (http://dailymed.nlm.nih.gov/dailymed/index.cfm, accessed 9/19/14) During an interview with the consultant pharmacist (CP) on 9/17/14 at 3:30 P.M., he said he had identified issue with CS unaccountability (uncharted CS medication administration on the MAR) for at least three months. He stated he had conducted an in-service with nursing staff on 8/11/14 to address this issue. He acknowledged despite the in-service, the staff were still not documenting CS medication administration, as required, to account for all control substances.2. During an interview on 9/17/14 at 3:30 P.M., the CP said discontinued CS medications or those for discharged residents would be given to the DON. He said he and the previous DON destroyed those medications together about once every three months. He stated they last destroyed CS medications on 8/11/14. At 4 P.M., a review of the CS disposition records in the DON's office found disposition records dating up to 5/5/14. In other words, no disposition records for after 5/5/14 were found. On 9/18/14 at 11:25 A.M., the CP said after further looking and inquiring, he could not find the CS disposition records which he conducted with the previous DON (PDON) on 8/11/14. CP acknowledged, without the said disposition records, the facility could not account for discontinued/discharged controlled medications from 5/5/14 to 8/11/14. During the interview, the CP provided a procedure entitled "B. DISPOSAL OF CONTROLLED DRUGS," dated 6/2013. It indicated: "Controlled Drugs listed in Schedule II, III, or IV of the Controlled Substances Act of 1970 shall be disposed of in the presence of an RN (employed by the facility) and a registered pharmacist. Document must include: Name of Resident Name and Strength of drug... Signature of 2 Witnesses (Pharmacist and RN) Method of Disposal Documentation shall be recorded on the control count sheet. The disposal record must be legally saved for three years."The violations had a direct relationship to the health, safety, or security of patients. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011261 |
A |
06-Feb-15 |
QS5P11 |
20978 |
F-224 ?483.13(c) Staff Treatment of Residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. ?483.13(c)(1)(i) Staff Treatment of Residents (1) The facility must- (i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; The facility failed to ensure 1 of 94 sampled residents (Resident A), who was unable to care for self, unable to walk, unable to provide food for herself, unable to toilet self, and unable to obtain necessary medications for her illness', was safely discharged to an appropriate care setting. The facility failed to provide goods and services to ensure a safe and appropriate discharge. As a result, Resident A was physically unable to care for self, was discharged to her trailer without a physician being notified, had a urinary catheter, and without means to care for herself. Resident A did not have a phone to call for help in case of an emergency, was unable to get out of bed on her own, unable to walk, unable to use the toilet, was a diabetic without medications or means to test her blood sugars, was a diabetic that had not eaten since lunch time, had no food in her trailer, and had no medications for her pain, or other critical medications that were required. Resident A lay in her bed at her home for hours before the police arrived. Resident A was found dirty and without necessary care/equipment to sustain life. This placed any of the 93 residents at the facility at risk of being discharged without a safe and appropriate after-care plan. Findings: Resident A was first admitted to a local acute care facility on 4/12/14, after she was found in her home unable to care for herself.Resident A was discharged from the local acute care facility on 4/15/14, with diagnoses that included, gravely disability (inability to care for self), inability to ambulate, failure to thrive (failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments) , diabetes (sugar in the blood), diabetic neuropathy (disease of the nerves that is painful; caused by diabetes), urinary tract infection (infection in the bladder or kidney), and dehydration, per the acute care facility's discharge summary. Also, Resident A had medical history diagnoses which included coronary artery disease and congestive heart failure. Resident A was admitted to this facility on 4/15/14, with diagnoses which included, failure to thrive, muscle disuse atrophy (muscle tone loss), muscle weakness, dysphasia (swallowing problem), insulin dependent diabetes (medication for high blood sugar), hypertension (high blood pressure), urinary tract infection and neuropathy (pain), per the facility's face sheet. Resident A was admitted with her companion of 4 years, a small dog. On 9/29/14, the department received two complaints, alleging that Resident A was discharged from the facility, to her home and was unable to care for herself. On 10/7/14 at 11:55 A.M., Resident A's clinical record was reviewed. According to the (Minimum Data Set-Resident Assessment) MDS dated 7/30/14, Resident A was unable to ambulate, required extensive assistance with bed mobility, transfers, eating, toilet use and personal hygiene. Resident A required total dependency for dressing and locomotion. Resident A also had physical limitations to both of her arms and legs. Resident A's (Brief Interview for Mental Status) BIMS was 12 (score range of 00 being completely impaired to 15 no impairment mentally.) According to the Certified Nursing Assistant (CNA) Daily Charting Form dated 8/1/14 through 9/8/14, Resident A required bed baths performed by the staff. The CNAs also documented Resident A had not ambulated and did not get out of bed. Resident A's pain level was documented every shift on the Medication Administration Record. According to Resident A's Pain Assessment Flow sheet, dated 9/6/14 through 9/9/14, the resident received pain medication three times per day. The pain medication administered to Resident A was Norco 5/325 mg (milligrams), 2 tablets.A physician's order dated 7/23/14 indicated Resident A routinely received 3 units of insulin before each meal. According to Resident A's Glucose/Insulin Record, dated 9/1/14 through 9/9/14, Resident A required finger sticks for blood sugar monitoring three times a day before meals. The results of the finger stick monitors dictated the amount of extra insulin Resident A required. Resident A required 1 extra unit of insulin before breakfast on 5 out of 9 days, 1-3 units of extra insulin on 2 out of 9 days before lunch and 1 extra unit of insulin on 5 out of 9 days before dinner.In addition, Resident A received, "Gabapentin 300 mg one capsule every night at bedtime for nerve pain; Atarax 10 mg every 8 hours for 14 days (to end 9/13/14) for itchiness; Lisinopril 20 mg every day for high blood pressure; Aspirin 81 mg every day for stroke prevention; Lasix 40 mg every morning for swelling; Klor-con (potassium) 20 mEq (milliequivalent) every morning; Lorstantin 20 mg every morning for hyperlipidemia for high cholesterol; Atenolol 50 mg 2 tablets every morning for high blood pressure; and Lovenox 30 mg subcutaneous injections every 12 hours for prevention of blood clots." Resident A was also ordered, "Nitroglycerin 0.4 mg one tablet under the tongue three times as needed for chest pain and to notify the physician if no pain relief; Clonazepam 0.5 mg one tablet by mouth three times a day as needed for muscle spasms; Hydrocodone 5/325 mg two tablets every 6 hours as needed for moderate pain; and, Hydrocortisone cream 1% to rash on right side of trunk twice a day and Hydrocortisone cream 1% to rash on right side of upper thigh twice a day."Nursing documentation dated, 10/26/14 (incorrect date documented due to Resident discharged 9/9/14), of Resident A's fall risk assessment scored resident as being a high risk for falls. The Licensed Nurse Weekly Summary, dated 9/8/14, Resident A's pain level ranged from 7 to 8 on a 0 (no pain) to 10 (extreme pain) pain scale. In addition, "Resident A had a 3 pound weight loss over the prior 3 weeks. Resident A with chronic back rash." The Occupational Therapy certification period of 8/16/14 through 9/12/14, read, "Patient is gravely debilitated. Patient complains of pain in varying spots, similar to fibromyalgia symptoms. Patient is unable to stand or perform Activities of Daily Living (ADL) tasks secondary to lack of insight of her deficits. Patient is unmotivated to learn or care for herself and wants others to do the care..." During the same Occupation Therapy Certification period, a functional skills assessment was performed. Resident A needed supervision for self-feeding, maximum assist with hygiene and grooming, total assistance with bathing, maximum assist with dressing, and total dependence with bed mobility. Resident A's care plan, dated 8/18/14 was reviewed. A care plan was initiated for MRSA (methicillin resistant staph aureus: bacterial infection resistant to most antibiotics) to back, UTI (urinary tract infection), CAD (coronary artery disease), CHF (congestive heart failure), Neurogenic bladder (loss of urinary control) with indwelling catheter (tube going into the bladder that is connected to a bag for urine to drain into), peripheral neuropathy (painful nerves in extremities), muscle spasms, and pet therapy ( her dog.) Per the discharge plan dated 8/23/14, "To discharge to appropriate placement." and "resident's estimated length of stay is 4-5 weeks." According to the nursing note dated 9/9/14 at 3:30 P.M., "...Stated she wanted to leave due to her dog not being able to accompany her in her room due to his barking. Visibly upset throughout the day due to dog not being in her room..."Resident A was discharged on 9/9/14. There was no physician's discharge order and no physician note in the clinical record. There were no discharge instructions in the clinical record. There were no prescriptions or medication education to the resident regarding the critical need for the medications. Resident A signed an AMA (Against Medical Advice) form.According to the facility's policy, dated 5/1/12, Discharge Against Medical Advice, "Mitigating circumstances influencing the resident's decision to leave should be evaluated and addressed in an effort to prevent the resident from leaving against medical advice." "A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave AMA." Documentation of nursing or physician's evaluation and addressing the reason Resident A signed out AMA could not be located in the clinical record. Complainant 1 was interviewed via telephone on 10/7/14 at 5:15 P.M.Complainant 1 stated that as soon as the department's survey team walked into the facility on 9/9/14, to conduct the annual recertification survey, the Administrator of the facility instructed her to take Resident A's dog outside and to keep the dog outside. Complainant 1 said that on that day, it was extremely hot and after 5 hours she and the dog needed water. She said she called into the facility to ask if she could go inside to retrieve her purse and water. She was told not to enter the facility and that someone would bring her purse and water. Complainant 1 further said the Administrator of the facility asked her to take the dog home. She said she informed the Administrator she would not and the Administrator instructed her to ask another employee. Complainant 1 added, she was unaware of complaints about the dog and said the dog did not bark. Complainant 1 further shared, SW 1 told her a cab was coming for Resident A and that the cab would pull around to the back of the facility and that they would sneak Resident A and her belongings into it. Complainant 1 said SW 1 instructed 2 CNAs to pick Resident A up from her wheelchair and place her into the cab. Complainant 1 said she was concerned for Resident A's welfare. She further said, Resident A wanted to go home because she could not have her dog with her. Complainant 1 said Resident A could not do things for herself and she was totally dependent on staff.Resident A was interviewed on 10/10/14 at 12:15 P.M. at her new long term care facility. Resident A was observed in her bed, in a hospital gown, and had limited mobility. Resident A attempted to pick up the phone receiver in an attempt to answer and had difficulty in picking up the receiver due to deformity of her hands. Resident A said she was angry at the previous long term care facility because "they" would not allow her to keep her dog. Resident A stated, "Skylark (dog) doesn't bark. I had him there for 4 1/2 months and all of a sudden, I can't have the dog, so I was out of there!" Resident A further said, she left AMA only because she was told that day that she could not have her dog. Resident A stated, "All of a sudden I was discharged AMA." Resident A said she would have stayed if they would have continued to allow her to keep her dog. Resident A also said the facility lied about her dog barking, stated it was the first time she had heard about it on that day (9/9/14.) Resident A also stated, it was because the Department was in the building conducting the survey. Resident A also said she did think about what she was going to do or how she was going to make it, but was tired and fell asleep. Resident A said she called the taxi herself and had to crawl inside of her trailer. Resident A said the facility did not provide her any discharge instructions regarding her medical condition (pain, diabetes care, indwelling catheter care), medication prescriptions (insulin for diabetes, pain medications, or nitroglycerin for chest pain), or arrange for any assistance in her home. On 10/10/14 at 2:55 P.M., Registered Nurse (RN) 1 was interviewed. RN 1 confirmed she was the nurse that discharged Resident A. RN 1 stated she did not speak to a physician and did not obtain a discharge order. RN 1 stated she only "took care of the paperwork." RN 1 confirmed that she did not discuss care of the indwelling catheter, medications, or follow up with Resident A. She further said her understanding was, if a resident discharged AMA, you would not go over medications, follow up or any discharge issues with them. On 10/10/14 at 3:40 P.M., CNA 1 was interviewed. CNA 1 said he was working a different hallway and was called to the back side of the facility to assist Resident A into a taxi. CNA 1 said it was very unusual for the taxi to pick up residents in the back and not the front of the facility. He further said, "It did feel sneaky, real sneaky." CNA 1 said after they transferred Resident A from her wheel chair into the taxi, he and CNA 2 rode in the Social Worker's car and followed the taxi to the resident's home. CNA 1 said the resident was not capable of caring for herself and was very concerned for her safety. CNA 1 stated, "It was not right and I kept saying it was not right." CNA 1 said the Social Worker told him not to worry and assured CNA 1 someone would check on Resident A. He further stated, "She could die, we even talked about it and was told not to worry (reassured by the Social Worker.)" CNA 1 described Resident A's living situation as poor. CNA 1 said they left Resident A in her bed. CNA 1 stated they left water beside her and there was no food. CNA 1 confirmed Resident A was unable to walk or to care for herself. CNA 1 said Resident A had her dog until 9/9/14. He further stated he believed the dog was taken away due to the recertification survey of the facility. CNA 1 stated, "I think the dog was her family and I think once they said the dog had to leave, she wanted to go." On 10/14/14 at 3:10 P.M., CNA 2 was interviewed. CNA 2 said he was asked by the Administrator to assist Resident A into the taxi. CNA 2 said the situation did not feel right because Resident A was a maximum assist. CNA 2 said after Resident A was in the taxi, he rode with the Social Worker and another CNA to Resident A's home.CNA 2 said the trailer was in "a mess" and that he kept saying it was not right. CNA 2 said the Social Worker told him it would be ok and she would call an agency to check on the resident. CNA 2 said he had not heard there was an issue with the dog until 9/9/14. CNA 2 further said he thought it became an issue due to the recertification survey. He further said once Resident A was told she could not have the dog, she was too mad and would not consider staying. CNA also said he could not believe the facility administration would allow her to leave since she could not care for herself.CNA 2 said the discharge occurred around 3:30 P.M. and Resident A had not eaten since lunch. CNA 2 also confirmed there was no food in Resident A's home. On 10/14/14 at 3:40 P.M., the Administrator was interviewed. The Administrator said she did not know much about the case. She said she remembered Resident A left AMA and they were concerned the Resident's daughter would not check on the resident. The Administrator believed SW 1 called Adult Protective Services. The Administrator said the AIT (Administrator in Training) took care of most of it and she was not involved because she was busy with the survey. The Administrator said she heard once there was a complaint about the dog barking. She said she was unaware that the dog had been in the facility for 4 1/2 months. The Administrator further stated, 9/9/14 was the first day she heard there was an issue. The Administrator said she did not believe Resident A left because of the dog. The Administrator continued to deny knowing anything about the AMA and the Resident's living situation. The Administrator said the AIT had communication problems and he had not informed her of the issue with the resident and the dog. On 10/20/14 at 10:10 A.M., AIT was interviewed. AIT said he was informed of Resident A's discharge when she was "in the action of leaving, physically leaving." AIT further said he did not tell anyone to discharge the resident and he did not tell anyone to take the dog outside and to stay outside. On 10/14/14 at 5:15 P.M., Social Worker (SW) 1 was interviewed. SW 1 said the AIT told her the Administrator said to keep the dog outside. SW 1 said she had not received complaints regarding issues with the dog until 9/9/14. SW 1 said there were no discharge plans in place for Resident A to be safely discharged. SW 1 said the AIT came and told her to discharge the resident. SW 1 said the AIT had been in Resident A's room alone and then came and told her to discharge the resident. SW 1 said she went into the resident's room but the resident was too angry and was not open to any further discussion. SW 1 further said, Resident A called her own taxi. SW 1 stated she informed the Administrator of the situation on that day (9/9/14.) SW 1 said CNA 1 and CNA 2 rode in her car with her to the Resident's home. SW 1 said the trailer was a mess and she started heaving because of the filth. SW 1 said there was no food in the trailer and that Resident A could not cook even if there were food items. SW 1 acknowledged Resident A as being totally dependent on others for her care and meal preparations. She further stated, the dog was not the issue and she felt that it was because the surveyors were at the facility. SW 1 confirmed the discharge was inappropriate. SW 1 confirmed she called Adult Protective Services once she returned to the facility because she knew the resident could not walk, go to the restroom, and do anything for herself. SW 1 also stated Resident A did not have the medications she needed and was unable to survive without assistance. Resident A's primary physician at the facility did not respond for an interview. On 10/16/14 at 1:18 P.M., NP stated he was notified of Resident A's discharge after the resident left the facility. According to the facility's undated policy, Discharge and Transfer of Residents, "To ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider.... The Attending Physician will review the resident's progress and determine a possible discharge date...The Attending Physician will provide an order for transfer or discharge which explains the reason for the transfer or discharge if the transfer or discharge is..." Resident A was discharged from the facility on 9/9/14 at 3:30 P.M., and left unattended at her residence. A neighbor called local law enforcement which arrived at Resident A's home at 7 P.M., and placed Resident A on a legal hold for grave disability at 9:45 P.M. Resident A was transported to a local emergency room and after a 6 day stay was admitted to a different skilled nursing facility.According to the police report dated 9/9/14, Resident A was found, unable to open the door, laying on her bed and a very dirty trailer from front to back. Resident A also had a "catheter in place and it appeared full". "Resident A was not able to sit up in her bed..not able to test her blood sugar levels as required twice a day, unable to get to the refrigerator without assistance.. is not able to get up to drink water or get food.. Resident A is also required to wear adult diapers, however she is unable to change them herself." According to the acute care facility's admission history and physical, dated 9/10/14, Resident A's diagnoses included, grave disability with failure to thrive, urinary tract infection, metabolic encephalopathy, type 2 diabetes, hypertension, hyperlipidemia, chronic congestive heart failure, left heel decubitus, dementia, pneumonia, and chest pain.Resident A also presented to the emergency room with two pressure ulcers (unstageable, on heel and toe), "urinary indwelling catheter bag that was full and the tubing was clogged, and Resident A had a "strong smell of urine and feces." On 10/15/14 at 2:15 P.M., an Immediate Jeopardy was called in regards to Neglect; based on the facility not providing services and goods to meet the needs of Resident A who discharge. The facility did not assess Resident A's mental capacity to ensure a safe discharge. Resident A, who was not able to provide care for herself, was left without food. In addition, the facility did not assess for safety, had no physician involvement or physician order. Resident A had severe medical needs that required monitoring and medications. Resident A was transferred from a taxi to her bed and left in her home, alone. Police arrived hours later and placed Resident A on a legal hold due to grave disability. Resident A required admission to an acute care facility for grave disability within hours of her discharge from the facility. These violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011262 |
A |
06-Feb-15 |
K4YL11 |
14872 |
F-327 ?483.25(j) Hydration ?483.25(j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and healthThe facility dietician, nursing staff, and physician failed to monitor the fluid intake and act upon abnormal laboratory values, to prevent dehydration in 1 of 24 sampled residents (Resident 77).As a result the resident was transferred to the general acute care hospital due to a dehydrated state.Findings: Resident 77 was readmitted to the facility on 3/15/14, with diagnoses which included a gastrostomy (feeding tube in the stomach), difficulty swallowing, and stroke per the Face Sheet. On 7/10/17, Resident 77 was transferred to a general acute care hospital emergency room.Per the MDS (Minimum Data Set) dated 3/31/14, Resident 77's BIMS (Brief Interview for Mental Status) was scored at 7, meaning the Resident had severe impairment of cognitive functioning (related to memory and ability to process thoughts).On 9/16/14 at 12:00 PM, Resident 77 was observed in the dining room sitting in a chair being assisted with lunch. Resident was quiet and non-talkative while being fed. Per the Certified Nursing Assistant on 9/16/14 at 12:00 PM, the Resident only speaks Tagalog and only a few English words on occasion. Resident 77 was eating chicken, potatoes and corn bread with assistance from the CNA.Per the admission orders dated 3/15/14, NP (Nurse Practitioner) 1 ordered Resident 77 to be NPO (nothing by mouth). In addition NP 1 ordered the resident to have Fibersource HN (liquid nutrition) at 55 cc's every 24 hours with a flush of 150 cc's of water every 8 hours through his gastrostomy tube.Per the Nursing Dehydration Assessment Score dated 3/15/14, the resident's score was assessed at 70. According to the Dehydration Assessment sheet, "High Risk-50+".Per the Nutrition Nursing Care Plan dated 3/15/14, the resident was at risk for weight loss and dehydration due to difficulty swallowing. The care plan included interventions which included: "Offer assistance as needed; Dietary Consult; Monitor of signs and symptoms of dehydration and notify MD as indicated; Dietician to assess nutrition and hydration as needed." Per the Nutritional Screening Assessment dated, 3/17/14, the Dietary Services Supervisor (DSS) documented Residents 77's weight as 137.2 lbs., and a Body Mass Index (a number calculated from a person's weight and height that provides a reliable indicator of body fat) of 25.1. Based on the Nutritional Screening Assessment, the resident's enteral nutrition (the delivery of nutrients in liquid form directly into the stomach) was to provide 1320 cc's of fluid, 1584 calories and 71 gm's of protein. In addition the DSS documented the following "TF (tube feeding trial), Res (Resident) tolerating TF well, spoke to ST (Speech Therapist) who stated the trial for po (by mouth) tolerance is going well and has been consuming 100% of B (breakfast), could not get a hold of family to find out UBW (usual body weight).On 3/17/14, NP 1 documented, "H & P (History and Physical) dictated. Meds and chart reviewed. CBC (Complete Blood Count) BMP (Basic Metabolic Panel) 1 week. RD (Registered Dietician Consult)."On 3/18/14, NP 1 ordered for Speech and Language services 5 times a week for 4 weeks due to Resident 77's difficulty swallowing.Per the RD (Registered Dietician) 1 notes dated 3/20/14, "meds/labs/skin noted, rec'd to change TF to Fibersource HN @ 70 ml x (times) 18 hours to provide 1260 ml/1512 kcal (kilocalories)/1020 ml of water to begin a 9 am until finished. Goals (1) Will tolerate TF (2) No sig (significant) wt. change (3) BM (bowel movement q (every) 1-3 d (days) (4) No s/s (signs and symptoms of dehydration, continue to monitor F/U (Follow Up) PRN (as needed).There was no further documentation by RD 1 until 5/7/14, a total of 37 days.On 5/7/14, RD 1 documented, "RD TF note, Spoke with ST who stated that he is doing well with meals. 4/21/14-133 # (lbs.), 4/14/14-133#, 3/2414-134.6 #. No new meds, labs 4/21 BUN 30 ? (elevated) no new skin issues. ST adding extra meal and will be getting L (lunch) and D (dinner) Mechanical Soft with thin liquids. Received change TF to Fibersource HN @ 75 ml/900 kcal/41 gm protein/ 607 ml water, change fluid flush to 200 ml TID, continue to monitor, F/U PRN."In addition the RD documented the following on 5/7/14. "Nutritional Update: Res (resident) seen/screened by ST noted L (lunch) D (dinner) meals. OK mechanical soft diet will monitor tolerance. ST to F/U progress." On 9/17/14 at 1:35 PM, RD 2 acknowledged the clinical record contained no documented visits by the RD from 5/7/14 until Resident 77's transfer to the general acute care hospital on 7/10/14. Per RD 2, Resident 77 should have been assessed by the RD at least every 30 days. Per the Intake and Output Record dated 4/1/14, Resident 77's Intake and Output was monitored between 3/25/14 and 3/31/14 (I & O (I & O documents how much liquid was consumed and how much was eliminated as urine). There was no I & O documented for the days between 3/17/14 and 3/25/14, nor any I & O documented after 3/25/14.Per the Laboratory Report dated 3/26/14, Resident 77's BUN (Blood Urea Nitrogen-A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys and liver are working) was "28 H (high). Normal BUN reference levels are 7-25 mgdl (milligrams per deciliter).Per the physicians order sheet dated 3/26/14, NP 1 ordered, "CBC, BMP next Monday".Per Resident 77's Laboratory Report dated 3/31/14, "Glucose 112H (High-Normal Range 70-99); BUN 29 H "High" BUN Normal 7-25 mgdl (milligrams per deciliter); WBC (White Blood Count) 12.7 "High-Normal Range 4.8-10.8; Hgb (Hemoglobin- the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues) 11.7 L "Low" Normal Range 12.0-16.0; Hct (Hematocrit-is the proportion, by volume, of the blood that consists of red blood cells) 35.6 % (percent) L "Low-Normal range 37.0-47.0 %" Per the NP 1's Monthly Visit note dated 4/10/14 at 0900, "S (Subjective): No complaints, no reports of acute events, tolerating tub feeding. No CP (chest pain), no SOB (Shortness of Breath). O (Objective): VSS (Vital signs stable) afebrile (no fever), Wt. 133 lbs.". There was no documentation by NP 1 related to Resident 77's elevated BUN level or other elevated laboratory values.On 4/19/14, NP 1 verbally ordered, "CBC and BMP for Monday".Per the Laboratory Report dated 4/21/14, Resident 77's BUN was 30 H "High" Normal 7-25 mgdl (milligrams per deciliter); and his Chloride (is a type of electrolyte. It works with other electrolytes such as potassium, sodium, and carbon dioxide (CO2). These substances help keep the proper balance of body fluids and maintain the body's acid-base balance) 110 H "High" Normal Range 98-107.There was no visit documented by an attending physician and or NP for the month of May 2014. During Resident 77's stay at the facility between 3/15/14 and until his transfer to the general acute care hospital on 7/10/14, there is no documentation the resident was seen by his attending physician in person after admission, as required by the regulations.Per the Monthly Visit note dated 6/20/14 by NP 1, "S (Subjective): No complaints, No SOB (shortness of breath) No Chest Pain".There was no documentation by the NP to acknowledge the residents abnormal laboratory values on 3/26/14, 3/31/14, or 4/21/14. There was no documentation by the NP to suggest Resident 77 was discussed in an Interdisciplinary Team meeting or Case Conference.There were no further NP or Attending Physician notes dated past 6/20/14, yet between 3/15/14 to 7/9/14, there were 18 separate Speech Therapy and/or Diet Clarification orders written for Resident 77.Per review of the Physician Order Sheet, NP 1 ordered on 7/9/14, for all meals to be given PO (by mouth). In addition NP 1 ordered, "ST eval, CBC, BMP, UA (urinalysis) and C & S (Culture and Sensitivity in AM." Per the laboratory results dated 7/10/14 at 12:55 PM, Resident 77's BUN was 31 H "High" (Normal Values 7-25 mgdl (milligrams per deciliter); Creatinine (the kidneys maintain the blood creatinine in a normal range. Creatinine (has been found to be a fairly reliable indicator of kidney function. Elevated creatinine level signifies impaired kidney function or kidney disease) 1.45 H "High"; Sodium (The sodium blood test measures the amount of sodium in the blood) 151 H "High" Normal 136-145; Chloride (Chloride is a type of electrolyte. It works with other electrolytes such as potassium, sodium, and carbon dioxide to help keep the proper balance of body fluids and maintain the body's acid-base balance) 110 H "High" Normal Values 98-107.Per the Licensed Personnel Weekly Progress Notes dated 7/10/14 at 7 PM, "Notified [name of attending physician] regarding labs abnormalities 151 NA (Sodium)-then faxed labs to MD office. T.O. (Telephone order) 1/2 N. S. ((Normal Saline-Normal saline is the name for the 0.9% strength of sodium chloride (salt) solution in water) @ 100 cc's/hour x 2 liters then BMP noted."Per the Licensed Personnel Weekly Progress Notes dated 7/10/14 at 8:45 PM, "T.O. (Telephone Order) Transfer pt. to [name of general acute care hospital] Dx. (Diagnosis) Dehydration (pt. had a hard stick for IV) noted."Per the Patient Transfer Form dated 7/10/14, per Section 4 Physicians Orders On Transfer, "Transfer pt. to [name of general acute care hospital], dehydration, hard stick IV." Per Section 20 Nursing Assessment and Recommendations, "Pt. hard stick. Order was 1/2 NS 100 cc/hour, but unable to insert IV. Per [Name of attending physician] transfer pt. out to hospital (see lab)." On 9/17/14 at 10:00 AM, ST (Speech Therapist) 1 stated she coordinated care with the dietician and nursing as such, "I talk to them on a daily basis. They changed the RD. But I always text them. I always talk to nursing and dietary".On 9/17/14 at 10:00 AM, the ST was asked if it would be important to maintain an I & O on a patient with a tube feeding and with so many changes in Resident 77's Speech Therapy orders. The ST stated, "It depends, yes, but if the patient was a recreational feeder, no".The ST was asked if she documented evidence of care coordination between herself, the physician, dietary, nursing related to the resident's goals regarding food and water intake. The ST stated, "I would document in the notes, kitchen notified. I always reported to his medication nurse".When asked if the different disciplines in the facility conductedcare conferences for Resident 77, the ST stated, "Not in a formal setting".The ST was asked if Resident 77's case was considered complicated, and the ST stated, "Yes". Based on her yes answer, the ST was asked if it would be important to discuss Resident 77's care with all disciplines. The ST stated, "I wouldn't say it was done in a formal meeting. But I did discuss his care with the ADON (Assistant Director of Nursing)."The ST went on to state she was never asked to participate in case conferences regarding the patients she cared for in the facility.On 9/17/14 at 1:35 PM, RD 2 stated [name of RD 1] was the dietician in March. RD 2 acknowledged Resident 77 was only seen by a Registered Dietician twice between his admission to the facility on 3/15/14 and his subsequent transfer to the general acute care hospital on 7/10/14. RD 2 stated the resident should have been seen by an RD at least every 30 days.When asked how a RD would be evaluate Resident 77's fluid intake, the RD 2 stated, "We would have seen how much he was drinking and we would request more information such as an I & O".According to RD 2, the RDs' would be following up monthly with the tube feeders, but stated, "We did not have the time allotment to meet the needs of the residents". RD 2 was asked if she was ever asked to participate in a care conference for Resident 77, and RD 2 stated, "No".The RD was asked based on her education and experience what her opinion was regarding Resident 77's laboratory report dated 7/10/14. The RD stated the resident's laboratory values were indicative of dehydration. On 9/17/14 at 8:00 AM, LN 10 stated residents with tube feedings should be on I & O if they come in with a Tube Feeding. LN 10 could not comment why Resident 77 did not have his I & O documented upon admission or afterward.Resident 77's clinical record did not contain any Interdisciplinary Team notes or Care Conference notes to indicate the Physician, Nurse Practitioner, Nursing Department, Speech Therapist, or Dietician met to discuss Resident 77's on-going care, multiple changes in his Speech Therapy orders or his hydration needs.On 9/18/14 at 2:30 PM, the Director of Nursing (DON) stated the facility should be doing care conferences. A joint clinical record review with the DON failed to produce any documented Interdisciplinary Team meeting notes or Case Conference notes for Resident 77. Per the DON, Case Conferences were to be done upon admission, quarterly or as needed if the patient's situation changed.MD 2 was not available on site at the facility during the survey for interview. In addition, the NP was not available during the survey for interview.On 9/17/14 at 8: 45 AM and on 9/18/14 9:12 AM, messages were left on the voice mail of the NP. There were no return calls to the survey team.On 9/18/14 at 8:47 AM, MD 2 stated in a telephone interview she could not comment on Resident 77's care since she was not currently on site at the facility. MD 2 was asked if she was aware of Resident 77's ongoing elevated BUN levels, MD 2 declined to answer. MD 2 asked if she could call the survey team back for interview, but never returned the call.Per the undated facility policy entitled Interdisciplinary Team Meetings, "1. Meetings will be held as follows: 2. Social Services will schedule the meetings. 3. Social Services will notify appropriate families and residents of the schedule for the upcoming week. 4. All disciplines will complete their MDS Sections, RAPS, and Update their care plan entries prior to the meetings. 5. The Charge Nurse will notify the Nursing Assistant's responsible for the resident of the impending meeting in order to assure the resident will be brought to the meeting. 6. All departments will attend meetings..." Per the undated facility policy entitled Care Planning, "IV. IDT MeetingsA. The facility will invite the resident and/or his/her family or legal representative to care planning meetings and use its best effort to schedule care planning meetings at times convenient for the resident, family, and/or legal representative.B. The care conference will be documented on NP-04-Form A-IDT Conference Record." The violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 080000056 |
CLAIREMONT HEALTHCARE & WELLNESS CENTRE, LLC |
080011263 |
A |
06-Feb-15 |
None |
10479 |
F-226 ?483.13(c) Staff Treatment of ResidentsThe facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. ?483.13(c)(1)(i) Staff Treatment of Residents (1) The facility must-- (i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; The facility staff failed to protect residents, investigate, and report allegations of abuse for 1 of 24 sampled residents (40) that exhibited assault behaviors toward the residents on multiple occasions. In addition the facility failed to investigate and report 1 of 24 sampled residents (50) regarding an allegation of abuse. As a result, the facility's failure to protect residents, investigate, and report the allegations of abuse had the potential to place all residents at risk for further abuse in the facility. Findings: 1. Resident 40 was re-admitted to the facility on 2/9/14, according to the facility's Face Sheet. Resident 40's clinical record was reviewed on 9/10/14. On 5/3/14, a Psychotropic Medication Review was completed by the psychiatrist. The Physician noted, "Pt (patient) has shown increasing aggressive behaviors when upset. States that it happened today with a pt. telling him to get out of here." The Nurses Notes were also reviewed. On 6/19/14 at 2 P.M., Licensed Nurse (LN) 8 documented a request for a psychiatric evaluation for Resident 40 related to inappropriate behaviors.Five days later, on 6/24/14 at 1:45 P.M., located in the nursing documentation was; the nursing staff left a message for the psychiatrist and requested a referral for a psychiatric evaluation. At 2:30 P.M., the primary physician ordered a psychiatrist evaluation secondary to increased agitation and increased episodes of inappropriate behavior. Again on 7/2/14 at 3 P.M., a nurse documented, Resident 40 had" increased episodes of aggression and agitation, towards staff and other residents."The nurse also documented that Resident 40 threatened the staff when they counseled him about his "inappropriate touching of staff and female residents." A Psychologist note dated 7/3/14, documented, "Psych consulted requested due to reoccurrence of behavioral, agitation, lability...poor impulse control, inappropriate touching of female staff and peers and poor boundaries...Intermittent explosive disorder..." On 7/4/14 at 1:15 P.M., LN 8 documented, a Certified Nursing Assistant (CNA) reported that Resident 40 was observed "touching a female resident's thigh close to her genital area." LN 8 also documented that while attempting to pull Resident 40 away from the female resident, Resident 40 struck the CNA in the mouth. The CNA sustained an upper lip laceration. The Medical Doctor (MD) was notified and again the MD recommended a psychiatric consultation (3rd time requested: 6/24, 7/3, and 7/4.) On 7/8/14 at 2 P.M., the nurse documented in the nurses notes," inappropriate behavior by Resident 40 when he flipped his middle finger at the physician." On 7/10/14, the physician ordered Provera (A hormone medication), 10 mg every morning for sexual deviation as exhibited by "Sexually touching etc., of staff and demented residents..." According to the Nurses Weekly Summary dated 7/12/14, documented by a nurse; "(Resident 40) with episodes of increased aggression and agitation." According to the Interdisciplinary Team Meeting notes dated 8/4/14, "No behavioral issues identified..." On 8/8/14 at 9:45 A.M., the Nurses Notes indicated that the physician was contacted and informed of Resident 40's aggressive behavior towards another female resident.On 9/9/14, after the facility was informed by a surveyor, of a failure to report, investigate, and protect other residents, the facility self-reported the abuse which occurred on 7/4/14 to the Department, 68 days after the date of the abuse incident. According to the Nurses Notes, dated 9/10/14, Resident 40 was transferred to an acute hospital for "evaluation and adjustment of medication...",On 9/10/14 at 1:45 P.M., Resident 41 was interviewed. Resident 41's room housed three residents. Resident 39 was located in Bed A, Resident 40 was located in Bed B, and Resident 41 was located in Bed C. Resident 41 stated, "We still have problems with Resident 40."Resident 41 said that residents are scared of Resident 40 because he "hits people." Resident 41 also said he had not been hit, but he had seen Resident 40 hit Resident 39 many times and that staff were aware of the incidents. He further stated, "Resident 39 and Resident 40 are like oil and vinegar." Resident 41 added, "Administration keeps saying if he does it one more time, he is out." Resident 41 said he did not understand why Resident 40 was not moved to another room. Resident 41 stated, "He could go off anytime, he is dangerous." Resident 41 said that he tried to be the peace keeper and tried to keep it calm in their room. On 9/11/14, the Administrator (ADM) was interviewed. The ADM was unaware of the incident on 7/4/14, until the abuse was identified by the Department during a complaint investigation on 9/9/14. On 9/15/14 at 8:50 A.M., LN 8 was interviewed. She confirmed her documentation of the 7/4/14 incident. She stated that she separated the 2 residents and had another CNA remove Resident 40 from the main dining room. She further stated that she informed the Previous Director of Nursing (PDON) of the incident and did not know if an investigation by the facility was conducted. At the time of this annual recertification survey, PDON was no longer employed by the facility, and was not available for interview. 2. Resident 50 was re-admitted to the facility on 8/13/14, according to the facility's Face Sheet. On 9/11/14 at 10:30 A.M., Resident 50 was interviewed. During the interview, Resident 50 stated, that in July 2014, he told PTA 1, he was considering leaving him some money when he died. Resident 50 further stated, Physical Therapy Aide (PTA) 1 shared this information with PTA 2 without his permission. PTA 2 informed Resident 50, he was going to run a background check on him to verify if he had the money. Resident 50 stated he was very worried that PTA 2 had done the background check on him. Resident 50 further stated he was fearful the 2 PTAs would discover his entire financial status. On 9/12/14, Resident 50's clinical record was reviewed jointly with LN 9.According to the nurse's note, dated 7/23/14 at 9 A.M., LN 9 documented, "Resident making statements that PT staff member has it out for him and that another PT staff member ruined his chances..."LN 9 confirmed her documentation dated 7/23/14 at 9 A.M. LN 9 had to reassure the resident he was safe and that no one was out to "get him." LN 9 stated she reported the allegation to the PDON on 7/23/14.There were no Interdisciplinary Team Meeting notes regarding the allegation of abuse in the clinical record. On 9/12/14 at 8:30 A.M., the Rehabilitation Director Physical Therapist (RDPT) was interviewed. He was unaware of the incident and reviewed the Therapy Staff meeting minutes. The RDPT was able to find documentation of the incident, but did not know if an investigation had been conducted by the facility. According to the facility's undated policy and procedure, entitled, Resident Abuse - Recognizing Symptoms, "To protect residents from abuse, neglect, and mistreatment by ensuring that all facility personnel, volunteers, and visitors promptly report any incident or suspected incident of resident neglect, abuse, mistreatment, or misappropriation of resident's property to the Administrator." "D. The Administrator will report the alleged incident to the Department of Public Health within 24 hours; and E. An immediate investigation will be initiated..." At the time of this annual recertification survey, PDON was no longer employed by the facility, and was not available for interview. On 9/12/14 at 9:34 A.M., the ADM was interviewed and was unaware of the incident. She confirmed that no investigation had been conducted regarding the incident. During the same interview, the ADM further acknowledged that the facility's policy and procedure was not followed and the facility did not report the 7/23/14 allegation of abuse to the Department until 9/9/14, 49 days after the allegation. Due to the facility's failure to: 1. Investigate and report the 2 allegations of abuse; and 2. Protect the residents in the facility by: A. Assessing the dangerous behavior of Patient 40; B. Implementing a behavior plan and preventing Resident 40 from assaulting other residents; C. Ensuring all staff members protect residents and report incidents of abuse; D. Utilize IDT and QA (Quality Assurance) for guidance with difficult issues that are not immediately addressed regarding resident safety and abuse. The survey team called an Immediate Jeopardy on 9/12/14 at 1:04 P.M., and informed the ADM and Vice President of Clinical Services (VPCS). The team requested the ADM and the VPCS provide the survey team with immediate measures the facility would implement to ensure the safety of the residents. Five days later, on 9/16/14, the survey team received and reviewed the Plan of Correction (POC) presented by the facility. According to the POC: 1. The facility investigated Resident 40 and Resident 50 incidents related to abuse; 2. The staff involved were placed on investigational leave; 3. The facility staff were inserviced on the facility's Abuse Policy and Procedure; 4. The Department Managers would observe how the staff were treating residents and would monitor signs and symptoms of abuse for any resident within the facility on a daily basis; 5. The Department Managers were inserviced on the facility's Abuse Policy and Procedure with emphasis on reporting to the Abuse Coordinator (ADM) immediately; 6. The contracted services (Rehab) would jointly investigate any allegation of abuse as it pertained to contracted services staff members; 7. The Abuse Coordinator (ADM) would report on a monthly basis, all allegations of abuse investigations to the Quality Assurance Committee from resident satisfaction surveys and observations. The survey team accepted the Allegation of Removal of Immediate Jeopardy (POC) and informed the ADM at 4:20 P.M., the Immediate Jeopardy was abated. The violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 090000714 |
CB/Fortuna Group Home |
090012185 |
B |
21-Apr-16 |
ID9J11 |
11553 |
Title 22 76916 Policies and Procedures (a) Each facility shall establish and implement the following policies and procedures (8) A procedure by which allegations of client abuse are immediately reported to the administrator. Such procedures shall assure that: (A) All alleged violations are thoroughly investigated. (B) The results of the investigation are reported to the administrator within 24 hours of the report of the incident. (C) Substantiated instances of client abuse are reported to the Department by telephone within 24 hours of the report of the incident, and confirmed in writing Health and Safety Code - ?1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.The facility failed to ensure that Client 1 was kept free from abuse, when Client 1 was sexually assaulted ([definition from DOJ- Department of Justice]- Sexual assault is any type of sexual contact or behavior that occurs without the explicit consent of the recipient. Falling under the definition of sexual assault are sexual activities as forced sexual intercourse, forcible sodomy, child molestation, incest, fondling, and attempted rape) by Client 2. This failure compromised Client 1's safety, which resulted in an increased risk for mental and physical stress. Client 1 was not protected from sexual assault by Client 2, who was identified to exhibit inappropriate touching and sexual act that required frequent staff monitoring. Client 1 had two incidents of sexual assaults on 11/4/15 that happened on same day, and another incident of sexual assault on 11/10/15. This incident posed threat to Client 1's safety and continues harm. As a result, these incidents had caused Client 1 from emotional distress and suffering as reported by the family to direct care staff (DCS) 1 related sudden change in behavior by screaming and refusal to enter the house, crying, and refusals to eat meals and only ate when spoon fed by staff.The facility failed to ensure staff implemented facility policy and procedure related to abuse reporting. Facility staff failed to report an abuse incident within the required time frame as indicated by state law.Client 1 was admitted to the facility on 7/10/05 with diagnoses that included angelman's syndrome (a genetic disorder characterized by intellectual disability, severe speech impairment, and problems with movement and balance) per the Individual Data sheet.Per the Eating Guidelines assessment dated 6/30/15, "Client 1 was able to eat finger foods independently, needs physical prompts to eat with a spoon of food..."Client 2 was admitted to the facility on 9/26/02 with diagnoses that included moderate intellectual disabilities per the Individual Data sheet. The facility reported the incident to the Department via fax on 11/7/15 at 9:48 A.M. This incident report for 11/4/15 indicated that "Client 2 approached Client 1 from behind her, from a standing position, placed his hand between her legs, and appeared to rub his hand across her vagina towards buttocks. This action occurred twice. Client 2 also attempted to insert his fingers in her vagina through her pants and incontinence brief while standing behind her." This incident was reported to the Department 3 days after the incident occurred.On 11/10/15 at 11:45 A.M., the qualified intellectual disabilities professionals (QIDP), house Nurse, and the behavior specialist were interviewed. The QIDP stated that two incident occurred at 5:30 P.M. on 11/4/15, DCS 3 reported to the QIDP next day on 11/5/15 at 5:30 P.M., however the facility held meeting on 11/6/15. The QIDP stated that the facility called to Client 1's primary physician at 2:30 P.M., on 11/6/15, and called the local law enforcement/police at 4:00 P.M. on 11/6/15, faxed the report to the Department at 5:00 P.M. on 11/6/15, and reported to Client 1's family member/responsible party (RP) on 11/6/15 after 5:00 P.M. The QIDP and the house nurse and the behavior specialist acknowledged that it was not reported to the physician, police, RP, and the Department in timely manner.On 12/30/15 at 2:02 P.M., a telephone interview was conducted with DCS 2. DCS 2 stated that on 11/4/15 between 4:00 P.M. and 5:00 P.M., DCS 2 was in the kitchen preparing meals for dinner when she heard DCS 3 called Client 2's name and telling "Don't do that." DCS 2 stated as she turned to her right, DCS 2 witnessed Client 2 grabbing Client 1 between her legs and around private area then walk away towards his room. DCS 2 acknowledged to witnessing two incidents on 11/4/15. When DCS 2 was asked if the first witnessed incident was reported, DCS 2 stated "No. I don't think it should be reported." DCS 2 stated that about two minutes after, Client 2 came back and grabbed Client 1 again on the same spot. DCS 2 stated that Client 2 put his hands between Client 1's legs, rub across the groin, and private area. DCS 2 stated that she walked towards Client 1 and told Client 2 to let go off Client 1. DCS 2 stated that only the second incident was reported to the supervisor at and the plan was to have a 1:1 staff assigned for Client 2.On 2/24/16 at 3:51 P.M., a telephone interview was conducted with DCS 3. DCS 3 stated that on 11/4/15 before dinner, she remembered Client 1 stood by the "Atrium" and looking out of the window. DCS 3 stated that there were three staff who worked that day. Client 2 was walking from his room "galloping" and ran up next to Client 1, bent over, and put hands between Client 1's legs. DCS 3 acknowledged that there had been reports of incidents in the therap (electronic documentation) log about Client 2's behavior of inappropriate touching. DCS 3 stated that after the incident, the plan was to keep an eye on Client 2, and apart from Client 1. DCS 3 acknowledged that Client 1 was not protected and Client 2 was not properly supervised and monitored.On 12/29/15 at 3:00 P.M., a telephone interview was conducted with the house manager (HM). The HM stated that she was aware of the three sexual assault incidents, two incidents on 11/4/15 and one incident on 11/10/15. The HM acknowledged that all staff were aware of Client 2's inappropriate touching and history of inappropriate touching at the day program that Client 2 was asked to stay home from the day program on 9/11/15, to protect Client 2's safety and the safety of the other consumers (clients) as indicated in the Behavioral Summary Report dated 11/2/15. The HM stated that the plan for Client 2 was to have a 1:1 staff, and on 11/10/15, she was assigned to Client 2 on a 1:1 monitor. The HM stated that on 11/10/15 between 3:00 P.M. and 4:00 P.M., all of the 6 clients were having snacks in the dining area, staff were present, and HM was standing right next to Client 2. The HM stated that Client 1 was on the other side of the table and got up of the table when a family friend came to visit Client 1. The HM stated that there two clients seated next to her that were arguing and intervened with them. The HM stated that all of a sudden, Client 2 stood up and went fast to Client 1, then Client 1 began crying and ate a little bit of dinner. The HM acknowledged that she should have focused her attention to Client 2 to prevent from coming near to Client 1. HM acknowledged that Client 1 was not protected and Client 2 was not properly supervised and monitored.On 12/29/15 at 3:53 P.M., a telephone interview was conducted with DCS 4. DCS 4 stated that on 11/10/15 around 4:00 P.M., six clients were at the table eating snacks. DCS 4 stated that Client 1 was seated on one side and Client 2 was seated on one head side of the table. DCS 4 stated that Client 1 had finished eating and went to the kitchen, the QIDP was at the hallway near the kitchen, and the HM was standing next to Client 2. DCS 4 stated that a family friend of Client 1 came over and stood at the hallway ledge. DCS 4 stated that Client 2 got up and came towards the kitchen very fast, grabbed Client 1 between her legs, then move away from Client 1. DCS 4 stated that the HM took Client 2 and away from the area. DCS 4 stated that Client 1 was moved away from the house, by the family friend and DCS 1 because Client 1 "was shaky and very upset." DCS 4 acknowledged that Client 2 was on 1:1 monitor and the incident could have been prevented if he was closely watched..." On 3/9/16 at 2:42 P.M., a telephone interview was conducted with a family member (FM). The FM stated that a notification of sexual assault incidents on 11/4/15 was received from the facility on 11/6/15, 2 days after the incident occurred. The FM stated that despite the facility's assurance that Client 2 would be closely monitored from coming near to Client 1, safety of Client 1 was not guaranteed due to the repeated incidents. The FM stated that there was an ineffective monitoring system since the incidents happened three times in one week. The FM acknowledged that the notification was late and expressed of feeling devastated to the fact that it happened twice in one day on 11/4/15. Also, the FM complained that the facility had not informed the family of Client 1's changes in condition related to refusals to eat meals and sudden change of behavior such as screaming, crying, and refusal to enter the house."The FM further stated that these incident affected Client 1 and her family members' well-being and caused mental stress.On 3/24/16 at 12:20 P.M., a telephone interview was conducted with the program manager (PM). The PM acknowledged that the facility had not developed a written policy and procedure related to protection of client towards client aggression. A review of the facility's policy and procedure (P&P) titled Consumer Rights and Protection was conducted. The P&P dated 5/14 indicated, "...Anyone witnessing abuse must intervene immediately to protect the individual. Suspected abuse...must be reported immediately to the facility administrator or the administrator's designee, who will then initiate an investigation...Reporting Suspected Abuse: All employees...are designated as mandated reporters by the State of California, and as such are required to immediately report any incidents of reasonably suspected abuse to the Ombudsman or local police..." The facility failed to develop a policy and procedure on abuse regarding client's rights and protection from other client's aggression when Client 1 was sexually assaulted by Client 2 and abuse reporting was delay. The facility failed to protect Client 1 and supervise and monitor Client 2. All facility employees are mandated reporters, and as required by state laws are required to report alleged or suspected abuse within 24 hours to the Ombudsman, the Department/CDPH, and law enforcement. Despite knowledge of an incident of client-to-client abuse occurring, it was not reported within the required time frame by facility staff. As a result, the notification of sexual assault incidents had been made two days after incidents occurred on 11/4/15. An abuse incident was not reported to the Ombudsman, CDPH, and law enforcement within 24 hours as required. This violated state law and had the potential to put Client 1's health, safety, and security at risk, and posed a continuous threat to all other clients' safety.The above violations either jointly, separately, or in any combination had a direct or immediate relationship to health, safety, or security of patients |
| 630010921 |
Crossroads III |
110009175 |
B |
13-Mar-15 |
RWEQ11 |
5429 |
W&I 4502(h) 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 ensure the rights of Client 1, when Client 1 accused DCS B of choking her, after red bruising was discovered on Client 1's neck.The facility is a six-bed Intermediate Care Facility for the Developmentally Disabled-Habilitative, licensed to provide care and services to people with varying degrees of developmental disability. Client 1 diagnoses included motor impairment, vision impairment, and hearing loss. Assistive devices included a hearing aid, eyeglasses, and wheelchair. During an observation and interview on 1/14/12 at 2:55 p.m., in Client 1's single bedroom, when asked to describe the events on the night of 1/12/12, Client 1 stated that she needed to urinate at about 2 a.m. Client 1 stated that she made it to the door of her bedroom the night of 1/12/12 and Direct Care Staff (DCS) B showed up and asked her what she wanted. Client 1 indicated DCS B started shaking her finger at her, was bad talking, and Client 1 almost tripped. Client 1 stated that she could not make out what DCS B was saying because she did not have her hearing aid in place.Client 1 stated and demonstrated, by lying down on the bed, how DCS B, put her hands near her throat and choked her pushing into the bed.During an observation of Client 1's neck on 1/14/12 at 3 p.m., several red marks were visible. (See pictures).In the, "Special Incident Report," received from Client 1's day program, the nurse examined Client 1's neck and described a red mark, on the left side of Clients 1's neck as approximately 1/2-inch in length, with another small red mark below it.During an interview on 1/14/12 at 4:10 p.m., DCS C stated that Client 1 told her that DCS B choked her. Staff C stated that she saw bruises when she was helping Client 1 get dressed, "Looks like she was held down." DCS C stated that she called the House Manager, who was at home, and reported the allegations and what she had seen. During an interview on 1/14/12 at 4:30 p.m., the House Manager (HM) stated that she received a call about the choking allegation, but did not report it because she felt that it was Client 1's normal behavior of screaming, hollering. and throwing herself around. The HM stated that before this incident, DCS B told her that Client 1 did not like DCS B, and they did not get along. When asked who she reported this problem to, the HM stated no one. When asked if Client B was given training to help her work with Client 1, the HM stated, "no." When asked about the allegation of choking, DCS B stated that she never touched Client 1 near her neck. DCS B stated that she worked the following Friday night, and Client 1 did not call all night. During an interview on 1/14/12 at 4:15 p.m., DCS A stated that Client 1 called DCS B a witch and stated that DCS B choked her.During an interview on 1/14/12 at 3:45 p.m., the Qualified Intellectual Disabilities Professional/Administrator (QIDP/Administrator) stated that he met with each client one to two times per week; however, has never inquired if they felt safe or how they got along with staff. Client 1 told him she did not like DCS B, but did not give any specifics why she did not like her. The QIDP stated that he did not follow-up on Client 1's dislike for DCS B. During an interview on 1/14/12, at 3:40 p.m., Client 2 stated Client 1 and DCS B did not get along, and Client 1 was always telling DCS B to get out of her room and to leave her alone. During an interview on 1/14/12, at 4:20 p.m., Client 3 stated that Client 1 and DCS B did not get along, and Client 1 yelled and woke her [Client 3] out of a sound sleep the night of 1/12/12. During an interview on 1/15/12 at 1 p.m., DCS B stated that Client 1 did not like her. DCS B stated that she only assisted Client 1 to get up at Client 1's request, and Client 1 did not want to be held onto. DCS B indicated Client 1 never put hearing aids in at night and yelled and screamed. DCS B stated that she told the HM that Client 1 did not like her, but nothing was done about it. The HM told DCS B that is the way she [Client 1] was. Review of the facility's policy and procedure, "Abuse Prevention, Investigation, and Reporting," (no date) indicated under the heading "All other abuse," page 2, "[Facility Name] shall identify, correct, and intervene in situations in which abuse or neglect is more likely to occur....... and deploy staff....that are likely to precipitate abuse or neglect." Therefore, the facility failed to ensure the rights of Client 1, when Client 1 accused DCS B of choking her, after red bruising was discovered on Client 1's neck.This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000003 |
Creekside Rehabilitation & Behavioral Health |
110009252 |
B |
16-May-12 |
91T511 |
1893 |
1418.21(a)(1)(B) Health & Safety Code (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: (B) An area used for employee breaks. 1418.21(a)(1)(C) Health & Safety Code (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. The facility violated the regulation when the facility staff failed to post the facility overall rating in an employee break room and a community room used by residents. This failure resulted in the potential residents and staff not being informed of the facility's overall rating. During a tour of the facility with the facility Administrator on 4/19/12 at 10 a.m., overall facility ratings were not posted in any of the communal areas for residents or employee break rooms. The facility Administrator stated facility staff had failed to post the overall rating after re-painting. Therefore, the facility violated the regulation when the facility staff failed to post the facility overall rating in an employee break room and a community room used by residents. This failure resulted in the potential residents and staff not being informed of the facility's overall rating. This failure had a direct relationship to health, safety, or security of patients. |
| 010000037 |
Cloverdale Healthcare Center |
110009476 |
B |
15-Feb-13 |
SVRC11 |
2320 |
HEALTH & SAFETY CODE 1418.91 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. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview, record review and document review the facility failed to report an allegation of sexual abuse within 24 hours, as required. This failure put Resident 2 and other residents at risk for further abuse.An anonymous complaint was received, on 12/12/11 at 8:22 a.m., by the California Department of Public Health, indicating that facility staff witnessed Resident 1 being sexually inappropriate with Resident 2 on multiple occasions.During an interview, on 12/13/11 at 1:30 p.m., Unlicensed Staff D stated that at Thanksgiving (11/24/11) she, "Walked into room 10 and saw Resident 1 with his genitals in one hand (right) and his left hand was holding Resident 2's hand. Resident 2 was flaccid.I told Licensed Staff C that day (11/24/11) and the next day (11/25/11) I told Administrative Staff A and he said the room was being changed and I thought that it had been dealt with."During an interview on 12/13/11 at 4 p.m., Administrative Staff B stated that she had heard that Resident 1 went to Resident 2's bedside and was holding his own genitals and she did not know if he was exposed or not. She also stated that Administrative A was aware and took care of it. During an interview on 12/14/11 at 9 a.m., Administrative Staff A stated that an unlicensed staff member, "Did come to me (11/25/11), and tell me that she had seen Resident 1 masturbating in his room under clothes (11/24/11). The unlicensed staff member was freaked out about what she saw." No report of sexual abuse was received by the California Department of Public Health. Review of the facility Policy and Procedure for Abuse Prevention, dated 2/2008, reveals the following: "INVESTIGATION The allegation will be reported within twenty-four (24) hours to the appropriate state agency, the Department of Health, and the Ombudsman."Therefore the facility failed to report an allegation of sexual abuse, by Resident 1, within 24 hours, as required. This failure put Resident 2 and other residents at risk for further abuse. |
| 010000037 |
Cloverdale Healthcare Center |
110009477 |
B |
15-Feb-13 |
SVRC11 |
2320 |
HEALTH & SAFETY CODE 1418.91 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. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview, record review and document review the facility failed to report an allegation of sexual abuse within 24 hours, as required. This failure put Resident 2 and other residents at risk for further abuse.An anonymous complaint was received, on 12/12/11 at 8:22 a.m., by the California Department of Public Health, indicating that facility staff witnessed Resident 1 being sexually inappropriate with Resident 2 on multiple occasions.During an interview, on 12/13/11 at 1:30 p.m., Unlicensed Staff D stated that at Thanksgiving (11/24/11) she, "Walked into room 10 and saw Resident 1 with his genitals in one hand (right) and his left hand was holding Resident 2's hand. Resident 2 was flaccid.I told Licensed Staff C that day (11/24/11) and the next day (11/25/11) I told Administrative Staff A and he said the room was being changed and I thought that it had been dealt with."During an interview on 12/13/11 at 4 p.m., Administrative Staff B stated that she had heard that Resident 1 went to Resident 2's bedside and was holding his own genitals and she did not know if he was exposed or not. She also stated that Administrative A was aware and took care of it. During an interview on 12/14/11 at 9 a.m., Administrative Staff A stated that an unlicensed staff member, "Did come to me (11/25/11), and tell me that she had seen Resident 1 masturbating in his room under clothes (11/24/11). The unlicensed staff member was freaked out about what she saw." No report of sexual abuse was received by the California Department of Public Health. Review of the facility Policy and Procedure for Abuse Prevention, dated 2/2008, reveals the following: "INVESTIGATION The allegation will be reported within twenty-four (24) hours to the appropriate state agency, the Department of Health, and the Ombudsman."Therefore the facility failed to report an allegation of sexual abuse, by Resident 1, within 24 hours, as required. This failure put Resident 2 and other residents at risk for further abuse. |
| 630010921 |
Crossroads III |
110009593 |
A |
06-Dec-12 |
N0RN11 |
7790 |
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 keep Client 1 safe and free from harm when facility staff neglected to ensure supervision of Client 1 in the kitchen area and the client, who was known to propel herself independently in the wheel chair, went through an open door in the kitchen and fell down two steps onto a cement floor into the laundry/garage. The client sustained multiple injuries which included a fracture of the right frontal bone (forehead) and orbital roof (eye socket) as well as a fracture of the orbital floor on the right, soft tissue injury, and blunt injury of the abdomen. The facility is an Intermediate Care Facility for people with developmental disabilities and is licensed to provide care and services for up to six clients with varying degrees of developmental disabilities.A review of Client 1's medical record indicated the client had multiple medical diagnoses which included quadriplegia and profound cognitive disability. A review of the client's Medical Summary indicated the client was nonverbal and non-ambulatory with the ability to propel herself in a wheel chair. During an interview on 12/10/11 at 11:02 a.m., Direct Care Staff (DCS) A stated Client 1 had the ability to use both hands. DCS A stated the client was "an escape artist," when staff described the client's wheel chair mobility. DCS stated the client did not have the ability to either release the wheel chair brakes or the seat belt.During an interview on 12/10/11 at 10:40 a.m., DCS A stated she was working at the facility during the morning shift when Client 1 fell. DCS A stated DCS B was assigned to perform personal care for Client 1 but staff worked as a team and help each other. DCS A stated that as she was walking from the back hallway toward the living room she heard a loud noise. DCS A stated she saw the garage door was open and saw Client 1 "face first" on the floor of the laundry room. DCS A took the wheel chair off the client. DCS A stated at the time the client fell, the client had braces on each leg secured to the wheel chair foot rests, and had her seat belt on. DCS A stated she talked to the client and asked her: "[Client] wake up." DCS A stated it looked like the client was unconscious for "at least one minute" and had her eyes closed. DCS A described the condition of the client: a large black eye on her right eye, swelling on the top of the eyelid, and bleeding through the nose. DCS A stated staff called 911 and the emergency medical technicians removed the client from the floor, onto a backboard, and transported the client to a local hospital emergency room. During an interview on 1/4/12 at 11:48 a.m., DCS A stated that when she left the kitchen the door was not closed and was left "open a crack." DCS A stated that when staff closed the door, the door would slowly creep open. DCS stated that the wheel chair brakes were not on at the time of the accident. DCS A stated that the car garage door was kept open in the morning in order for staff to see the bus. DCS A stated that after the accident she learned that the client could open the door by using the door knob and had recently saw the client do so, but before the fall, did not know the client was able to open a door. During an interview on 1/9/12 at 2 p.m., DCS B stated that she worked the morning of the accident and the last time she saw Client 1, the client was in the living room. DCS B stated that staff kept the kitchen door open in order that staff could see the bus. DCS B stated that she went in the back room to help another client. DCS B stated that she heard a noise like something had fallen, and heard DCS A call for help. DCS B stated that it appeared the client fell down the steps face forward in the wheel chair.During an interview on 12/10/11 at 11:10 a.m., the Qualified Mental Retardation Professional (QMRP) stated that Client 1 did not have the ability to open the door. The QMRP stated the client had the ability to bear weight and use hand rails to practice walking with staff assistance.During an observation and concurrent interview on 12/10/11 at 11:20 a.m., there was a door in the kitchen area, near and across from a kitchen dining table. The door did not lock. The QMRP demonstrated how the door would not latch properly when closed and demonstrated how the door slowly crept open from a closed position. The QMRP stated that staff had routinely kept the kitchen door open, along with the more distant car garage door open, so staff had a line of sight and could see when the transport bus arrived in the morning.During an interview on 1/4/12 at 11:46 a.m., the HM (House Manager,) stated that the she was familiar with the morning shift routine. The HM stated that in order to close the kitchen door "you have to make it a point to push it closed." The HM stated that the door might sound like the door is latched; it would make a click sound, but it then crept back open again. The HM stated that staff looks through the kitchen door and through the open car garage door because there were no front windows at the house and it was the only view to the front, and helped staff see when the bus arrived. During the same interview on 1/4/12, the HM stated she arrived at the acute hospital to be with Client 1 right after the fall. The HM stated the client had a big bruise around the eye and stated that the client also had scratches and bruises on her abdomen.A review of the CT (computerized tomography, a diagnostic tool,) dated 11/22/11 indicated a fracture through the right frontal bone and orbital roof (eye socket) as well as a fracture of the right orbital floor. The report indicated a "possible subtle fracture through the nasal spine." The report indicated moderate soft tissue swelling surrounding the eye as well soft tissue surrounding the maxilla (upper jaw). A review of the hospital discharge indicated the client was discharged on 11/25/11 which included the diagnoses of closed fracture of facial bones and blunt injury of the abdomen. During an interview on 12/20/11 at 11:48 a.m., the QMRP affirmed that the facility was responsible for all clients' safety. The QMRP stated that wheel chair safety is discussed if new issues regarding wheel chairs come up but there was no specific policy on wheel chair safety or training staff on wheel chair safety. The QMRP could not find a specific policy on wheel chair safety. The facility failed to keep Client 1 safe when facility staff left the client unsupervised in the kitchen area and the client, known to propel herself independently in the wheel chair, went through an open door in the kitchen and fell down two steps onto a cement floor into the laundry/garage. The client sustained multiple injuries which included a fracture through the right frontal bone and orbital roof as well as a fracture of the orbital floor on the right, soft tissue injury, and blunt injury of the abdomen. This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 010000864 |
Crossroads II |
110009687 |
B |
10-Jan-13 |
J3OU11 |
3486 |
Health & Safety Code 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Health & Safety Code 1418.91(b) (b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview and document review the facility failed to report to the Department two allegations of suspected abuse. This resulted in the delay of objective oversight and had the potential for clients to be subjected to ongoing abuse. Findings:On 1/11/2011 the California Department of Public Health received a complaint alleging abuse of Client 1. During an interview on 2/10/11 at 9:45 a.m., Administrative Staff A stated that on 1/31/11 Direct Care Staff B reported possible abuse of a client to the facility administration. DCS B had reported that a DCS H restrained Client 1 in a toilet chair with a seat belt and DCS E belted a door knob to a hand rail in order to keep Client 1 in his room. Administrative Staff A stated that she did report the allegation to the California Department of Public Health because she did not believe Staff B. Administrative Staff A stated Staff B was a problem employee.During an interview on 2/10/11 at 1:20 p.m., Administrative Staff C, the Human Resource Manager, stated that Staff B called her in mid to late January 2011 and reported that she (Staff B) had witnessed Client 1 being strapped or buckled onto a chair over the toilet. Administrative Staff C stated that she told Staff B to report this to Administrative Staff F, the QMRP. Administrative Staff C also stated that she did not report the incident to anyone.During an interview on 2/10/11 at 12:30 p.m., Administrative Staff F stated that he was informed of the belt being used to keep Client 1's bedroom door closed on 1/28/11 but he failed to report the incident. Document review was conducted on 2/14/11. A document titled "Abuse Prevention, Investigation, and Reporting", included direction as follows: "The Administrator shall notify the required agencies by telephone and forward a copy of the employee's written statement within 24 hours of the reporting of any alleged abuse, neglect or mistreatment of clients, also inviting each agency to conduct an investigation of their own. Those agencies include: Department of Health Services-Now Known as the California Department of Public Health Client's Regional Center Representative Client's legal representative or conservator Ombudsman. The Administration shall complete a Special incident Report, and forward it to all agencies listed within 24 hours of the reporting of any alleged abuse, neglect or mistreatment of clients".Notes from the facility investigation, conducted by Administrative Staff A, dated 1/31/11, indicated that Staff B had been interviewed and had reported the following to facility administrative staff: "She (Staff B) saw [name deleted (Staff H)] use the seatbelt on the potty seat for [name deleted (Client 1)] while he was using the restroom. She (Staff B) also saw [name deleted (Staff E)] secure [name deleted (Client 1's)] door closed"...Talked to [name deleted (Staff F), Agree its inappropriate use of restraints. Need to talk to [names deleted Staff H and Staff E] and co-workers". Continued notes, dated 2/8/11, indicated "Write incident report and send to licensing the fact that she (Staff B) is alleging abuse...2/9/11 Faxed report to licensing". |
| 010001128 |
Care Meridian, LLC |
110009925 |
B |
05-Sep-14 |
1TDM11 |
16163 |
72311(a)(1)(C) Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.72311(a)(3)(B) Nursing Services - 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. The facility failed to provide adequate nursing services when staff did not continuously assess Resident 1's care needs as he was experiencing a change in condition manifested by severe pain, failed to advocate on his behalf to obtain adequate pain medication and failed to update his care plan to demonstrate that he was experiencing ongoing and severe pain that was not relieved by his current pain management plan. The failure to provide adequate nursing services led to Resident 1 obtaining pain medication from someone outside of the facility and resulted in a medication overdose and subsequent death.Resident 1 was a 46 year old male, alert, admitted to the facility on 12/24/12 for spinal cord injury with paraplegia (an impairment in motor or sensory function of the lower extremities), and status-post left hip ischial tuberosity muscle flap closure dehiscence (stage 4 involving muscle and bone left hip pressure ulcer). Other diagnoses included neurogenic (a problem in which a person lacks bladder control due to a brain, spinal cord or nerve condition) bladder and bowel, and severe intermittent neurogenic (a complex, chronic pain state that usually is accompanied by tissue injury) pain in his hip joints and lower extremities. Resident 1 had fallen out of his wheelchair, while at the facility on 2/07/13, which resulted in a fracture of his lower right leg.Resident 1's clinical record, reviewed on 4/08/13, revealed the following: Resident 1's Advance Health Care Directive dated 02/25/12, witnessed, signed by Resident 1 and a physician, was a full code and expressly stated, "I want my life to be prolonged as possible within the limits of generally accepted health care standards." An Admission History and Physical Transfer Medication, dated 12/28/12, reflected that Resident 1 was receiving Methadone (a highly addictive synthetic narcotic that is prescribed for moderate to severe chronic pain) 120 mg by mouth three times a day. Other prescribed pain related medications included: Cymbalta 30 mg daily, Lyrica 50 mg twice a day, Hydromorphone (Dilaudid) 4 mg every 4 hours as needed.Resident 1's prescription for Methadone was gradually reduced on the following physician orders dated 12/28/12, 01/14/13, 1/22/13, 2/01/13, 2/11/13, and finally, on 3/11/13 Methadone was reduced to 5 mg three times a day for five days then ordered to be discontinued. Review of Nurses notes dated 3/15/13 to 3/20/13 indicated Resident 1 experienced 12 documented episodes of pain after Methadone was discontinued based on a Universal Pain Scale (0=No Hurt, 2= Hurts Little Bit, 4=hurts Little ore, 6=Hurts Even More, 8=Hurts Whole Lot and 10=Hurts Worst) On 3/15/13 evening shift, pain level of 8. Dilaudid 4 mg PO (by mouth) given. On 3/16/13 night shift, complained of pain level of 6 at bilateral hip and generalized discomfort and insomnia. Dilaudid 4 mg po and Ambien 10 mg given. On 3/17/13 morning shift, pain level of 7, Dilaudid 4 mg given. and during the night shift, a pain level of 6, Dilaudid 4 mg tablet given at 8:30 p.m. On 3/18/13 morning shift, pain of 3 and 6 in the lower back, Dilaudid 4 mg prn given and during the night shift, a pain level of 7. Ambien 10 mg tablet given to promote sleep at 12:30 p.m. On 3/19/13 morning shift, pain level of 6, medicated with Dilaudid 4 mg and during the night shift at 2230 and 0515 hours, a pain level of 8 and 7, medicated one time for pain. On 3/20/13 morning shift, pain level of 2 for two episodes and during the night shift, a pain level of 5. Resident 1 medicated with Dilaudid 4 mg. both times.Review of nurses notes dated 3/21/13 to 3/25/13, indicated: On 3/21/13 morning shift, pain level of 7 during two episodes and during the night shift, pain level of 6 times two episodes. Physician was informed and a new telephone order from Management Staff B was received.On 3/21/13, a physician order of 8 mg Dilaudid (a narcotic pain medication that is prescribed to treat moderate to severe pain) by mouth every 4 hours PRN pain and to discontinue the Dilaudid 4 mg every 4 hours prn breakthrough pain, a transfer medication on admission history and physical dated 12/24/12.Resident 1 medicated with Dilaudid 8 mg at 9:40 p.m. for pain of 6 and Ambien 10 mg at 10:30 p.m to promote sleep. On 3/22/13 morning shift, pain level of level of 7, Dilaudid 8 mg administered and during the night shift, pain level of 4 at 8:45 p.m. and pain level of 5-6 in the hip at 3:40 a.m. Dilaudid 8 mg administered. On 3/23/13 morning shift, pain level of 6 and 4, Dilaudid 8 mg administered both times with good effect. On 3/24/13 morning shift, pain level of 7 at 8 a.m. Dilaudid 8 mg given at 9 a.m. with minimal improvement, pain down to 6. Resident 1 reported that distraction helps him, television and being up in wheelchair. At 3 p.m., pain level of 8 in lower back. Dilaudid 8 mg administered at 7 p.m. During the night shift, pain level of 7 in the lower back. PRN Dilaudid administered. On 3/25/13, a physician order to reduce Dilaudid to 4 mg po every 4 hours prn pain.Review of Nurses Notes dated 3/25/13 to 4/4/13, documented an increase of complaints of pain to 49 episodes. On 3/25/13 morning shift, pain level of 8 in lower back, Dilaudid 8 mg administered. During night shift, a pain level of 5 times two episodes, medicated both times with Dilaudid 4 mg. On 3/26/13 morning shift, pain level of 7 during three episodes and during the night shift, pain level of 5 during two episodes. Documented Dilaudid 4 mg administered x 3 and a repeat of Ambien 10 mg. dose On 3/27/13 morning shift, pain level of 7 during two episodes and during the night shift, pain levels of 7 and 8. Dilaudid 4 mg administered x 4 and a repeat dose of Ambien 10 mg. On 3/28/13 morning shift, pain level of 5 during two episodes and during the night shift, pain level of 8, 7 and 4. Dilaudid 4 mg administered x 4. On 3/29/13 morning shift, pain level of 7 and 8, and during the night shift, pain level of of 6. Documented Dilaudid 4 mg administered x 2 and Ambien 10 mg to promote sleep at 10 p.m. On 3/30/13 morning shift, pain level of 8 and 7 during two episodes and during the night shift, pain level of 6 and 5. Dilaudid 4 mg administered x 6 and Ambien 10 mg. to promote sleep. On 3/31/13 morning shift, pain level of of 6 during 3 episodes and during the night shift, pain level of 6 during two episodes. Dilaudid 4 mg administered x 4 and repeat dose of Ambien 10 mg to promote sleep. On 4/01/13 morning shift, pain level of 7 and 10 and during the night shift, pain level of 8 times 2 episodes. Dilaudid 4 mg administered x 3 and Ambien 10 mg for inability to sleep.On 4/02/13 morning shift, pain level of 8 during two episodes and during the night shift, pain level of 8 during two episodes. Dilaudid 4 mg administered x 3 and Ambien x 1 dose. On 4/3/13 morning shift, pain level of 7 during three episodes and during the night shift pain level of 5 to 6 during three episodes. Documented Dilaudid 4 mg administered x 4 and repeat dose of Ambien 10 mg. to induce sleep. On 4/4/13 morning shift, pain level of 8 and 7, and during the nigh shift, pain level of 4 during two episodes. Documented Dilaudid 4 mg administered and repeat dose of Ambien 10 mg for sleep. Record review on 4/8/13 of Resident 1's Care Plan on Pain intervention initiated 12/24/12 indicated "monitor and document for pain unrelieved. Notify Physician if pain is unrelenting." The facility was unable to demonstrate that it notified the physician of Resident 1's increased frequency of complaints of pain. Review of Resident 1's care plan revealed that it was not updated to reflect the change in condition when he experienced increased frequency of pain and had no evidence of documentation of re-assessment and evaluation of interventions to treat the pain. Review of Nurses Notes entry on 4/5/13 between 7 p.m. to 11 p.m., "...found patient slumped over with head on blanket in vomit, no pulse noted, patient cyanotic...911 was called immediately, CPR (cardio-pulmonary resuscitation) was initiated by nursing staff and emergency personnel took over from 2300 0300 hours but CPR ineffective. time of death 11:19 p.m." Management Staff A stated during an interview, on 4/10/13 at 11:57 a.m., that she spoke with Family Member A, who admitted to bringing Methadone to her husband.Family Member A was interviewed by telephone on 4/10/13 at 2:35 p.m., stated she visited twice a week on Mondays and Fridays and that every time she talked to him, he was complaining of pain and he had told her that a lot of times he couldn't sleep because he was in pain. On her 4/4/13 visit, he was complaining of severe pain. During the Interdisciplinary Team Meeting (IDT) on 4/4/13, Licensed Staff J was going to check with Management Staff B about his pain because he was going home. Family Member A stated "Everybody, all of the nurses knew he was always in pain." Resident 1 was no longer receiving Methadone and had severe pain in his hip.During a telephone interview on 4/10/13 at 2:35 p.m., Family Member A stated Resident 1 had begged her to bring him Methadone. Family Member A stated that she brought him approximately 40 Methadone 10 mg pills on 4/4/13 and stated that her husband was upset about the delay of being discharged to home. She stated that she did not inform the nurses that she had brought the pills into the facility.A follow up telephone interview with Family Member A was made on 4/11/13 at 4:33 p.m. When asked with whom she talked about Resident 1's pain and his inability to sleep, she stated that all the nurses were aware, (Licensed Staff K, Licensed Staff E, and Licensed Staff J). She stated that Resident 1 had a different nurse every day and that he had complained to all of his nurses that he was in pain.Licensed Staff H, who usually worked the day shift, stated during an interview, on 4/11/13 at 6:25 p.m., that Resident 1 was complaining of pain "most of the time". He stated that when Resident 1 complained of pain, he would look at PRN medications and assess him. If pain medications were not enough to relieve his pain he would inform Management Staff B. When asked by surveyor if Resident 1 was pre-medicated prior to wound dressing changes, Licensed Staff H, responded, "Not all the time that we pre-medicated him for pain prior to dressing change." Daily Nurses Notes on 4/1/13, revealed Resident 1 complained of a pain at a level of 10 during wound dressing change.Licensed Staff J stated during an interview, on 4/11/13 at 7:58 p.m., that Resident 1 was complaining of pain frequently and if it was appropriate, License Staff J would ask him if he wanted PRN pain medications. If he would say "yes" and she would give him the medications as ordered. Licensed Staff J stated that all the nurses were aware of Resident 1's pain and that Resident 1 was complaining of pain most of the time.Interview with Administrative Staff P on 4/08/13 at 3:09 p.m., stated Resident 1 was excited about going home.Unlicensed Staff L stated during an interview, on 4/11/13 at 6:30 p.m., that Resident 1 was happy that he was going home. He would frequently use his call light to ask for pain medication.Unlicensed Staff N stated during an interview, on 4/11/13 at 6:40 p.m., that Resident 1 was excited about going home and that he was frequently asking for medicine for pain.Management Staff D stated during an interview, on 4/11/13 at 6:47 p.m., that Resident 1 was very clear about his pain and that he took up smoking again when they lowered his pain medication.License Staff I who worked night shift stated during an interview, on 4/11/13 at 7:09 p.m. and 9:59 p.m., that Resident 1 often said that he was experiencing pain. The facility was making attempts to reduce the dosage because he was getting ready for discharge.Unlicensed Staff O, working night shift, stated during an interview, on 4/11/13 at 9:06 p.m., that Resident 1 would wake up two or three times each night and ask for pain medicine.Management Staff C stated during an interview, on 4/11/13 at 10:16 p.m., that he attended the IDT meeting on 4/4/13 and that Resident 1 was genuinely excited about going home.Management Staff B (a physician) stated during an interview, on 05/22/13 at 1:01 p.m., that Resident 1 was going to be discharged and no doctor was going to have him except for a chiropractor. Management Staff B stated that Resident 1 was getting weaned off Methadone and he was more restrictive in giving Resident 1 more medications because he seemed to exhibit drug seeking behaviors. The Surveyor asked how often the nurses would call him regarding Resident 1's care and complaints of pain. "They were calling anytime." Management Staff B said he asked the nurses if he (Resident 1) was in pain and the nurses would say "No."Management Staff A stated during an interview, on 6/12/13 at 3:16 p.m., that she was aware that Resident 1 had ongoing pain issues.Record review on 4/08/13 of Interdisciplinary Team Conference Report dated 4/4/13, on Nursing Recommendations/Treatment Plan indicated, to "monitor for adequacy of pain control." Record review on 4/08/13 of facility Policies and Procedures, subject: Pain Assessment and Management, revised on 08/3/10, indicated: That every resident shall be assessed for pain upon admission and during the course of their inpatient stay. The purpose is to determine the level of pain related to their current medical condition and/or diagnosis for appropriate intervention and management. Procedure: 1. Assess resident for presence or absence of pain in the following situations: c. In the event of worsening pain using the Daily Nurses Notes. 2. Obtain the resident's pain status, including pain history,origin, location, severity, alleviating, and exacerbation factors; current treatment for pain; and response to treatment. 7. The resident's care plan will be initiated and revised as needed and will include interventions that support and assist the resident reach his/her goals for optimal pain management. 8. If pain medication (per MD order) is given, assess for effectiveness of pain medication (prn or routine) 30 minutes to 1 hour post administration using any or or all of appropriate pain scales mentioned above and document in the MAR (Medication Administration Record) and/or Daily Nurses Notes. Notify MD of results as needed. The coroner's report dated 4/26/13 reflected that the cause of death was determined to be: Results of Toxicology: 1. Diazepam=310 ng/mL, toxic effects may be produced by blood concentrations in excess of 1500 ng/mL 2. Nordiazepam=320 ng/mL, reported limit 2.0 ng/mL 3. Methadone=1300ng/mL, toxic blood concentrations in methadone- related fatalities is 400-1800 ng/mL 4. EDDP=94 ng/mL, reported limit 50 ng/mL 5. Hydromorphone Free=13 ng/mL 6. Medical Cause of Death: Acute Multiple Prescription Drug Toxicity 7. Other Significant Findings: Remote Blunt Impact Injuries The facility's failure to advocate on Resident 1's behalf when he was experiencing a change in condition manifested by severe and ongoing pain, the facility's failure to update his care plan to demonstrate the change in condition and failure to notify the physician of his distress prevented him from receiving adequate pain relief which prompted him to plead with his wife to bring methadone from home and and resulted in Resident 1's death when he overdosed by self-medicating.The above violations had a direct relationship to the health, safety or security of the Resident. |
| 010001128 |
Care Meridian, LLC |
110011284 |
A |
02-Jul-15 |
M9BT11 |
5955 |
T22 DIV5 CH3 ART3-72313(a)(2) NURSING Service - Administration (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. The facility failed to administer medications as prescribed by the physician when Licensed Staff F administered an excessive dose of Morphine Sulphate (pain medication) to Patient 1, which resulted in him becoming non-responsive and experiencing a change in condition which required an emergency transport to the emergency room for evaluation and treatment followed by a ten day inpatient hospitalization.Patient 1 was admitted to the facility on 1/29/15 with diagnoses including hypoxic (lack of oxygen) respiratory failure, pleural effusion (fluid in the lungs) and back pain. He was his own responsible party for healthcare decision making.Patient 1's diagnoses included chronic obstructive respiratory disease (a condition where the lung tissue has become rigid and unable to move air into the lungs without a great deal of effort), congestive heart failure (a condition where the heart is unable to pump blood efficiently resulting in a decreased blood supply to all organs of the body, causing symptoms including shortness of breath and generalized weakness). These conditions made it difficult for Patient 1 to perform activities of daily living, such as eating, bathing, physical therapy, and walking. Patient 1's medical record was reviewed on 2/17/15. A physician's order that was dated 1/31/15 instructed for 20 milligrams of Morphine Sulfate to be administered by mouth every 4 hours as needed for pain.Patient 1's medication administration record for the period of 2/01/15 to 2/28/15 indicated an order for Morphine Sulfate solution 20 milligrams per 5 milliliter, to be administered at 20 mg by mouth every 4 hours as needed for pain.An entry for 2/01/15 at 7:33 p.m. indicated that Licensed Staff F administered one dose of Morphine Sulfate. The Emergency Drug Kit Usage Report (a document used to track emergency medication use) indicated that Staff F used Morphine Sulfate, 5 milliliters on 2/01/15 at 7:30 p.m. The note at the bottom of this document was signed by Licensed Staff F and read: "This is a 2nd dose of 5 milliliters from the bottle that was opened from the E-kit (drugs stored for emergency use) last night. Order is Q4 hours (every 4 hours) PRN (as needed)..."Nursing notes documented an entry on 2/01/15, at 7:25 p.m. indicated that Licensed Staff L administered 5 ml of Morphine Sulfate solution to Patient 1.During a phone interview on 2/17/15, at 2:55 p.m., Medical Doctor E, stated the reported incident on 2/01/15 with Patientt 1 involved a medication error that resulted in a medication overdose. He stated the nurse gave 100 milligrams instead of 20 milligrams of Morphine Sulfate and that he thought it had occurred when the medication in the Emergency Kit was a different strength per milliliter from the one that was previously administered.During a phone interview on 2/18/15, at 1:45 p.m., Licensed Staff F, stated that on 2/01/15, Patient 1 was experiencing severe pain and that she then read the physician's order, which directed her to give 20 milligrams in 5 milliliters of Morphine Sulfate. She removed 5 milliliters from a bottle (labeled 20 milligrams in 1 milliliter) and did not check the bottle against the Medication Administration record. She said she removed it from the medication cart and the bottle had been previously removed from the E-kit. Licensed Staff F stated that she felt rushed and Patient 1 was screaming in pain when she administered 5 milliliters (100 milligrams from the bottle labeled 20 milligrams in 1 milliliter) of Morphine Sulfate to him.The facility investigation report for Patient 1 stated..."on 2.1.15 0725: the patient was given 100 mg of Morphine, instead of 20 mg..." During an interview on 2/17/15, at 3 p.m., with Administrative Staff A, she stated the medication error occurred on 2/01/15 because Licensed Staff F did not follow the policy and procedure.The facility policy and procedure titled Medication Administration, General Guidelines (California Specific), dated 12/12, Section 7.1, Page 1 of 6, General Guidelines, Procedures, Medication Preparation: Item 3, included the following instruction: Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescribe's orders are checked for the correct dosage schedule. Apply a "direction change" sticker to label if directions have changed from the current label. Further review of the policy and procedure titled Medication Administration, General Guidelines, Page 3 of 6, Medication Administration indicated the following: 1. "Medications are administered in accordance with orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate." These facility failures resulted in Patient 1's non-responsive state that lead to a doctor's order for a 911 phone call, Patient 1's emergency transport to an acute care hospital, and the administration of Narcan (a narcotic reversal drug). Patient 1 remained at the acute care hospital for ten days. 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. |
| 010001128 |
Care Meridian, LLC |
110011436 |
B |
02-Jul-15 |
JC4T11 |
2522 |
A195 T22 DIV5 CH3 ART3-72315(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 treat Patient 1 with dignity and respect when he was verbally abused and humiliated by a direct care staff member (CNA-A). Patient1's clinical record revealed that he was admitted to the facility on 2/26/14 with diagnoses that included left sided weakness due to a CVA (stroke). Patient 1's physical needs required total assistance from staff with activities of daily living. Review of a document titled "Comprehensive Progress Note", dated 3/11/2015 described Patient 1 as alert, cooperative and well-oriented. During an interview on 4/2/15, at 1:15 p.m., Patient 1 stated that CNA-A had been rough with him during care where he would hit his face against the side-rails at times while CNA-A would reposition him.Patient 1 stated that one evening, while CNA-A was providing personal care to him after he had a bowel movement, she put her finger up to his nose and said: "This is poo, why did you do this?" Patient 1 stated "It was very demeaning, as if you were training a dog not to go to the bathroom inside the house". Patient 1 further stated that he could not recall the exact time of the incident and that he had not reported CNA-A's "abusive behavior" when he was handled in a rough manner in the past. During an interview on 4/2/15 at 11:50 a.m., the Interim Director of Nursing (DON) stated the Occupational Therapist reported the incident to her after she had become aware of it. She stated that Patient 1 told her about the incident after CNA-A had provided personal care to him and after he had a bowel movement. He said she put her gloved finger covered with feces up to Patient 1's nose and stated: "Smell this, this is poo-poo." During a phone interview on 4/2/15, at 12:30 p.m., CNA-A denied the incident occurred.Review of Patient 1 clinical record that was titled "Daily Nurses Notes", dated 4/2/14 at 2:10 p.m., indicated that on the night of the incident 3/5/15, at 2:30 a.m., Patient 1 was incontinent of bowel.Review of facility policy and procedure titled "Abuse-dependent adult/child" dated 1/1/11, revised 7/2/14, revealed "All staff members are responsible for ensuring that all residents are free from physical/mental/sexual/financial abuse..."The violation of the regulation caused significant humiliation, indignity, anxiety, or other emotional trauma to the patient. |
| 010000004 |
Crescent City Skilled Nursing |
110011805 |
A |
10-Oct-16 |
V1YU11 |
5739 |
?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 ensure Resident 7's transfer by staff using a shower sling and a mechanical lift. This failure resulted in Resident 7 falling to the floor sustaining a right hip fracture with subsequence surgery to repair the hip. Resident 7's admission record indicated Resident 7 was admitted to the facility on 3/19/14, with diagnoses including spasm of muscle, depressive disorder, and multiple sclerosis (a disease affecting the brain and spinal cord). Resident 7's MDS (minimum data set, an assessment tool), dated 6/27/15, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. Resident 7's plan of care for ADL (activities of daily living), initiated on 8/8/15, indicated Resident 7 required "2 staff participation using a lift with transfers." During a concurrent observation and interview on 9/15/15, at 11:15 a.m., Resident 7 was in bed and alert. Resident 7 stated on 8/29/15, at approximately noon, she was transferred from the shower bed to her own bed by Unlicensed Staff J and K. Resident 7 stated when Unlicensed Staff J and K lifted (using a mechanical lift) her up at approximately to the height of a calendar of the wall (53 3/4 inches to the floor, measured by Administrative Staff A on 9/15/15 at 2:10 p.m.), Unlicensed Staff K stood on her (Resident 7) back and pulled the sling from the back and her buttock causing her to fall on the floor. Resident 7 stated her buttock hit the floor and had pain greater than 10/10 on the pain scale (10 indicating most severe pain). Resident 7 stated she was sent to the hospital for a fracture and surgery. During an interview on 9/15/15, at 10:50 a.m., Unlicensed Staff J stated on 8/29/15, she was helping Unlicensed Staff K to use a mechanical lift and a shower sling to transfer Resident 7 from a shower bed to resident's own bed. Unlicensed Staff J stated while they lifted Resident 7 "up on air" (resident was not on a surface), Resident 7 was tilted to her right side on the shower sling. She stated Unlicensed Staff K tried to push the resident and reposition resident to her back while Resident 7 was lifted up in the air. Unlicensed Staff J stated she told Unlicensed Staff K to stop pushing resident but Unlicensed Staff K already pushed the resident causing Resident 7 to slip out of the sling. Unlicensed Staff J stated staff should not reposition the resident while the resident was lifted up in the air. During an interview on 9/16/15, at 10:30 a.m., Administrative Staff C stated staff should not reposition the resident on the sling while the resident was lifted up from the bed or wheelchair because all resident's weight would be on the sling. She stated if the sling was not balanced, the resident would fall. Administrative Staff C stated staff must put resident back to bed or a surface to reposition the resident and the sling. During an interview on 10/14/15, at 6 p.m., Administrative Staff C stated she did not find any in-service record for use of mechanical lifts and slings prior to the incident up to 2011. She stated she only had the in-service record after the incident. Administrative Staff C stated she did not find any observation for staff competency of using lifts and slings. During a concurrent observation and interview on 10/13/15, at 12:20 p.m., Unlicensed Staff J stated they used the lift #1 and the shower sling for transferring Resident 7 on the day Resident 7 fell out from the sling. Unlicensed Staff J stated she did not feel safe to use the lift #1 because the spaces of the hooks were too narrow. She stated she preferred the lift #8 but Unlicensed Staff K already had Resident 7 on lift #1. During a concurrent interview and record review with the Care Coordinator Director (CCD) and Administrative Staff B on 9/16/15, at 12:30 p.m., the incident report, dated 8/29/15, indicated "Nursing Description: RT (resident) WAS BEING TRANSFERRED FROM THE SHOWER BED TO RT BED BY THE CNA'S AND SLID OUT OF THE SLING TO THE FLOOR." The acute care hospital x-ray report, dated 8/29/15, and the discharge summary, dated 9/4/15, indicated Resident 7 sustained a right hip fracture from the fall and underwent a surgical repair of the right hip fracture. The [name of company/brand] Manual/Electric Portable patient Lift Owner's Installation and Operating Instructions, dated 2001, indicated "Adjustments for safety and comfort should be made before moving the patient." The facility policy and procedure titled "Safe Lifting and Movement of Residents," revised December 2013, indicated "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents...Staff responsible for direct resident care will be trained in the use of manual...and mechanical lifting devices...Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques..." Therefore, the facility failed to ensure staff properly transferred Resident 7 using a shower sling and a mechanical lift causing Resident 7 to fall on the floor and sustain a right hip fracture. This failure also caused Resident 7 to undergo a right hip surgery. The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000004 |
Crescent City Skilled Nursing |
110011806 |
A |
10-Oct-16 |
V1YU11 |
9289 |
?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 and assistance to prevent accidents when staff did not follow care plan interventions to prevent Resident 8 from falling. Resident 8 had two falls during a two day period from 8/30/15 to 9/1/15. Theses failure caused Resident 8 to sustain a subdural hematoma (a mass of accumulated blood inside the head caused by bleeding, usually results from a serious head injury and can be life threatening) and hospitalization from the second fall.
Resident 8's admission record indicated Resident 8 was admitted to the facility on XXXXXXX15, with diagnoses including specific rehabilitation procedure, difficulty in walking, personal history of fall, unspecific backache, and depressive disorder.
Resident 8's MDS (minimum data set, an assessment tool), dated 8/5/15, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory.
The Care Area Assessment (CAA, a tool used to identify resident concerns and develop an individualized care plan), dated 8/5/15, indicated Resident 8 "is at risk for falls because she has trouble with balancing, she has a history of falls and she is taking an antidepressant."
The fall risk evaluation, dated 7/31/15 and 8/30/15, indicated Resident 8 was at moderate risk for fall due to problems including use of diuretics (water pills), antihypertensive (medication for high blood pressure), and gait balance problems, and history of falls.
Resident 8's care plan for ADL (activities of daily living), initiated on 8/10/15, indicated Resident 8 required "1 staff participation to use toilet...require assistance to wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet and to use toilet...require 1 staff participation with transfers...require supervision, cueing, encouragement, specify physical assistance with transferring..."
Resident 8's care plan for fall risk, initiated on 8/10/15, indicated interventions for Resident 8 including "Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance..."
First Fall:
The incident report, dated 8/30/15 at 2048 (8:48 p.m.) revision date 8/30/15 at 2343 (11:43 p.m.) indicated "Nursing description: Rt (resident) had unwitnessed fall. Heard loud thump noise, followed by a loud yell for help. Rt was found on bathroom floor..."
The progress note, dated 8/31/15 at 9:27 a.m., indicated "IDT (interdisciplinary team) team met and care plan updated. Encourage resident to ask for assistance during transfers, and we will evaluate a raised sit for the commode."
The facility updated Resident 8's care plan for fall risk with new interventions including "...Commode will be evaluated. It may need to be higher because RT [resident] has trouble bending..." and continued on intervention "Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance..."
Resident 8's continuous care plan for ADL, initiated on 8/10/15, indicated Resident 8 required "1 staff participation to use toilet...require assistance to wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet and to use toilet...require 1 staff participation with transfers...require supervision, cueing, encouragement, specify physical assistance with transferring..."
Second fall:
The progress note, dated 9/1/15, at 6:46 a.m., indicated "Resident was found on the floor @ 0540 in the doorway of her room, unconscious with minimal/abdominal breathing, ambulance called..."
During a concurrent observation and interview on 9/15/15, at 2:20 p.m., Resident 8 was in bed and awake. Resident 8 stated she fell in the early morning when she got up and walked to the bathroom by herself. She stated she fell on the floor and hit her head. She stated she did not remember if she used the call light that morning. Resident 8 stated when no staff in the room, she would use the call light for help, but she had to wait for the staff for one hour or longer. Resident 8 stated on 9/14/15, she had to wait for more than one hour for staff to assist her to bed.
During an interview on 9/16/15, at 7:15 a.m., Unlicensed Staff Q stated she was not assigned to Resident 8 on 9/1/15. Unlicensed Staff Q stated she walked by Resident 8's room and saw Resident 8 was not in her bed and thinking Resident 8 was in the bathroom. Unlicensed Staff Q stated she continued walking pass Resident 8's room and about two resident's rooms away, she heard a loud thud. Unlicensed Staff Q stated she immediately went to check Resident 8 and found Resident 8 was on the floor by the door and was not responsive. She stated she called stat and yelled for help.
During an interview on 9/16/15, at 11:30 a.m., Licensed Staff N stated prior to the fall on 9/1/15, Resident 8 used a walker to go to the bathroom and needed supervision for transfer and toileting. When asked what "supervision" meant, Licensed Staff N stated "I think she (Resident 8) did not need supervision."
During an interview on 9/16/15, at 3:45 p.m., Licensed Staff O stated she was Resident 8's nurse on 9/1/15 when Resident 8 fell. Licensed Staff O stated she heard CNA (certified nursing assistant) yelled for help when she was in another hall, she went to Resident 8's room and saw Resident 8 on the floor and not responsive. She stated prior to the fall on 9/1/15, Resident 8 was independent. Licensed Staff O stated the physical therapist permitted Resident 8 to use a walker. She stated Resident 8 used a walker to go to the bathroom and walk in the hallway by herself. When asked if Resident 8 should transfer and walk by herself, Licensed Staff O stated "I think so. She was pretty independent and physical therapist permitted her to use a walker." Licensed Staff O also stated she would go into Resident 8's room and check on the resident if she saw Resident 8 was not in her bed in the early morning. She further stated resident might not really awake in the morning and would not be safe for resident to get up and look for things by herself.
During a concurrent interview and record review on 10/14/15, at 2:30 p.m., the Physical Therapist (PT) stated prior to Resident 8's first fall on 8/30/15, Resident 8 could transfer and ambulate herself with a wheelchair and front wheel walker (FWW) with staff's supervision. The PT stated staff had to be with the resident but not physically assist the resident while transferring and ambulating. The PT provided the "Therapist Progress and Updated Plan of Care," dated 8/28/15, which indicated Resident 8's current level of function "The patient ambulates 200 feet and on level surfaces requiring supervision (needs verbal cueing but no physical assist) with rolling walker for safety...The patient is able to safely transition from sit < > stand (sit to stand and wise versus) requiring supervision..." The PT stated he also verbally communicated Resident 8's needs to the staff.
During an interview on 10/15/15, at 12:03 p.m., Administrative Staff B stated she expected staff to stay with the resident and watch the resident when resident needed supervision for transfer and ambulating.
The acute care hospital CT (computerized tomography, special x-ray imaging) result dated 9/1/15, and the History and Physical, dated 9/10/15, indicated Resident 8 sustained a subdural hematoma from the fall. Resident 8 was admitted to an acute care hospital on XXXXXXX 15 for medical interventions for the subdural hematoma.
The facility policy and procedure titled "Fall Prevention Program," dated 2014, indicated "[facility name] are to develop a culture of safety for our residents to thrive. The [facility] Watch Program (LWP) was designed to assist facility staff in this development. Steps include: review of at-risk residents, prevention through addressing risks, appropriate fall response, and initiation of effective interventions...The DON (director of nursing) oversees all steps in the Falls Response and coordinates implementation of individualized care plans...For those assigned Moderate Fall risk, identify causative factors and care plan interventions as appropriate, but not added to the LWP..." The policy and procedure did not specify how staff would implement the care plan.
Therefore, the facility failed to provide adequate supervision and assistance to prevent accidents when staff did not follow care plan interventions to prevent Resident 8 from falling. Resident 8 had two falls during a two day period from 8/30/15 to 9/1/15. This failure caused Resident 8 to sustain a subdural hematoma (a mass of accumulated blood inside the head caused by bleeding, usually resulted from serious head injuries and can be life threatening) and hospitalization from the second fall.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000004 |
Crescent City Skilled Nursing |
110011807 |
B |
10-Oct-16 |
V1YU11 |
5378 |
?483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure Resident 3 was free from verbal and mental abuse when the occupational therapist (OT) directed abusive language towards Resident 3. This failure negatively impacted the resident's psychosocial well-being when Resident 3 felt hurt and angry. This failure had the potential to continue to cause anger and anxiety to Resident 3 and other residents who might hear about the incident when the perpetrator was not removed from resident care immediately following the incident. A review of Resident 3's clinical chart revealed that Resident 3 was admitted to the facility on 12/11/14, with diagnoses including arthritis (inflammation of the joints), respiratory failure, COPD (chronic obstructive pulmonary disease, a chronic lung disease), and kidney disease. Resident 3's MDS (minimum data set, an assessment tool), dated 3/23/15 and 10/2/15, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. During a concurrent observation and interview on 10/13/15, at 4:45 p.m., regarding the incident on April 14, 2015, Resident 3 was in bed and alert. Resident 3 stated the Occupational Therapist (OT) came in her room when Unlicensed Staff G was in her room. Resident 3 stated she told the OT to leave the room because the OT should not be in her (Resident 3) room. Resident 3 stated she did not get along well with the OT because the OT pushed her too much on her therapy. Resident 3 stated she could not tolerate therapy when OT pushed too much. Resident 3 stated OT made a "face" and heard her say to Unlicensed Staff G "She (Resident 3) was a bitch and fuck her." Resident 3 stated she felt hurt and angry. During an interview on 10/14/15, at 2:10 p.m., the Physical Therapy Assistant (PTA) stated she remembered Resident 3 stated that the OT was "too pushy," but she did not recall that the OT should not go into Resident 3's room. The PTA stated she knew another resident had refused working with the OT. During an interview on 10/13/15, at 9:45 a.m., Administrative Staff A stated Unlicensed Staff G witnessed the incident , however Unlicensed Staff G no longer worked at the facility. Administrative Staff A stated she escorted the OT out of the facility when she was notified of the incident on 4/16/15. During a concurrent interview and record review of the facility investigation report on 10/14/15, at 9:20 a.m., Administrative Staff A stated she did not remember who brought the incident to her attention. According to the facility investigation report, the incident occurred on 4/14/15 and reported to her on 4/16/15 by Administrative Staff B. Administrative Staff A stated she did not find any statement for the incident from Unlicensed Staff G. The facility investigation report, dated 4/16/15, indicated the incident occurred on 4/14/15 and was reported to the administrator on 4/16/15. The report indicated "Resident was visiting with a CNA when the OT came to ask if she could work with her. [Resident 3] told the OT no because they did not work well together. The OT ...made a facial expression to the CNA...and told the CNA that [Resident 3] is a bitch...[Resident 3] and this OT have a previous history, according to [Resident 3], where they did not work well together. Therapy stated that [Resident 3] had agreed to give it another try..." The facility investigation resulted "...OT, willfully used inappropriate and offensive language toward a resident...and not permitted on facilities premises..." The facility policy and procedure titled "Abuse Prevention Program," revised August 2006, indicated "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion...Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual..." The Department's investigation identified that the facility's failure to ensure the right to be free from verbal and mental abuse for Resident 3 when the occupational therapist (OT) directed abusive language towards Resident 3. This failure negatively impacted the resident's psychosocial well-being when Resident 3 felt hurt and angry. This failure had the potential to continue to cause anger and anxiety to Resident 3 and other residents who might hear about the incident when the perpetrator was not removed from resident care immediately following the incident. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 010000004 |
Crescent City Skilled Nursing |
110011808 |
B |
10-Oct-16 |
V1YU11 |
2947 |
Health & Safety Code 1418-1418.91(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 an allegation of verbal abuse by the Occupational Therapist to Resident 3 within 24 hours. This failure had the potential for ongoing verbal abuse. The Department's intake information form, dated 4/16/15 revealed the facility reported an allegation of employee to resident abuse. A review of Resident 3's clinical chart revealed Resident 3 ' s admitting diagnosis included arthritis (inflammation of the joints). During a concurrent observation and interview on 10/13/15, at 4:45 p.m., regarding the incident on April 14, 2015, Resident 3 was in bed and alert. Resident 3 stated the Occupational Therapist (OT) came in her room when Unlicensed Staff G was in her room. Resident 3 stated she told the OT to leave the room because the OT should not be in her (Resident 3) room. Resident 3 stated she did not get along well with the OT because the OT pushed her too much on her therapy. Resident 3 stated she could not tolerate therapy when OT pushed too much. Resident 3 stated OT made a "face" and heard her say to Unlicensed Staff G "She (Resident 3) was a bitch and fuck her." Resident 3 stated she felt hurt and angry. During an interview on 10/13/15, at 9:45 a.m., when asked about the incident, Administrative Staff A stated she was notified of the incident on 4/16/15 and she escorted OT out of the facility immediately. During a concurrent interview and record review of the facility investigation report on 10/14/15, at 9:20 a.m., Administrative Staff A stated she did not remember who brought the incident to her attention. According to the facility investigation report, the incident occurred on 4/14/15 and reported to her on 4/16/15 by Administrative Staff B. The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals," dated December 2009, indicated "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility...Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone..." The facility failed to report an allegation of verbal abuse by the Occupational Therapist to Resident 3 within 24 hours. This failure had the potential for ongoing verbal abuse. |
| 010000004 |
Crescent City Skilled Nursing |
110011820 |
B |
10-Oct-16 |
V1YU11 |
3467 |
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 an allegation of resident (Random Resident 16) to resident (Random Resident 17), abuse within 24 hours, with the potential for ongoing altercations and abuse to other clients. Resident 16 was a 61 year old female who had a diagnosis of alcohol induced dementia. During an interview on 10/14/15, at 8 a.m., Administrative Staff A, upon request, presented a random SOC 341 form (used for reporting suspected dependent adult/elder abuse) dated 8/15/15. Administrative Staff A stated the incident was not reported to the state licensing agency because an algorithm, prepared by the Ombudsmen Program (The primary responsibility of the program is to investigate and endeavor to resolve complaints made by, or on behalf of, individual residents in long-term care facilities.), was followed and it did not indicate the need to report to the licensing agency. Administrative Staff A stated there was an assumption the algorithm flow chart was an accepted document by the state licensing agency. During document review on 10/14/15, a SOC 341 dated 8/15/15 noted an incident occurred on 8/14/15 at 2:30 p.m. where Random Resident 16 kicked Random Resident 17. SOC 341 indicated notification of the Ombudsmen but not the state licensing agency. Review of the algorithm flow chart instructions indicated; " Note: This training tool is not intended to cover all reporting requirements for skilled nursing and residential care facilities. Reporters should refer to their respective licensing laws to assure all reporting requirements have been met." During review of two facility policy's, the first titled "Abuse Prevention Program" dated 2014 indicated that "If abuse is witnessed or suspected, reporting and investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who are reporting will notify the following entities: a. Adult Protective Services b. Ombudsman c. State Survey Agency d. Law enforcement when applicable e. Facility Director of Nursing (DON)." The second policy titled "Reporting Abuse to state Agencies and Other Entities/Individuals", dated December 2009 indicated to 1. "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director" and 2. "Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone." The facility failed to report allegations of resident to resident abuse to the Department within 24 hours, with the potential for ongoing abuse to the residents. |
| 010000004 |
Crescent City Skilled Nursing |
110011821 |
B |
10-Oct-16 |
V1YU11 |
3510 |
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 allegations of resident (Random Resident 16) to resident (Random Resident 18) abuse to the Department within 24 hours, with the potential for ongoing altercations and abuse to other clients. Resident 16 was a 61 year old female who had a diagnosis of alcohol induced dementia. During an interview on 10/14/15, at 8 a.m., Administrative Staff A, upon request, presented a random SOC 341 form (used for reporting suspected dependent adult/elder abuse) dated 8/1/15. Administrative Staff A stated the incident was not reported to the state licensing agency because an algorithm, prepared by the Ombudsmen Program (The primary responsibility of the program is to investigate and endeavor to resolve complaints made by, or on behalf of, individual residents in long-term care facilities.), was followed and it did not indicate the need to report to the licensing agency. Administrative Staff A stated there was an assumption the algorithm flow chart was an accepted document by the state licensing agency. During document review on 10/14/15, a SOC 341 dated 8/16/15 noted an incident occurred on 8/15/15 at 1:30 p.m., where Random Resident 16 made contact with Random Resident 18 with her hands. SOC 341 indicated notification of the Ombudsmen but not the state licensing agency. Review of the algorithm flow chart instructions indicated; " Note: This training tool is not intended to cover all reporting requirements for skilled nursing and residential care facilities. Reporters should refer to their respective licensing laws to assure all reporting requirements have been met." During review of two facility policy's, the first titled "Abuse Prevention Program" dated 2014 indicated that "If abuse is witnessed or suspected, reporting and investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who are reporting will notify the following entities: a. Adult Protective Services b. Ombudsman c. State Survey Agency d. Law enforcement when applicable e. Facility Director of Nursing (DON)." The second policy titled "Reporting Abuse to state Agencies and Other Entities/Individuals", dated December 2009 indicated to 1. "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director" and 2. "Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone." The facility failed to report an allegation of resident to resident abuse to the Department within 24 hours, with the potential for ongoing abuse to the residents. |
| 010000004 |
Crescent City Skilled Nursing |
110011822 |
B |
10-Oct-16 |
V1YU11 |
3516 |
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 an allegation of resident (Random Resident 16) to resident (Random Resident 18) abuse to the Department within 24 hours, with the potential for ongoing altercations and abuse to other clients. Resident 16 was a 61 year old female who had a diagnosis of alcohol induced dementia. During an interview on 10/14/15, at 8 a.m., Administrative Staff A, upon request, presented a random SOC 341 form (used for reporting suspected dependent adult/elder abuse) dated 8/1/15. Administrative Staff A stated the incident was not reported to the state licensing agency because an algorithm, prepared by the Ombudsmen Program (The primary responsibility of the program is to investigate and endeavor to resolve complaints made by, or on behalf of, individual residents in long-term care facilities.), was followed and it did not indicate the need to report to the licensing agency. Administrative Staff A stated there was an assumption the algorithm flow chart was an accepted document by the state licensing agency. During document review on 10/14/15, a SOC 341 dated 8/16/15 noted an incident occurred on 8/16/15 at 5:45 p.m., where Random Resident 16 threw a vase which made contact with Random Resident 19. SOC 341 indicated notification of the Ombudsmen but not the state licensing agency. Review of the algorithm flow chart instructions indicated; " Note: This training tool is not intended to cover all reporting requirements for skilled nursing and residential care facilities. Reporters should refer to their respective licensing laws to assure all reporting requirements have been met." During review of two facility policy's, the first titled "Abuse Prevention Program" dated 2014 indicated that "If abuse is witnessed or suspected, reporting and investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who are reporting will notify the following entities: a. Adult Protective Services b. Ombudsman c. State Survey Agency d. Law enforcement when applicable e. Facility Director of Nursing (DON)." The second policy titled "Reporting Abuse to state Agencies and Other Entities/Individuals", dated December 2009 indicated to 1. "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director" and 2. "Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone." The facility failed to report an allegation of resident to resident abuse to the Department within 24 hours, with the potential for ongoing abuse to the residents. |
| 010000003 |
Creekside Rehabilitation & Behavioral Health |
110011994 |
B |
28-Mar-16 |
XGTZ11 |
10261 |
F425 ?483.60(a)(b) Pharmaceutical Svc - Accurate Procedures, Rph The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. The facility failed to ensure that the facility policy for obtaining a Schedule II medication (a classification for medications with the greatest potential for abuse per the Uniform Controlled Drug Act of 1970 and for which prescriptions cannot be refilled, as a new prescription is required for each dispensing) met state regulatory requirements which the contract between the contracted pharmacy, Pharmacy N, and the facility stipulated the pharmacy must meet. The policy required an order seven days in advance of dispensing a schedule II medication while state regulation, Title 22, Section 72355(a)(1)(C), requires the medication must be made available the same day unless it would be started the next day. The facility also failed to ensure Pharmacy N provided the service in a timely manner as stipulated by the contract with Pharmacy N.The facility notified the pharmacy by fax that it needed a narcotic, Dilaudid (a potent opioid pain relieving medication) for Resident 1 on 4/20/15 and 4/24/15 but it was not delivered until 4/27/15. As result Resident 1 missed four doses of the Dilaudid which he took for pain secondary to strokes he had in the past and would have missed a fifth dose if the facility had not contacted Physician A on the morning of 4/27/15 for an urgent one time order for Dilaudid which staff then obtained from the facility emergency medication supply located on the skilled nursing side of the facility and administered to Resident 1.Resident 1 had a history of strokes and his physician, Physician E, stated that withdrawal secondary to lack of the Dilaudid could result in Resident 1 in suffering a stroke. Findings: 1. On 5/14/15 a review of Resident 1's clinical record indicated a physician had prescribed Dilaudid 2 mg orally twice daily for leg pain on 6/20/13. On 4/27/15 Physician A ordered staff, via a telephone order, to administer one 2 mg tablet of Dilaudid "now for the 0900 (9 a.m.) dose X 1 only". A review of the April 2015 medication administration record (MAR: used by nurses to accurately medicate their patients and to document the date and time a dose of medication was administered) indicated it had an entry for Dilaudid 2 mg twice daily. Staff had circled the entries for the 9 a.m. and 5 p.m. doses on 4/25/15, the 9 a.m. and 5 p.m. doses on 4/26/15 and the 9 a.m. dose on 4/27/15. The circle indicated the medication was not given as ordered. A review of the medication notes on the MAR indicated that staff documented the Dilaudid was not available at 9 a.m. on 4/25/15 and at 9 a.m. on 4/27/15. A review of a nurse's note dated 4/27/15 at 12 noon indicated Resident 1 had missed five doses of Dilaudid and Resident 1 had no complaints of discomfort and pain. During an interview of Licensed Staff C at 2:25 p.m. on 5/14/15, she stated she took care of Resident 1 and he had no complaints of discomfort or pain. A review of the medication notes on another MAR on 12/23/15 indicated that staff documented the Dilaudid was not available at 5 p.m. on 4/25/15 and at 5 p.m. on 4/26/15. A review of another MAR indicated staff had documented the extra one time dose was administered at 12:30 p.m. on 4/27/15 (normal morning administration time was 9 a.m.).On 5/14/15 at 2:33 p.m. during an interview of Administrative Staff B, she stated staff had faxed a refill request for the Dilaudid to Pharmacy N five days prior to the time the Dilaudid would run out. Administrative Staff B stated Pharmacy N staff claimed they had not received this fax but she stated she had confirmation they had received the fax. She said staff faxed a second request for the Dilaudid to Pharmacy N on 4/24/15 and the pharmacy subsequently informed the facility they needed a prescription from the doctor. The Pharmacy N staff informed the facility they could not get a hold of the doctor to obtain a prescription. Administrative Staff B stated the facility could get a hold of an alternate doctor 24 hours a day seven days a week and she did not understand why there was a delay in the delivery of the Dilaudid. Administrative Staff B stated she obtained authorization from a physician and the pharmacy to obtain a dose of Dilaudid from an emergency medication supply on Monday morning (4/27/15) so Resident 1 missed the 4/25 and the 4/26/15 doses of Dilaudid (four doses total) but not the 4/27/15 doses (although the morning dose was given 3.5 hours after the normal morning administration time of 9 a.m.). On 5/14/15 a review of two "Transmission Verification Reports" indicated facility staff had faxed two requests for Dilaudid for Resident 1 to Pharmacy N on a form with the name and fax number of Pharmacy N printed on the form.The first Transmission Verification Report documented the fax had been sent to the fax number for Pharmacy N printed on the upper right corner of the form and that the fax had been sent on 4/20/15 at 4:17 p.m. The second Transmission Verification Report documented the fax had been sent to the fax number for Pharmacy N printed on the upper right corner of the form and that the fax had been sent on 4/24/15 at 3:30 p.m. On 10/7/15 at 3:10 p.m. during an interview of Administrative Staff D a request for any information regarding the missed doses of Dilaudid in April 2015 resulted in the provision of an e-mail sent by Administrative Staff B to Pharmacy N on 4/27/15 at 10:30 a.m. A review of this e-mail at that time indicated it documented Administrative Staff D had told Administrative Staff B that Resident 1 had issues regarding the availability of Dilaudid in the past and had "suffered from opioid withdrawal" at that time. During a concurrent interview of Administrative Staff D at that time, when asked about the past incident of opioid withdrawal, she provided a second e-mail by Administrative Staff D. A review of this e-mail indicated it was sent by Administrative Staff D to Pharmacy N on 5/1/13 (two years previously) at 11:27 a.m. It documented Resident 1 took 4 mg of Dilaudid daily and that facility staff requested Dilaudid on 4/27/13 as the facility would run out of doses on 4/29/13. No deliveries were made and staff sent a second request to Pharmacy N on 4/29/13. The e-mail documented no deliveries were made on 4/29, 4/30 or in the morning of 5/1/13 so Resident 1 missed the second dose on 4/29, both doses on 4/30, and the morning dose on 5/1/13. The e-mail documented that Physician E was concerned Resident 1 was going into withdrawal as Resident 1 had chest pain, an increase in pulse, and an increase in blood pressure. The e-mail documented Physician E was concerned that Resident 1 had "... missed four doses of a prescribed narcotic and that his health was put at risk". On 12/9/15 at 1:45 p.m. during an interview of Physician E she stated she was Resident 1's physician. Physician E stated that Resident 1 had a history of two strokes plus an incident of a deep vein blood clot. Physician E stated that Resident 1 had chronic pain related to the strokes. She stated that in 2013 Resident 1 had missed Dilaudid doses and had to go to the (Hospital O) emergency department for examination as his blood pressure and pulse had increased. Physician E stated she recalled she was concerned at that time that Resident 1 may have another stroke as a result of the withdrawal symptoms. Physician E stated that if Resident 1 had gone into withdrawal following the missed doses of Dilaudid in April 2015 Resident 1 could have had a stroke. On 10/6/15 a review of the PHARMACEUTICAL SERVICES AGREEMENT, a contract between Pharmacy N and the facility, indicated it stipulated under "PHARMACY OBLIGATIONS": "Pharmacy shall use its best efforts to provide Facility with the requested Products within reasonably requested time-frames" and "... Pharmacy is to provide pharmaceutical services ... in accordance with any applicable requirements of federal, state or local laws and regulations".Title 22, 72355(a)(1)(C) stipulates " ... all new drug orders shall be available on the same day ordered unless the drug would not normally be started until the next day". On 12/10/15 a review of the policy and procedure entitled ORDERING AND RECEIVING MEDICATIONS FROM (Pharmacy N) indicated it stipulated Schedule II controlled substances were to be ordered " ... at least 7 days in advance of need". The policy had come from the Pharmacy N policies and procedure manual which Administrative Staff B and Administrative Staff D identified as a manual of current policies in the facility during an interview conducted at 3:43 p.m. on 12/10/15. Therefore, the facility failed to ensure that the facility policy for obtaining a Schedule II medication met state regulatory requirements which the contract between Pharmacy N and the facility stipulated Pharmacy N must meet when it did not deliver Dilaudid to the facility within a day of the time the facility ordered it. The facility also failed to ensure Pharmacy N provided the service in a timely manner as stipulated by the contract with Pharmacy N when Pharmacy N delivered the Dilaudid seven days after it was ordered. As result Resident 1 missed four doses of the Dilaudid which he took for pain secondary to strokes he had in the past and received a fifth dose 3.5 hours after he would normally have received it. Resident 1 had a history of strokes and his physician, Physician E, stated that withdrawal secondary to lack of the Dilaudid could result in Resident 1 in suffering a stroke. These violations had a direct relationship to the health and safety of Resident 1. |
| 010001128 |
Care Meridian, LLC |
110012228 |
B |
16-Jun-16 |
ZBSF11 |
4352 |
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.1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report one incident of alleged staff-to-resident abuse to the California Department of Public Health within 24 hours. This failure resulted in the Department's inability to independently investigate the alleged mental abuse without delay. This failure had the potential for other residents to be exposed to mental abuse if measures were not taken to ensure complete investigation, implementation of effective interventions, monitoring and a follow-up investigation.On 4/29/16, the CDPH received a report of alleged abuse from another agency. The report alleged a Licensed Nurse (Licensed Staff A) had "upset and frightened" Resident 1 during an interaction on the night from 4/14/16 to 4/15/16.During a phone conversation on 4/29/16 at 9:32 a.m., Licensed Staff B stated Resident 1 stated to staff that the night shift nurse (Licensed Staff A) had upset and frightened him during the night shift on 4/14/16. Licensed Staff B stated the incident had been investigated, "internally," and Licensed Staff A was allowed back to work. Licensed Staff B stated it should not be, "up to the facility alone to determine if abuse occurred or not." Licensed Staff B stated she did not contact CDPH.During an interview on 4/29/16 at 1:35 p.m., Licensed Staff H was asked what she would do if she witnessed abuse. Licensed Staff H stated she would have the involved parties, "go their own way," and, "call the supervisor and follow what the supervisor would like me to do." Licensed Staff H stated she had not received any training in regards to abuse prevention or reporting.During an interview on 4/29/16 at 2:44 p.m., Licensed Staff D was asked about reporting alleged abuse. Licensed Staff D stated she would, "inform the supervisor," about the alleged incident. Licensed Staff D did not state the need to notify CDPH.During an interview on 4/29/16 at 1:25 p.m., Unlicensed Staff G was asked to whom she would report alleged abuse. Unlicensed Staff G stated, "the nurse." When asked if she needed to report to someone else, she shook her head and stated, "that's it."During an interview on 4/29/16 at 2:40 p.m., Unlicensed Staff I stated she had received training in abuse prevention and reporting, and would report to the nurse and would make sure everyone was safe.During an interview on 4/29/16 at 2 p.m., Management Staff E stated she notified her supervisor (Administrative Staff F) and Human Resources in the event of alleged abuse. Management Staff E did not state she would notify CDPH.During a phone interview on 5/5/16 at 10:18 a.m., Administrative Staff F stated he thought staff at the facility had notified CDPH. Administrative Staff F was informed no one had notified CDPH as required. Administrative Staff F stated since the internal investigation concluded there were no indications of abuse, there had been no need to report to CDPH.A document titled, "Policy and Procedures: Subject: Abuse-Dependent Adult/Child," dated 01/01/2011, and revised 01/06/2016, revealed under, "Definition of Terms" for "Abuse"..."treatment with resulting physical harm or pain or mental suffering." The document defined, "Mandated Reporter," as "Any person who works for or has a contractual agreement with Care Meridian, including administrators, supervisors, nursing staff, therapists, social worker, dietician, including support and maintenance staff." The document revealed under, "Reporting/Response" "a. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, in a timely manner... l. When an alleged or suspected case of mistreatment...is reported, the Administrator/DON will notify the following individuals or agencies, as applicable, within 24 hours of the alleged incident: The State Licensing/certification agency responsible for surveying/licensing the facility..."Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic class "B" violation . |
| 010000003 |
Creekside Rehabilitation & Behavioral Health |
110012260 |
B |
15-Jun-16 |
IC4011 |
3111 |
(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 sexual abuse to the Department immediately or within 24 hours. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay and the potential for further abuse to the other residents. Findings: On 5/9/16 at 4:55 p.m. the Department received a report of an abuse allegation via fax machine. The Facility reported, "Resident 1 called son to report that a CNA (Certified Nursing Assistant), had sexually assaulted her. Santa Rosa Police Officer arrived to investigate and the resident would not disclose any information about the Incident. The CNA was suspended pending investigation. The resident continues to refuse to give any details." In an interview on 5/10/16 at 3:30 p.m., Staff A stated that she found out about the alleged abuse "Friday Evening," 5/6/16, from the police department. The son from Indiana had called the Santa Rosa Police Department asking for a welfare check on Resident 1. Staff A learned that Resident 1 had accused CNA A of sexual abuse. Staff A called the DON the evening of 5/6/16 to report the issue. The DON suspended the CNA A that Friday evening. In an interview 5/11/16 at 2:30 p.m., the DON stated that she heard about the incident Friday and suspended CNA A that evening. She said that the police arrived at 6:30 p.m.; she was reached by the staff at 7:30 p.m., and called off CNA A at 8:58 p.m. In an interview on 5/12/16 at 4:05 p.m., the DON was asked, "when did you report the allegation to CDPH?" She answered "Monday." The facility's Step-by-Step Guide to Abuse and Neglect Intervention, Investigation and Management form indicated that the CDPH was notified on 5/9/16. The guide form included an action step to report to CDPH "Within 24 hours." On 5/9/16 CDPH received a copy of the Confidential Adverse Incident Initial Report, from the facility via fax and the time stamp at the top of the page read, "May 09 2016 at 1656, (4:56 p.m.)" A facility copy of this form included documentation that the DON faxed it on 5/9/16 at 4:55 p.m. The facility policy and procedure that was titled, "Reporting Abuse to State Agencies and Other Entities/ Individuals," dated 2001, and revised December 2009, indicated: "1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source or abuse... be reported, the facility Administrator or his/her designee, will promptly notify the following persons, or agencies (verbally and written) of such incident. a. The State licensing/certification agency responsible for surveying/licensing the facility..." "2. Verbal/written notices to agencies will be made within twenty four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, and email or by telephone..." |
| 010000003 |
Creekside Rehabilitation & Behavioral Health |
110012382 |
AA |
25-Oct-16 |
N0ZZ11 |
11238 |
F365 ?483.35(d)(3) FOOD IN FORM TO MEET INDIVIDUAL NEEDS Each resident receives and the facility provides food prepared in a form designed to meet individual needs. The facility failed to follow the physician's diet order for Resident 16, one of twenty-five sampled residents who were identified as being at risk for choking. Residents 16 was given a quesadilla that was not prepared according to a mechanical soft diet (texture and consistency of foods are changed). Resident 16 had a diagnosis of dysphagia (difficulty swallowing) and her physician ordered her to receive a mechanical soft diet. Licensed Staff CC stated Resident 16 ordered a quesadilla off the substitution menu. The quesadilla was cut into large pieces, not bite-sized pieces, as indicated by the recipe. When Resident 16 began to choke on the quesadilla, staff performed the Heimlich maneuver (a technique of abdominal thrusts for dislodging objects obstructing the airway) but were unable to clear her airway. Facility staff called 911 for emergency assistance. Firefighters arrived at the facility and removed a large piece of food from Resident 16's airway. The failure of the facility to provide food to Resident 16, as ordered by the physician, resulted in Resident 16's choking episode, and subsequent death. Resident 16 was identified by facility documentation as a seventy-two year old, developmentally delayed (impairment in physical, learning, language, or behavior areas) female who was admitted to the facility on 2/18/2004. Review of Resident 16's medical record indicated she had diagnoses that included dysphagia (difficulty swallowing), generalized muscle weakness, and left hemiparesis (muscle weakness affecting one side of the body) due to cerebral vascular accident (stroke). Resident 16's care plan, dated 1/4/14, indicated she was a choking risk due to mastication (chewing) and swallowing problems. The care plan indicated she had a history of eating too fast and choking. The goal of the care plan was for Resident 16 to tolerate her diet without choking. Interventions included following ST (speech therapy) guidelines, following physician's diet order, Registered Dietitian (RD) consultation, reminding resident to eat slowly, and getting resident up in chair for all meals. Resident 16's Minimum Data Set (MDS - an assessment tool), dated 1/4/15 and 1/4/14, indicated she was on a mechanically altered diet. Resident 16's active physician orders, dated 4/1/15, indicated she was on a mechanical soft texture diet (order start date 1/19/15). Review of Resident 16's physician discharge summary from a local hospital, dated 1/5/12, indicated she had choked on an, "unbitten" bagel in the facility and was transferred to the hospital. Review of a physician progress note from a local hospital, dated 10/30/12, indicated this was the second admission that year for Resident 16 because of a choking episode at the convalescent facility in which she lived. The note indicated she choked on a piece of chicken. An ST (speech therapy) note, dated 3/22/13, indicated Resident 16 had significant oral stage dysphagia (difficulty chewing and swallowing). An ST note, dated 4/10/13, (six months after the 10/30/12 choking incident) indicated Resident 16 could safely consume a mechanical soft diet. Review of a nursing progress note, dated 4/1/15 at 9:00 p.m. (documented by Licensed Staff CC), indicated Resident 16 was up in a wheel chair for dinner (6:05 p.m.) when she started choking on a piece of food. The note indicated staff started the Heimlich procedure and called 911 (emergency medical assistance) for help. During an interview on 5/13/15 at 3:40 p.m., Licensed Staff CC stated a Certified Nursing Assistant (CNA) notified her that Resident 16 was choking. She stated she and another nurse performed the Heimlich procedure until the paramedics arrived. She stated the paramedics used a fork-like instrument to remove the obstruction blocking Resident 16's airway. She stated Resident 16 had ordered a cheese quesadilla and the paramedics removed a "big piece" of flour tortilla and cheese. In continued interview, Licensed Staff CC stated Resident 16 was on a mechanical soft diet. She stated the quesadilla on which Resident 16 choked was in big pieces. She stated the quesadilla was large and cut in four or five pieces. In continued interview, Licensed Staff CC stated that was the third time Resident 16 had choked at the facility. She stated Resident 16 had previously been sent to the hospital after choking. During an interview on 5/14/15 at 3:45 p.m., Unlicensed Staff DD stated he was passing dinner trays when Resident 16 was choking. He stated she could not speak and he hit her on her back to try to help. He stated Resident 16's quesadilla was cut in, "big pieces." During an interview on 5/27/15 at 1:15 p.m., Unlicensed Staff EE stated he was working in activities the evening Resident 16 choked. He stated someone called 911 and he saw the paramedics remove a "big" piece of quesadilla from Resident 16's airway. He stated he thought it was about two inches. During an interview on 5/27/15 at 4:45 p.m., Paramedic II stated the local firefighters were the first responders (first on the scene) to Resident 16's choking incident. She stated the firefighters removed a large piece of food. She stated the food was a "pretty big" quesadilla that was about the size of her palm. She stated it was in one solid piece. She observed the quesadilla lying on the ground next to Resident 16 and stated, "we (emergency responders) all made comments that it was very large." During an interview on 7/16/15 at 11:45 a.m., Emergency Medical Technician (EMT) JJ stated Resident 16's airway obstruction had been removed when he arrived at the scene. He stated, "I remember thinking it was pretty big" and stated the piece of food was "large enough to choke on." Review of Pre-Hospital Care Report (dated 4/1/15) indicated the first responders were able to remove a, "large piece of food" that appeared to be causing the airway obstruction. The document indicated an oral airway was placed (to help Resident 16 breathe), but she became pulseless and Cardiopulmonary Resuscitation (CPR) was initiated. During an interview on 6/15/15 at 4:55 p.m., Physician KK stated Resident 16 died from respiratory failure due to choking on a bolus (mixture of food and saliva that forms in the mouth during chewing) of food. He stated she had had a stroke in the past and was on a mechanically soft diet. He stated she ate rapidly, gobbled down her food, and would not chew carefully. Review of Resident 16's death certificate (dated 6/25/15) indicated her immediate cause of death was (A) Respiratory failure and, (B) Choking on food bolus. During an interview on 5/14/15 at 1:50 p.m., Registered Dietitian AA (RD AA) stated Resident 16's quesadilla was on the alternate menu (food alternatives different from the scheduled menu). She stated food on a mechanical soft diet should be soft enough to cut with the edge of a fork. During a subsequent interview at 2:45 p.m. on 5/14/15, she stated that a quesadilla on a mechanical soft diet should be cut into bite-sized pieces or strips. During an interview on 5/27/15 at 1:45 p.m., Dietary Cook MM stated chicken on a mechanical soft diet should be cut into small pieces, the size of cubes. When asked how he would cut a quesadilla on a mechanical soft diet, he drew a half circle with multiple squares. He stated he would cut the quesadilla the same way in which he depicted it (multiple squares). Review of facility recipe entitled, "Cheese Quesadilla," subtitled, "Method" (dated 2015) indicated, "5. Note for mechanical soft: cut into bite size pieces." During an interview on 5/27/15 at 2:10 p.m., Speech Therapist LL stated Resident 16 was not seen (evaluated) by speech therapy since 2013. Review of final speech therapy note, dated 4/5/13, indicated Resident 16 could safely consume a mechanical soft diet. During an interview on 5/27/15 at 1:45 p.m., RD AA stated Resident 16 ate "so fast." Review of Resident 16's, "Registered Dietitian Annual Assessment," dated 1/7/15 (three months before her death), indicated she required a mechanical soft texture diet due to not chewing food well. During an interview on 4/22/16 at 10:30 a.m., the Director of Nursing (DON) was asked if a nurse had checked Resident 16's dinner tray before serving it to her (to ensure it was the correct diet as ordered by the physician and in a form to meet Resident 16's individual needs). The DON stated she did not know because she had not asked the nurse assigned to care for Resident 16 at the time of the choking incident. She also stated Resident 16's quesadilla, "was cut in wedges." During an interview on 4/22/16 at 1:30 p.m., Administrative Staff A stated Resident 16's quesadilla had been cut into wedges. He stated, "we believe it was bite-size." Resident 16's care plan, dated 1/4/14, indicated the facility had advised Resident 16 and her Responsible Party (RP) of the health risks related to continued weight gain, up to and including death. The care plan did not indicate the facility discussed potential choking risks associated with food intake with Resident 16 or her RP. Review of an Interdisciplinary Team (IDT- health team members including nursing, dietary social services, etc.) note, dated 4/9/14, one year before Resident 16's death, indicated the team met to discuss Resident 16's ten-pound weight gain. The note indicated Resident 16's Responsible Party was aware of the serious consequences related to her obese weight which included skin breakdown, loss of mobility and, "possible death." The note did not indicate the team addressed diet-related choking risks with Resident 16 or her RP. Review of multiple IDT notes, dated 6/4/14, 6/18/14, 8/6/14, and 11/12/14, indicated the team addressed various issues affecting Resident 16, including weight gain, food-seeking behaviors, family bringing food and snacks, resident's non-compliance with diet, weight loss, and encouraging healthy food choices for weight loss. These IDT notes did not indicate the facility addressed any potential diet-related choking risks with the Resident 16 or her RP. An IDT note dated 2/11/15, approximately two months before Resident 16's death, indicated Resident 16 was becoming less alert and she would continue on current diet (mechanical soft). The note did not indicate the team addressed potential diet-related choking risks with the Resident 16 or her RP. Therefore, the facility failed to follow the physician's diet order for Resident 16 (who was identified as being at risk for choking) when they served and she consumed a quesadilla that was not prepared according to a mechanical soft diet. Resident 16's quesadilla was cut into large pieces, not bite-sized pieces. The facility failed to provide to and failed to ensure that Resident l6 received food in a manner designed to meet her individual needs. These failures resulted in Resident 16's death. The regulatory violations described presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were the direct proximate cause of Resident 16's death. |
| 010000037 |
Cloverdale Healthcare Center |
110013108 |
B |
1-Jun-17 |
0L1T11 |
16609 |
F226: 483.12(b)(1)-(3), 483.95(c)(1)-(3)
DEVELOP / IMPLEMENT ABUSE / NEGLECT, ETC. POLICIES
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 facility failed to implement their abuse policies and procedures for reporting, investigation, protection of residents during an investigation, and careplanning when Resident 1 made an allegation of sexual abuse. In addition, the facility failed to develop a policy for specific procedures for reporting and management of residents related to allegations of sexual assault. These failures had the potential that investigations of allegations of abuse would not be conducted timely and placed Resident 1 and other residents at risk for abuse.
On 3/21/17, the Department received a report from the facility's Business Operations Manager (BOM), dated 3/20/17, which documented Resident 1 reported to a nurse on Sunday (3/19/17) that she was raped by three men the previous night (3/18/17). The facility submitted an attached Investigation Summary Report, dated 3/20/17, which documented Resident 1 reported to Licensed Staff A on 3/19/17 that she was raped by four men on 3/18/17. The report noted Licensed Nurse A did not see any signs of abuse, made a note in the chart and reported to the BOM, who was identified as the abuse coordinator.
Review of Resident 1's Admission Record, printed by the facility on 3/21/17, documented Resident 1 was admitted to the facility on XXXXXXX 14 with diagnosis that included major recurrent depressive disorder, severe with psychotic symptoms.
During an interview on 3/21/17 at 11:40 a.m., the BOM stated Resident 1's story changed multiple times. The BOM stated Licensed Staff A called him Sunday afternoon (3/19/17) and informed him that the Resident reported five guys raped her. Licensed Staff A had reported the resident's account of events were not consistent. The BOM stated he asked Licensed Staff A about the "viability" of the story and Licensed Staff A informed him she did not think it was a credible allegation and thought maybe the resident was hallucinating due to a urinary tract infection or recent medication change. The BOM stated he informed Licensed Staff A to "keep him in the loop" and stated that was the end of the investigation for that day until the next day, Monday (3/20/17). When asked if the Resident 1 had received an examination or assessment after the allegation of rape / assault was made or if police were notified that day, the BOM stated he did not believe the resident received a full exam. The BOM stated it was not until the next day, 3/20/17, that police and the resident's physician were notified of the allegation as part of "due diligence." The BOM stated he instructed staff not to interview the resident until after the police had interviewed her.
The BOM stated after police interviewed Resident 1 on 3/20/17 that was the first time he had heard descriptions of the accused. He stated the resident identified a white male with curly hair named [X] who served food. The BOM stated no one at the facility met that description or name. The BOM stated Resident 1 also identified two other males. The BOM stated CNA D and CNA E worked on 3/18/17 and potentially met the resident's description. The BOM stated CNA D was orienting with CNA C on 3/18/17 but had not provided care and CNA E had worked at the facility for a long time. He stated Resident 1 stated she had never seen the men before.
The BOM stated he had not yet interviewed the CNAs who were on duty the evening of 3/18/17. He stated CNA C and CNA E did not work Sunday (3/19/17) or Monday (3/20/17). He stated CNA D did work on Sunday (3/19/17) but was still in orientation. The BOM stated the action plan was only female CNAs would be assigned to work with Resident 1. The Administrator stated he had not suspended any staff from providing care to other residents pending completion of the investigation because he did not feel any staff were a threat and stated the police had indicated the allegation was not substantiated. The BOM confirmed he had not yet completed his investigation or completed interviews of staff who were on duty the night of the alleged event.
During an interview and concurrent record review on 3/21/17 at 12:25 p.m., the Acting Director of Nurses (DON) provided Resident 1's care plan dated 3/21/17 which documented Resident 1 was resistive to care related to anxiety and Resident 1 would yell at staff and make accusations of sexual abuse when resisting care. Interventions included only female caregivers with a partner. The Acting DON stated they had conducted an inservice to staff on 3/20/17 related to providing female only caregivers to Resident 1, but a care plan had not been developed until 3/21/17 related to Resident 1's history of making false allegations or the interventions implemented related to allegation of sexual abuse.
During an observation on 3/21/17 at 12:30 p.m., Resident 1 was observed in the dining room. Resident 1 propelled herself out of the dining room and announced to staff that she could not wait to go to court for, "what they did." When staff asked Resident what she was referring to, Resident 1 announced she was raped and stated "he is in there now" referring to the dining room.
During an interview on 3/21/17 at 1:05 p.m., the BOM stated the staff member identified by Resident 1 in the dining room was CNA C who had just returned to work that day after being off. The BOM stated he had not yet had a chance to interview CNA C prior to starting his shift that day. During a follow up interview at 1:25 p.m., the BOM stated he had just suspended CNA C and CNA C, D and E would be removed from the schedule until completion of the investigation.
During an interview, on 3/21/17 at 1:30 p.m., Licensed Staff A stated on the afternoon of 3/19/17, Resident 1 reported to her that four men had raped her the previous night. Licensed Staff A stated she asked the resident for details and the resident stated they "played" with her one after another and then went away. Licensed Staff A stated she asked the resident if she was "ok" and the resident stated no, "four men raped me." Licensed Staff A stated Resident 1 did not provide any descriptions of the alleged individuals. Licensed Staff A stated she asked Resident 1 if she had any pain or problem urinating to which the resident denied. Licensed Staff A stated she asked the CNAs if they noticed any bruising on the resident when they changed her. Licensed Staff A stated she did not physically assess or examine the resident herself because the resident was in a chair. She stated if the resident was in bed she may have looked at her if she changed her. Licensed Staff A stated Resident 1 had an increase in her paranoia that day and stated that was a change. Licensed Staff A stated she did not notify the physician of the resident's allegation of rape, nor of her noted changed condition on 3/19/17. She stated the resident's physician came in the next morning and she informed the physician at that time. When asked how she protected the resident and other residents pending completion of the investigation, she stated she instituted female only caregivers for Resident 1. Licensed Staff A stated she documented "something" and passed it on to the oncoming nurse.
Concurrent review of a Nursing note, dated 3/19/17 at 3:27 p.m., Licensed Staff A documented Resident 1 was "paranoid, thinks that four men raped her last night." Licensed Staff A documented Resident 1 continued with foul language towards staff and other residents and was not easy to redirect. The resident denied pain when asked and had no reports of discomfort with urination. There was no documentation of notification to the Administrator or abuse coordinator, no notification to the physician and no documentation of complete evaluation of the resident or immediate interventions to protect the resident or other residents during the investigation. Licensed Staff A confirmed that was the only nursing note she wrote that day regarding the incident.
Licensed Staff A was asked how she ensured staff instituted female only caregivers. She stated she left a poster visible to all at the nursing station and spoke to the CNAs. Licensed Staff A stated she did not document or develop a care plan related to the incident or immediate interventions. Licensed Nurse A stated the facility policy related to allegations of abuse or rape included to notify the Administrator and notify the physician. Licensed Nurse A stated the BOM happened to call her that afternoon of 3/19/17 about another issue and that was when she let him know about Resident 1's allegation as an "FYI". Licensed Staff A stated she did not document that notification and stated she should have.
During a telephone interview on 4/3/17 at 10 a.m., CNA F stated she worked on the p.m. shift on 3/18/17 but was not assigned to care for Resident 1. CNA F stated during the early evening (of 3/18/17) CNA E, who was Resident 1's assigned CNA, asked her to assist him with Resident 1's request to go back to bed. CNA F stated Resident 1 began to make racist and vulgar comments to her and the other CNAs in the room (CNA D and CNA E). CNA F stated Resident 1 started calling out that staff were raping her and kept yelling "rape, rape." CNA F stated she just quickly put an incontinent brief on the resident. She stated she had never seen her so upset before and stated another female, CNA G, came into the room later to try to calm Resident 1 down. She stated they decided to just leave the Resident alone and give her some time.
CNA F was asked if she or other staff reported the resident's allegation of rape to licensed staff. CNA F stated she informed Licensed Staff B after they got out of the room. CNA F stated she told Licensed Staff B that when they tried to change the resident the resident accused them of raping her. CNA F stated Licensed Staff B stated to just leave the resident alone and only female staff should go in there. CNA F stated Resident 1 had a history of making things up and she did not believe anything she said.
During an interview on 4/3/17 at 12 p.m., Licensed Staff B stated she worked the p.m. shift on 3/18/17. Licensed Staff B stated around 7:30 p.m. that night, a CNA informed her Resident 1 agreed to go to bed. She stated two male CNAs (CNA E and CNA D) and one female, CNA F, went in Resident 1's room to assist her to bed. Licensed Staff B stated she did not hear anything the whole time they were in the room. Licensed Staff B stated CNA F came out later and told her Resident 1 had called the two male CNAs racially inappropriate statements and made vulgar comments to CNA F. Licensed Staff B stated she was fairly new to working with Resident 1 but stated her behavior was not new and was not a change from her normal behavior. She stated Resident 1 had a history of yelling at staff and confabulation (making up stories) and stated it was not a change from her normal state. Licensed Staff B stated after the CNAs had left Resident 1's room and were helping other residents, she went in to check on Resident 1 who swore at her and told her to get out of the room. Licensed Staff B stated Resident 1 did not report any allegation of rape to her at that time. Licensed Staff B stated no CNAs reported that Resident 1 had made any allegations of rape. Licensed Staff B stated if she had been told that, she would have immediately notified the BOM, who was the facility's abuse coordinator, initiated female only staff and would have had the involved staff clock out during the investigation.
During an interview on 4/3/17 at 2:50 p.m., CNA C stated he worked as a "float" (no specific assigned resident) on 3/18/17 and worked a 12 hour shift that day until after 7 p.m. CNA C stated he did not usually work in the hall where Resident 1 lived but he did that day due to his float status. CNA C stated he was next door to Resident 1's room and he could hear a bunch of commotion. When he went outside the door of Resident 1's room he could hear her yelling "they're raping me" repeatedly. When he went into the room, CNA F, CNA D and CNA E were trying to assist the resident into bed. CNA C stated Resident 1 sometimes kicked and bites at staff. CNA C stated he did not assist in changing Resident 1's brief, but stated he may have assisted to strap one side of a velcro strap to her brief. CNA C stated Resident 1 told him he had touched her private part, that it was rape and she would see him in court. CNA C stated he "brushed it off" and went next door to assist another resident.
CNA C stated he did not report the resident's allegations and stated he now realized he should have reported it to licensed staff. He stated Resident 1 was often combative and made things up. He stated since he was the float CNA, he assumed someone else would report it. CNA C stated he had no knowledge if any other staff reported the allegation to licensed staff or administration. CNA C stated he frequently worked in the dining room at lunch time with Resident 1 and she often referred to him as [X] and "as the guy who serves food in the dining room." CNA C stated other staff have often heard Resident 1 refer to him that way.
Review of the policy and procedure, Abuse Prevention, revised 11/28/16 documented under the sections:
Prevention: Staff had knowledge of the individual residents care need. Assess, care plan and monitor residents with history of aggressive behaviors, communication disorders.
Identification: All identified events were reported to the Administrator / Designee immediately and would be thoroughly investigated. When an incident or allegation of resident abuse was identified, the Administrator would initiate an investigation. A licensed nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. The investigation shall consist of an interview with the person reporting the incident; an interview with the resident; interviews with any witness to the incident, including the alleged perpetrator as appropriate; a review of the resident's medical record; an interview with staff members (on all shifts) having contact with the accused employee and a review of all circumstances surround the incident.
Protection: If a resident incident was reported, the facility would take the following steps to prevent further potential abuse while the investigation was in progress: If the suspected perpetrator was an employee: Remove employee immediately from the care of any resident; Suspend employee during the investigation.
The policy did not identify specific interventions related to allegations of sexual abuse / rape in regards to guidelines for reporting to law enforcement, physician notification or procedures in event forensic exam (collect and secure evidence for criminal investigation) was indicated in coordination with the resident or responsible party, the resident's physician and / or law enforcement.
The facility failed to implement their abuse policies and procedures for reporting, investigation, protection of residents during an investigation and careplanning when Resident 1 made an allegation of sexual abuse. In addition, the facility failed to develop a policy for specific procedures for reporting and management of residents related to allegations of sexual assault. These failures had the potential that investigations of allegations of abuse would not be conducted timely and placed Resident 1 and other residents at risk for abuse.
These failures had a direct relationship to the health, safety, or security of patients. |
| 960001152 |
CAPISTRANO DIVISION |
120009144 |
B |
16-Mar-12 |
QOF011 |
4846 |
W&I 4502 Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a 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 person with developmental disabilities shall have rights including, but not limited to, the following: (b) A right to privacy On February 7, 2012 and on February 9, 2012 during a re-certification survey the facility staff was observed leaving Client 1 nude on the toilet on February 7, 2012 and again totally nude standing in the corridor on February 9, 2012. The facility?s staff was observed leaving Client 4 totally nude exposing his genital and buttock in his bedroom with the door open.Based on observation, interview, and record review the facility staff failed to: (1) Ensure Client 1 and 4 had privacy during morning care by not closing the bathroom door, not closing the bedroom door, and not using a privacy screen. As a result, anyone passing in the main corridor could see Client 1 and 4?s nude bodies.(a) On February 7, 2012 at 6:15 a.m., upon entrance into the facility Client 1 was observed in the bathroom (door open) seated on the toilet completely nude from the waist down. Client 4 was also observed at 6:15 a.m., in the bedroom seated on a shower chair (door open) completely nude the client?s entire genial area and buttock were exposed.On February 7, 2012 at 6:17 a.m., during an interview with Staff K she stated, she was attempting to close the door while Client 1 was on the toilet, and shower Client 4 at the same time because the night shift staff (Staff A) was on a smoking break. When asked about privacy curtains, Staff K stated the facility did not have privacy curtains to ensure the privacy of the clients. The staff failed to close the bedroom door to Client 4?s bedroom allowing visual access to whoever traveled down the main corridor. The staff also failed to ensure Client 1's privacy during morning care by not closing the door to the bathroom, and not using a privacy screen. As a result of the staff failing to close the door and use a privacy screen, Client 4's entire body and Client 1 ' s genital area were exposed to anyone passing in the main corridor. On February 7, 2012 at 6:46 a.m., during an interview with the Qualified Mental Retardation Professional (QMRP), he stated that the staff should have ensured the privacy of the client, by placing a privacy screen at the door. On February 7, 2012 at 7: 01 a.m., during an interview with the House Leader she stated, the staff had received many in-service training regarding the importance of ensuring the client ' s privacy at all times. The House Leader said that unfortunately the facility did not have privacy screens and that she placed an order for the screens more than a month ago.(b) On February 9, 2012 at 5:50 a.m., during the morning observation Client 1 was observed in the corridor standing completely nude.During an interview with Staff B on February 9, 2012 at 6:05 a.m., she stated she was aware of the privacy policy. When asked why she did not use the privacy screen she stated in a very firm tone, "I did not use the privacy screen." On February 9, 2012 at 6: 30 a.m., during an interview with the Qualified Mental Retardation Professional (QMRP), he stated the staff was in violation of the company's policy and procedure regarding maintaining client's privacy. The QMRP further stated, the staff should have utilized a privacy screen which was provided for the staff to use on February 8, 2012. On February 9, 2012 a review of the facility's policy and procedure titled, "client's rights" disclosed the clients have a right to privacy.Client 1 was admitted to the facility May 24, 2010, with the diagnosis of Moderate Mental Retardation, and Autism. Client 1 was completely dependent on staff to complete his activities of daily living according to the Nursing monthly record dated January 2012.Client 4 was admitted to the facility January 27, 2003, with the diagnoses of Profound Mental Retardation and Seizure Disorder. Client 4 was completely dependent on staff to complete his activities of daily living according to the Nursing monthly record dated January 2012. On February 10, 2012 at 12:15 p.m., a review of the facility in-service records disclosed the staff received an additional in-service training regarding "privacy" on February 9, 2012.The above violation cause or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to both Client 1 and 4. |
| 170001776 |
CANYON SPRINGS |
170009363 |
B |
24-Jan-14 |
469311 |
4386 |
Title 22 76525 (a) (20) Clients' RightsEach client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulation by failing to ensure that Client A was not subjected to sexual abuse when Client A performed an inappropriate sexual activity to a friend during a visit to the facility.Review of facility documentation dated 12/19/11, revealed that on 12/18/11, Staff 1 asked Client A about his visit with Friend 1 on 12/17/11. Client A responded, "I s----d my [Friend 1]'s d-k". Client A stated that his friend brought him a Big Mac, large fries, and a large coke. The lights were off in the room, and his friend was sitting by the door. Friend 1 then asked me, "do you want to s-k my d-k? Client A said yes, then Friend 1 said go for it. Client A was asked if the friend wore a condom. Client A responded yes, Friend 1 took it from a package in his pocket. Client A stated that Friend 1 said thank you and not to tell anyone.Facility documentation indicated as of 12/12/11, Friend 1 was Client A's Volunteer Advocate for approximately one year and had left the advocacy services in 11/2011. He was visiting Client A as a friend not as a volunteer advocate.Client A was admitted to the facility on 2/28/03, with diagnosis of mild intellectual disability. The Standard Compliance Coordinator stated during the interview on 4/30/12 at 2:45 p.m., that the facility does not have a specific visiting time. The visitor checks in with the hospital police officers (HPO), and requests to see a specific client. The HPO would call the unit to have the client brought into the visiting area. She further stated that there are no visitor requirements unless specifically indicated by the client or conservator. Client A is not conserved.Client A stated during an interview on 5/8/13 at 12:30 p.m. that he has a new volunteer advocate. His former volunteer advocate [Friend 1] was inappropriate. He was asked how was Friend 1 inappropriate, he said, "[Friend 1] showed me his penis, not good." He was asked if he touched it Client A shook his head no. Client A stated that Friend 1 gave him a McDonald burger, large fries, and large diet coke. Client A was asked about the last visit with Friend 1. Client A stated that they were in the visiting room watching a TV movie called Mrs. Santa Claus. At this point, Client A terminated the interview. Friend 1 was unavailable for interview after several attempts by phone.Review of the facility's investigative report dated 9/5/13 reviewed on 9/9/13 revealed that Client A was visited by Friend 1 on 12/17/11, between 5:15 p.m. and 6:55 p.m. During the visit, Client A alleged that Friend 1 had asked Client A if he would orally copulate his penis. Client A agreed and orally copulated Friend 1's penis. In the report an interview conducted by the Office of Protective Services, Special Investigation Unit (OPS/SIU) with Staff 1; Staff 1 reported that Client A's initial disclosure of the incident was spontaneous. Staff 1 further stated that Client A had never made allegations of this sort in the past. Client A appeared calm and stated the incident as simple as having a conversation with Staff 1 about the visit.The facility had two criminalists obtain samples from the room occupied by Client A and Friend 1 during the above visit. All areas of the room, including Client A's clothing screened negative for acid phosphatase (a component of semen that may have been left behind after the above incident.)Review of the Administrative Policy 307 - Clinical Services dated 10/22/12 indicated there is no procedure in place to ensure staff's accountability in conducting safety rounds/check in the visiting area during visiting hours.Client A, on 12/17/11 from 5:15 p.m. to 6:55 p.m. during a visit, was subjected to inappropriate sexual activity (oral copulation) to a visitor. The failure of the facility to protect Client A from harm caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 170001776 |
CANYON SPRINGS |
170010492 |
B |
10-Apr-14 |
4XUY11 |
5474 |
483.420(d)(1) The facility must develop and implement policies and procedures that prohibit mistreatment, neglect or abuse of the client. 483.420 (d)(1)(i) Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment. 483.420(d)(2) The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.The facility failed to ensure physical abuse by a staff member did not occur to Client 1. The facility staff also failed to report a witnessed abuse incident by a staff member to a client immediately to the Facility Director/ Administrator on Duty ( AOD ) / Designee and resulted in the delay of the reporting to the California Department of Public Health (CDPH) within 24 hours.On 10/22/13, the facility reported to the Department an allegation of physical abuse to Client 1. It was alleged by an eyewitness staff member, Psychiatric Technician A (PT A), that Psychiatric Technician B (PT B) choked Client 1 while in a facility observation room on 10/19/13. Facility investigation determined and substantiated the eyewitness did not immediately report the incident when it actually occurred two days prior on 10/19/13. Review of the General Event Report (GER), dated 10/21/13, verified on 1/28/14, notifications to the Facility Administrator and Office of Protective Services (OPS) occurred on 10/21/13 and subsequently the California Department of Public Health was not notified until 10/22/13. An eyewitness Psychiatric Technician A (PT A) and the alleged assaultive staff member, Psychiatric Technician (PT B); were present in the room at the time of the incident; Client 1 hit PT B causing a scratch to his arm; PT B grabbed Client 1 by the neck very forcefully and pushed her backwards; Client 1 was assessed by the PT A who noted superficial scratches to the Client 1's upper right cheek - 4 cm (centimeter) X 0.1 cm and .5 cm x 0.1 cm and 2 cm x 2 cm to the left cheek; a 3 cm x 1.5 cm and 1 cm x 0.2 cm bruise to the upper left chest area noted.Review of the facility's Administrative Policy 304 (dated 7/16/13) entitled "Incident Reporting/Unusual Occurrences" conducted on 1/28/14, identified events that were expected to be reported. Guidelines for alleged or suspected abuse and/or neglect incidents were articulated under "Notification to Facility Director (AOD)/Designee" and required "1) immediate notification (as soon as possible, after ensuring the safety of involved residents)." Review of the Office of Protective Services (OPS) report conducted on 1/29/14, revealed additional findings from the eyewitness PT A. In the report, PT A stated that PT B "put his hands around Client 1's neck and choked her." PT A also stated she was in shock and froze. PT A became emotional and started crying. She became afraid because of what she had just witnessed. PT A stated she that she waited to report the event because she felt intimidated by PT B and afraid he might do something to her. OPS interview of Client 1 confirmed Client 1 was sent to the observation room on 10/19/13 after being confronted about having cigarettes by PT B. PT B directed her to the observation room where she took off her clothes and attempted to dislodge a baseboard from the wall using a necklace. In the process, Client 1 stated she hit PT B's arm. PT B's reaction was to get on top of her and use his knee causing her to pass out. Client 1 stated she thought she had passed out and when she came to, she felt cold.Review of The Investigation Disposition Report on 1/29/14, included details from the eyewitness, PT A, who observed PT B putting both hands on Client 1's neck. The Investigation Disposition Report also included that PT A left the room to obtain restraints and returned 2-3 minutes later, leaving Client 1 alone in the room with PT B. PT A also stated in this report that after Client 1 was placed in restraints PT A was told by PT B, "You didn't see anything." Another staff, PT C, verified that she was asked to help out with restraint, and heard Client 1 stated she was choked by the PT B, but initially did not think an allegation was being made. PT C also heard the statement made by the PT B to the eyewitness PT A, "You didn't see anything." In an interview with the Standards Compliance Coordinator (SCC) on 1/29/14 at 7:30 a.m., the SCC discussed some of the action taken by the facility in response to the event. The SCC explained and verified administrative action had been taken with the eyewitness and second witness for late reporting and administrative action with the alleged perpetrator was pending. The SCC stated that the eyewitnesses' late reporting may have been due to fear of intimidation by the alleged perpetrator.The facility failed to implement their policies and procedures related to Abuse, Neglect and Exploitation Prevention and Reporting and Incident Reporting/Unusual Occurrences and failed to ensure physical abuse by a staff member did not occur to Client 1. The facility staff also failed to report a witnessed abuse incident by a staff member to a client immediately to the Facility Director/ Administrator on Duty ( AOD ) / Designee and to the California Department of Public Health (CDPH) within 24 hours.The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001776 |
CANYON SPRINGS |
170010493 |
B |
14-Apr-14 |
4XUY11 |
8727 |
483.410 The governing body must exercise general policy, budget, and operating direction over the facility.483.420 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The following citation was written as a result of an investigation of Entity Reported Incident (ERI) CA00373620 that was conducted during a Full Recertification Survey on 1/28/14. The Department determined the facility failed to: 1. Properly supervise clients by failing to ensure bed checks included direct visual observation and/or accountability at all times. 2. Implement their policy and procedure for "Missing Client Search Procedures" when the staff failed to notify the Office of Protective Service of the missing client after staff had been searching for over 15 minutes. An investigation of ERI CA00373620 was conducted during the survey on 1/28/14. Review of the ERI "Intake Detail" indicated that on 10/12/13, at approximately 1:30 AM, Client 1 approached staff and asked regarding the whereabouts of Client 2. Licensed Staff A immediately went to Client 2's room to check on him. He was not in his bed. A search of the residence ensued. During the search, a law enforcement officer called the facility and indicated he had picked up Client 2 at a local hotel/casino. The client was escorted back to the facility by the law enforcement officer, and arrived back at the facility at approximately 2:25 a.m. Client 2 was 22 a year-old male with a diagnoses that included Mild Intellectual Disabilities and Impulse Control Disorder. His level of supervision at the time of the Absence Without Leave ( AWOL) incident was general supervision (described as direct visual observation and/or accountability at all times) throughout the facility, with an escort ratio of 1:5 (one staff to five clients) in the community. Client 1 was a 23 year-old male with Mild Intellectual Disabilities, with a history of poor insight, impaired judgment, and poor impulse control. He had a history of making threats to AWOL from the facility, and an actual AWOL on 10/2/12. His behaviors included refusal to follow rules, and attempts to manipulate or "con" others for his own gain. He was on a general supervision throughout the facility at the time of the AWOL. A special team meeting (a meeting held by facility staff / Interdisciplinary Team Members to discuss unusual incidents) was held with Client 2 on 10/14/13. The client told the team he planned his AWOL attempt for that evening of 10/11/13 and waited until approximately 11:30 p.m. to make his attempt. He stated his roommate had "Gold Access" (when clients have independent access to enter courtyard during leisure time). When his roommate fell asleep, he took his badge out of his roommate's pocket and used the badge to exit from the B2 living room into the courtyard. He propped the door open with the doormat. Client 2 then knocked on his peer's (Client 1's) window. That peer came out to the courtyard through the propped door. His peer then used his (peer's) body to push open the gate leading out of the courtyard.Client 2 stated he took off running towards the hotel/casino. He stated that when he arrived at the hotel/casino, he informed them that he would like to live there, and wanted to know if they had a room for him. The hotel staff notified law enforcement and the sheriff responded. The sheriff ran the clients name, but the search did not yield any information, so he took the client to the local acute hospital. The acute hospital staff was able to provide information that Client 2 lived at the facility. He was returned to the facility at approximately 2:25 a.m. by a law enforcement officer. He was assessed for injuries and none were found. On 10/12/13 at approximately 1:30 a.m., Client 1 made a comment to Licensed Staff A that he couldn't find Client 2, and they were supposed to "hang out" together. The staff thought the comment was odd and went to check on Client 2. She called out his name, and when he did not answer she pulled the covers back and found a pile of clothes in the bed. She notified Licensed Staff B, and a search ensued. During the search, a call was received from a law enforcement officer stating he had Client 2 with him, and would return him to the facility. Client 1 was interviewed by OPS (Office of Protective Service) on 10/12/13 at approximately 3:05a.m. Client 1 stated that Client 2 knocked on his window at approximately 11:00 p.m. and told him to go to the B2 group room next door. He left his room and went to the group room door exit and found it propped open. Client 1 said he looked out the door for Client 2, and he was gone. Client 1 stated he did not help Client 2 get out of the gate. On 10/15/13, Client 1 reported to the Clients Rights Advocate that he had assisted Client 2 in his AWOL from the facility and had accompanied him to the hotel/casino. He stated that his peer was approached by hotel/casino staff and Client 1 became nervous and returned to the facility. He was assessed for injury, no injury was noted. During the initial visit made to the facility to investigate the incident, interview was conducted with the Special Investigator on 10/17/13 at 1:45 p.m. The investigator indicated that he walked to the hotel/casino and found it took him 41 minutes to walk there, and the distance was 2.2 miles Review of the approximate timeline from the Special Investigator reviewing the case indicated that the client left the facility to walk to the hotel/casino at approximately 11:20 p.m. to 11:30 p.m. The walk to the hotel/casino took approximately 30 to 35 minutes. Client 2, was first noted by hotel staff to be at the hotel/casino at approximately 11:55 p.m. to 12:05 a.m. Client 1 contacted staff at the facility asking about Client 2's whereabouts at 1:20 am to1:23 a.m.. Review of the "Round Sheets" dated 10/11/13 and 10/12/13 completed by Licensed Staff A indicated that Client 2 was in bed from 11 p.m. to 1:20 a.m. Documentation further indicated Client 1 was in the hallway at 11:40 p.m. and in bed after that until 1:20 a.m. when he was noted to be in the hallway. An interview was conducted with Licensed Staff A on 1/28/14 at 2:50 p.m. She indicated that she had checked on Client 2 during the times documented, but she did not remove the covers to check to see if he was in bed. She stated that he normally slept with his covers over his head, and she did not suspect he was not in his bed. She stated that she became suspicious of Client 2's whereabouts when Client 1 asked about his whereabouts. She stated she immediately went to check on him and found him missing. Licensed Staff A also indicated she thought Client 1 was in his bed during the checks she conducted. Review of the Administrative Policy # 324 titled "Client Supervision" dated 9/29/11was conducted on 1/29/14. The policy indicated, "Every staff member of (name of facility) is responsible for the safety and well-being of clients. Staff shall be constantly alert to ensure that the physical and emotional well-being of a client is not endangered in any way........General supervision is described as direct visual observation and/or accountability at all times." Review of the Administrative Policy dated 4/20/12, "Missing Client Search Procedures", conducted on 1/28/14, under "Missing Client Search" under "2.1.3.3 If the client is not found within 15 minutes from when noted to be missing, contact the OPS Officer in order to implement Phase II of the search.". Review of the Crime/Incident Report dated 10/12/13 was conducted on 1/28/14. The report indicated that during the Special Investigator's interview conducted with Licensed Staff B SPT (Senior Psychiatric Technician) on 10/17/13, Licensed Staff B indicated the staff searched the residence for approximately 30 minutes before receiving the phone call from the law enforcement officer. During an interview conducted by the Special Investigator with Licensed Staff B on 10/17/13, the staff member indicated he was aware of the policy that indicated to make proper notifications after 15 minutes, and he should have stopped the initial search after 15 minutes had lapsed. The facility staff failed to conduct thorough rounds, when staff failed to physically inspect the client's individual bed to determine if Client 2 was in his bed sleeping, and the facility failed to implement their policy and procedure for "Missing Client Search Procedures" when the staff failed to notify the OPS officer of the missing client after staff had been searching for over 15 minutesThe Department determined that the above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001776 |
CANYON SPRINGS |
170010494 |
B |
14-Apr-14 |
4XUY11 |
11021 |
483.420 The following citation was written as a result of a review of facility incident reports conducted on 1/28/14 at 10:15 a.m. as part of a Full Recertification Survey, and as a result of an investigation of Entity Reported Incidents (ERI) CA00365327 CA 00368604, CA00369839 The facility failed to protect a conserved client, Client 1, from sexual abuse by not implementing their policy for enhanced supervision (line of sight) and by not implementing its abuse prevention, reporting and supervision policies.During review of facility incident reports on 1/28/14 at 10:15 a.m. for allegations of abuse, neglect, mistreatment and exploitation reported during the time parameter of 12/14/12 through 1/27/14, it was revealed the facility reported and investigated six allegations of sexual abuse involving Client 1. Three of six incidents reported were substantiated due to Client 1 being on enhanced supervision and a conserved client at the time of occurrence.Review of the documentation from the Department of Development Disabilities dated 11/13/2008, indicated that powers and authority were outlined under "Limited Conservator of the Person" which also included, "full power to make decisions concerning the conservatee's social and sexual contacts." On 8/7/13 the facility reported an incident of sexual abuse wherein it was alleged by Client 1 that she and Client 2 performed oral copulation and sexual intercourse on a male peer (Client 3). She also reported that they were forced to perform the inappropriate sexual acts. Per GER (General Event Report) a Level 1 review was conducted on 8/12/13 at 12:45 p.m. It indicated that Client 1's level of supervision at the time of the event was line of sight and will continue to be line of sight. The OPS (Office of Protective Services) investigative report with a completion date of 11/01/13 was reviewed. Under "Summary of Findings and Investigation Conclusion", it stated that the allegation of sexual abuse was substantiated. Client 1 and Client 2 performed oral sex on a male peer (Client 3) because they were scared. The allegation of client supervision was substantiated. The facility staff were ultimately responsible for the health and safety of all clients in Room 241 (vocational classroom), which included Client 1, the female peer [Client 2] and the male peer (Client 3) . The staff failed to adequately monitor the courtyard where Client 1, and a female peer (Client 2) performed oral sex. An interview was conducted with the Standards Compliance Coordinator on 1/30/13 at 1:45 p.m. She confirmed that Client 1's level of supervision at the time of the incident was line of sight as per GER. She also confirmed that the OPS investigation report concluded that the allegation of sexual abuse and client supervision were substantiated.On 8/22/13, the facility reported an incident of sexual abuse wherein it was alleged by Client 1 that she had sexual relations with her roommate, Client 4. The allegation included oral sex, digital manipulation and "humping" each other. Per GER the incident was reported on 8/22/13 at 7:00 p.m. Review of the accompanying Special Investigations report narrative, it was documented that the event took place on 8/21/13 at 9 p.m. in the clients' bedroom with the door locked. Under "Summary of Findings and Investigation Conclusions" the report indicated, "1.Substantiated: [Client 1] engaged in sexual activity/contact with [Client 4]. [Client 1] is unable to give consent to engage in sexual activity/contact. [Client 4] violated [Facility's name] Administrative Policy of abuse, 301; 2.4 - Sexual Abuse." On 9/15/13 the facility reported an incident of sexual abuse wherein it was alleged by Client 1 she engaged in sexual activity with Client 5. The incident took place in Room 466 at 3 p.m. Per the Office of Protective Service (OPS) report under "Narrative" it was documented both clients admitted to fondling each other and Client 1 inserted a marker into Client 5's vagina and a chap stick container into her own vagina. The report further stated "Client 1 is a conserved client. She cannot give any consent for sexual relations." Additionally, the report documented "One green cap less Crayola marker and one all white chap stick container" were placed in the "Evidence Locker." During an interview with the night Shift Lead/Senior Psychiatric Technician (SPT) on 1/28/14 at 4:25 p.m., he stated that Client 1 had poor boundaries and sexual behavior that was inappropriate. He also stated that she's currently on line of sight supervision throughout the day. When he was asked to describe what line of sight was, he stated, "Visual contact, knowing her whereabouts the whole time." He also stated that Client 1 was on general supervision (direct visual observation and/or accountability at all times) and every fifteen minutes check when she's in her room.The Shift Lead/SPT stated that Client 1's supervision level was line of sight when she was involved in multiple inappropriate sexual activities. When asked why it happened, he stated, "Somebody broke the chain", indicating that staff failed to implement the line of sight supervision. During an observation on 1/29/14 at 9:05 a.m. in the Vocational Room (Room 401), Client 1 was observed sitting in the corner of the room by herself for four minutes. Three staff in the room were engaged with other clients inside the room.During an observation on the same day between 9:10 a.m. and 9:30 a.m., Client 1 was observed on two occasions being escorted by Psychiatric Technician H (PT H) and Psychiatric Technician I (PT I) in two different areas. Both staff were observed walking in front of Client 2 with their backs turned. During an observation on the same day at 9:40 a.m. in the Vocational Room (Room 401), one staff (PT I) was observed with seven clients (two males and five females including Client 1). A female client suddenly became agitated and attempted to attack another female client. PT I positioned himself in between the two clients to prevent a physical altercation.PT I continued to calm the agitated client by talking to her. Client 1 was observed without line of sight supervision for 15 minutes, while talking to two male clients in the room. During an interview with the Vocational Supervisor on 1/29/14 at 9:55 a.m., he stated that Client 1 was on line of sight supervision because of her sexual behavior. He stated that Client 1 invites male clients in the bathroom with her. He also stated that the line of sight supervision was being able to see Client 1 at all times in the coed (male and female) area.The Vocational Supervisor stated that Client 1's level of supervision becomes general supervision when she's in the unit, because it was not a coed unit. When asked about how staff should be escorting Client 1, he stated, "If the staff is walking with her (Client 1), the client should be always visible to the staff. If the client was behind the staff and their backs were turned, that's breaking it." During an interview with PT H on the same day at 10 a.m., she stated that Client 1 was on line of sight when there's coed in the room. She also stated that staff should be keeping an eye on her within line of sight at all times, knowing her whereabouts. She further stated, "She can't be behind us, because we won't be able to see her."During an interview with PT I on the same day at 10:15 a.m., he stated that Client 1 was on line of sight because of her sexual behavior with male peers. He also stated, "I have to be able to see her at all times, under no circumstances that she's out of my vision." He also stated that when the staff's back was turned, there was no line of sight supervision.PT I acknowledged that the line of sight was not provided to Client 1 during an incident where he had to intervene, because his back was turned and he was all by himself. He also stated, "What could I have done differently?"During an interview with the Standards Compliance Coordinator (SCC) on the same day at 3:50 p.m., she stated, "The staff should have pulled his alarm. Every staff was trained on how to use their alarm." The SCC acknowledged that the line of sight supervision was breached when staff (PT 1) attended to the incident between clients. The clinical record for Client 1 was reviewed on 1/30/14. The Individual Program Plan (IPP) Narrative dated 2/6/13 indicated that she was a 24 year old female admitted in the facility on 3/5/08, with diagnoses that included mild intellectual disability, schizoaffective disorder (psychiatric disorder), and impulse control disorder. The IPP Narrative also indicated that she had an open behavioral plan, "B5-1 Sexually Inappropriate Behavior - ...defined as asking peers for sex, exposing herself, touching others, entering bathrooms while someone is using it, hugging and touching peers inappropriately." Client 1's Approaches and Strategies indicated that she was placed on line of sight supervision on 8/8/13. However, her Behavior Support Plan for sexually inappropriate behavior dated 8/29/13 did not indicate and specify the level of supervision provided while she's in the unit, bedroom, vocational room, and other areas where she could have contact with both male and female peers. The Special IPP Narrative dated 8/26/13, 10/7/13, and 10/28/13 indicated that recommendations were made to continue the line of sight supervision for Client 1 due to incidents of sexually inappropriate behavior. There was no documented evidence found indicating that the line of sight supervision would revert back to general supervision once Client 1 was in her unit or room. The Enhanced Supervision for Client Protection-Restrictive Plan with a review date of 1/28/14 indicated that the Interdisciplinary Team decided on 11/12/13 to change the level of supervision for Client 1. It further indicated, "On 11/19/13 [Client 1's] enhanced supervision was decreased from LOS (Line Of Sight) in all areas to all coed areas and activities." The Administrative Policy 324 titled, "Client Supervision." dated 11/25/13 was reviewed on 1/30/14. It indicated, "Staff working with clients will be responsible to ensure that active treatment services are delivered safely by maintaining the level of supervision determined by the Interdisciplinary Team and documented in their Individual Program Plans, or when re-determined by changes in behavior as a Temporary Intervention Plan (TIP.)". Line of sight supervision was also identified requiring that "staff members place themselves in a vantage point approximately 4 to 25 feet determined by the IDT so they can view the client immediately and intervene when indicated as per the individual program plan.The facility failed to protect a conserved client, Client 1, from sexual abuse by not implementing their policy for enhanced supervision (line of sight) and by not implementing its abuse prevention, reporting and supervision policies.The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001776 |
CANYON SPRINGS |
170010615 |
B |
14-Apr-14 |
DDL411 |
5523 |
483.420 (d) (1)The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The following citation was written as a result of a visit to the facility on 4/30/13 to investigate Entity Reported Incident #CA00328143. The Department determined the facility failed to: Provide supervision of Client A, allowing him to gain access to a staff member's badge providing him with the ability to leave the facility not observed by staff on 10/02/12 at approximately 4 PM. While out of the facility, Client A was observed by an off-duty staff member walking down a busy road, and was observed being picked up by a vehicle driven by an unknown person. These failures resulted in Client A being placed in a dangerous situation when he was observed walking down a busy road and was picked up by an unknown motorist. A review of Client A's medical record was conducted on 4/30/13. Client A was admitted to the facility on 9/22/09 with diagnoses that included mild intellectual disability. His level of supervision at the time he left the facility without staff knowledge was general, which is defined as direct visual observation and/or accountability at all times, per facility policy dated 9/29/11.Record review indicated that on 10/02/12 at approximately 1600, following a basketball game in the facility gymnasium, staff noticed that Client A was no longer in the area. A search was conducted, and he could not be located. A search team was deployed, and the client was located and returned to the facility. There was no evidence of physical injury. Client A gave no insight into his leaving the facility, except to say that he was upset with his situation right now. Further investigation on 4/30/13 revealed that on 10/02/12 at 1515, Staff 1 took 6 clients to the gymnasium to play basketball. There was one other staff present in the gymnasium on a 1 to 1 observation with a client. Client A, did not want to play basketball, and wanted to use the exercise machines instead. Staff 1 stated that at 1555, the gym activities concluded, and clients and staff returned to the unit. Upon reaching the unit, Staff 1 noticed he did not have his badge, and went to the gym to look for it. At 1600 a headcount was done, and it was discovered Client A was missing. An interview was conducted with the Special Investigator on 6/19/13 at 10 AM. He indicated that Staff 1 did not notice his badge was missing or that Client A was missing from the time the basketball game started until he returned to the unit, a period of approximately one hour.An interview was conducted with the HPO (Hospital Police Officer) on 7/17/13 at 6:25 PM. He stated he received a call at about 1600 on 10/02/12 from an off duty staff member (PT 2) asking if there was a missing client. She was on her way home from work at the facility, and observed Client A on the road. At the same time, PT 1 called to report his missing badge. During interview conducted with PT 2 on 4/04/14, she indicated she had left the facility at 1630, and observed someone she thought was a client hitchhiking a few miles north of the facility. She turned her car around to see if he was, in fact, a client. She called the HPO and asked if Client A was missing. She observed a silver colored SUV stop in the middle of the road, engage the client in conversation, and Client A then got into the vehicle. PT 2 reported the license plate of the vehicle to the HPO, and proceeded to follow the vehicle, flashing her lights, honking, and using emergency flashers. The driver proceeded to "flip her off" and sped up to "75 miles per hour". They finally had to stop due to road construction and she was able to tell the driver the client was a patient from a state facility. The driver said, I don't want any trouble, and told Client A to get out of the car.PT 2 said that when Client A saw her, he crossed the road and began to approach her car. He appeared dazed and somewhat confused, yet agitated. She threw a bottle of water out the window to him and encouraged him to drink the water. He then lay down on the sand and exhibited "seizure-like movements". He then suddenly got up and ran into the desert hills in the surrounding area. She maintained visual contact until staff arrived.Client A was returned to Canyon Springs. He was calm and cooperative with staff direction. His face was slightly red, but no physical distress or injury was noted. The client was gone for approximately 45-60 minutes from facility.Review of the facility policy titled "Client Supervision" dated 9/29/11 conducted on 4/30/13, indicated the following: "Every staff member of (name of facility) is responsible for the safety and well-being of clients. Staff shall be constantly alert to ensure that the physical and emotional well-being of a client is not endangered in any way. This includes when clients participate in facility activities, receive services from other agencies and participate in activities in neighboring communities." The Department determined that the facility failed to: Provide supervision of Client A, allowing him to gain access to a staff members badge providing him with the ability to leave the facility not observed by staff. While out of the facility, Client A was observed by an off-duty staff member walking down a busy road, and observed him being picked up by a vehicle driven by an unknown person. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 220000197 |
CALIFORNIA PACIFIC MEDICAL CENTER - CALIFORNIA EAST CAMPUS HOSPITAL D/P SNF |
220010042 |
B |
01-Aug-13 |
X7DV11 |
7688 |
72311(b) Nursing Service -- General. (b) All attempts to notify physicians shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending physician or his designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g) 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. 72311(a)(3)(B)(C)(D) 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. (C) An unusual occurrence involving a patient, as defined in Section 72541. (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's physician.72547(a)(5)(B) Nursing Service--General (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (B) Meaningful and informative nurses' progress notes written by licensed nurses as often as the patient's condition warrants. However, weekly nurses' progress notes shall be written by licensed nurses on each patient and shall be specific to the patient's needs, the patient care plan and the patient's response to care and treatments.These regulations were not met as evidenced by: The 88 year old resident was admitted to the facility for rehabilitative care following surgical repair of a fractured hip. Her condition was stable, with severely impaired decision-making ability. She had a poor appetite in the last 14 days, frequent incontinence of bowel and bladder, but no history of constipation. Activity was limited because of no weight bearing due to her hip fracture. The resident had no identified gastrointestinal issues and no history of constipation per her personal physician, rather, intermittent self-limiting episodes of diarrhea several times per year. The resident received a variety of medications to offset constipation during the first five days in the facility since only one bowel movement was noted in the first five days. The result was multiple loose stools for several days and medications and bulk laxatives were adjusted. Bowel movements became irregular and intermittent. During this time, the patient experienced significant weight loss of 14.74 pounds in the first week and another 6.8 pounds in the second week at the facility. Nursing documentation of significant weight loss, poor appetite, and irregular bowel movements were not included in the nursing care plan or documented in a narrative nursing progress note at the conclusion of every shift, per the facility policy and procedures. Additionally, the facility policy regarding "Change of Patient Status" to inform the physician of any adverse change of signs and symptoms in the patient in a timely were not followed because there is an absence of documentation in the patient record reflecting physician notification. The resident continued to experience an irregular bowel pattern and began to experience nausea and vomiting for which an additional anti-emetic was added (Reglan). Despite two anti-emetics and a variety of stool softeners, bulk laxatives, and motility agents, the resident showed no signs of improvement. Her appetite was poor, energy level low, thereby reducing participation in physical rehabilitation. Interviews with licensed nurses involved in the resident's care indicated for two days beginning 2/13/12 she experienced nausea, vomiting and abdominal distention. An RN remembered administering anti-nausea medication on the afternoon of 2/14/12 and indicated the patient had a distended abdomen but did not document her brief assessment in the medical record because she was too busy. Later on 2/14/12, the record indicates the resident had a large amount of emesis that was too large to measure. Intravenous fluids were initiated; however, the medical record lacks specific documentation the physician was notified of the patient's condition. In the morning of 2/15/12, the physician ordered an abdominal x-ray and findings showed stool present in the left colon and rectum, an abnormal bowel pattern compatible with an ileus or a distal bowel obstruction with clinical correlation recommended. The physician requested a digital exam where in an interview the LVN stated she felt something hard in the rectum. There is no documentation in the medial record of the exam performed or physician notification of findings. An enema was ordered and given with good results, however the resident continued with nausea and vomiting. The medical record is absent a narrative nursing progress note reflecting the resident's condition, additionally end of shift assessments and notes are not present, care plans are not updated identifying the patient's new problems. On the evening of 2/15/12, the physician ordered another enema. In an interview, the licensed nurse indicated he asked the patient's private caregiver to place her on the bedside commode because he was too busy with another patient. He responded to scream from the resident's room where he said the patient vomiting copious amounts of dark-brown fecal-smelling fluid from her mouth and nose. A suction apparatus was not available in the room, but eventually was obtained. Emesis covered the dinner tray and floor and filled the suction canister, with an estimated amount exceeding 1000 milliliters. The resident lost consciousness and was returned to bed and a CODE was called to resuscitate. The resident did not regain a heartbeat despite multiple injections (ten) of epinephrine to stimulate the heart. The patient expired and the family requested an autopsy. The medical record does not contain nursing documentation of the events described above.The family indicates they noticed their mother's increasing abdomen, poor appetite and reduced energy level the week prior to her death. They indicated enemas, anti-nausea medications were given but nothing worked. They repeatedly asked the physician about her increasing abdominal size but did not receive an answer or reason why her stomach was so large that she looked pregnant.Autopsy findings, performed by a California Pacific Medical Center pathologist, indicated major aspiration with additional comments describing the small and large bowel filled with well-formed feces.Conclusion: The facility failed to follow their established policy and procedures to provide a safe environment for the resident and additionally, continually assess, review and document significant changes in patient status.The facility failed to satisfy that duty with appropriate care planning for specific needs, providing meaningful and informative nursing progress notes specific to patient needs, response to care and treatments and the patient care plan.The facility failed to document physician notification with the time, method and name of the physician contacted for changes in patient status.The violations of the cited regulations jointly, separately or in combination presented a direct or immediate relationship to patient's health, safety, or security. |
| 220000046 |
Central Gardens |
220010921 |
B |
13-Aug-14 |
BJO811 |
6931 |
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. This STATUTE is not met as evidenced by: The facility failed to implement their policies and procedures for Resident Abuse Prohibition, Reporting Abuse to State Agencies, and Abuse Investigations for one resident (Resident 1) when the facility failed to identify, investigate and report an incident of abuse through intimidation of Resident 1 by one Certified Nursing Assistant (CNA 1).The failure to implement the facility's policies regarding abuse prevention resulted in lack of protection after abuse through intimidation of Resident 1, lack of protection after alleged rough handling of Resident 2, and had the potential for abuse for any residents at the facility under CNA 1's care.Findings:Resident 1 was admitted to the facility on 5/6/05 with diagnoses including stroke (death of brain cells related to inadequate blood flow) in the right side of the brain, depression, aphasia (partial or total loss of the ability to communicate either verbally or using written words), and seizure disorder (disruption of the brain's normal activity that can result in convulsions- jerking of the muscles).Record review of the Minimum Data Set (MDS- a resident assessment tool), dated 11/2013, indicated Resident 1 sometimes makes self- understood, and sometimes has the ability to understand others. Resident 1's cognition was assessed as moderately impaired.Record review of the facility's care plan for depression, re-evaluation dates 1/2013, 4/2013, 8/2013 and 11/2013, indicated "Problems/Needs- Episodes of depression manifested by irritability, aggression ...angry when he can't get staff's attention ...Approaches- Always approach resident calmly and unhurriedly. Speak in a calm voice... "Record review of a letter found in the facility's employee file for CNA 1 regarding abuse of Resident 1 by CNA 1, dated 4/4/13, indicated "On 4/3/2013 Resident # 4206 (Resident 1) was very agitated and explained through the use of hand signals that he had been hit in the face...asked resident who it was that hit him; he became very agitated and pointed towards employee (CNA 1)...Resident became aggressive and began shaking his over-bed table and pointing at employee (CNA 1)...I received a phone call today 4/4/13 concerning an alleged complaint of abuse by you towards resident # 4206 (Resident 1)...On 4/3/2013 it was witnessed by this person that you "smacked" a resident in the face after resident grabbed your arm...it was reported that you had walked by and Resident #4206 (Resident 1) grabbed your arm and you in turn smacked him in the face, the right side...After interviewing employee his statement was that resident did in fact grab his arm, and he in turn raised his hand as "if " to smack him, he did not have any contact with resident ...He admitted that this was wrong, and requested that he apologize to Resident (1)..." During an interview on 11/14/13 at 10:20 AM, the Director of Nursing (DON) stated, " He (CNA 1) didn't actually hit him, he just raised his hand making a hand gesture ...Resident (1) gets agitated, acts out." The DON stated she could not find the investigative report or any other documents regarding this incident, that it was not considered abuse by the previous Administrator (Adm 1) and the DON because CNA 1 didn't actually touch him (Resident 1), and that may be the reason the incident was not further investigated or reported to the State department. The DON confirmed the letter found in the file regarding abuse, dated 4/4/13, was written by Adm 1.During an interview on 11/14/13 at 10:45 AM, the DON confirmed that the incident between Resident 1 and CNA 1 was not reported to the State department, and that she could not find the investigative report or any other documents regarding this incident. Documentation of suspension or reassignment to nonresident care duties for CNA 1 was not provided. When asked to give examples of abuse, the DON stated, "rough treatment or leaving the call light out of (the resident's) reach ...alleged abuse needs to be reported right away." When asked if she considered a resident in a wheelchair with someone standing over them with their hand raised as if to "smack" them was abuse or intimidation, she did not answer. Record review of the facility's Resident Abuse Prohibition policy and procedure, revision date 2/26/13, indicated "Policy Interpretation and Implementation- Abuse means the willful infliction of injury, unreasonable confinement, intimidation..."Record review of the facility's Reporting Abuse to State Agencies and Other Entities/Individuals policy and procedure, dated 5/17/2011, indicated "Policy Statement- All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies...Policy Interpretation and Implementation- 1. Should a suspected violation or substantiated incident of mistreatment...or abuse be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/ certification agency responsible for surveying/ licensing the facility...2. Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence ...5. Should the allegation be true, the employee(s) will be terminated from employment ..." Record review of the facility's Abuse Investigations policy and procedure, dated 5/7/11, indicated "Policy Statement- All reports of resident abuse...shall be promptly and thoroughly investigated by facility management...Policy Interpretation and Implementation- 9. Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator...15. The Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state survey and certification agency..."The facility failed to implement their policies and procedures for Resident Abuse Prohibition, Reporting Abuse to State Agencies, and Abuse Investigations for one resident (Resident 1) when the facility failed to identify, investigate and report an incident of abuse through intimidation of Resident 1 by one Certified Nursing Assistant (CNA 1).The failure to implement the facility's policies regarding abuse prevention resulted in lack of protection after abuse through intimidation of Resident 1, lack of protection after alleged rough handling of Resident 2, and had the potential for abuse for any residents at the facility under CNA 1's care.The facility ' s failure had a direct relationship to the health, safety, or security of residents. |
| 220000046 |
Central Gardens |
220011716 |
B |
10-Sep-15 |
M4GZ11 |
6472 |
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. This Requirement is not met as evidenced by: The facility failed to provide adequate supervision to prevent the elopement of one Patient (Patient1) when: 1. there was no documented evidence for the one to two hourly visual checks before 4/18/15 when the elopement took place. 2. the staff (Registered Nurse 1, Certified Nursing Assistant 1) were not alerted when Patient 1 eloped because the front door alarm was turned off on 4/18/15. This deficient practice had resulted in Patient 1's emergency room admission to treat head injury and facial contusion related to a fall outside the facility after she eloped on 4/18/15. Findings: Patient 1 was admitted with diagnoses including: dementia (a decline in mental ability severe enough to interfere with daily life), senile degeneration of the brain (a disease caused by degeneration of the brain cells) , paranoid schizophrenia (a thought disorder characterized by paranoid delusion and/or hallucination), failure to thrive (a disorder with insufficient weight gain or inappropriate weight loss). Review of MDS (Minimal Data Set - Patient assessment tool), dated 2/9/15, indicated Patient1 wandered on 4-6 days during the 7 day look-back period.Review of MDS (Minimal Data Set: a Patient assessment tool), dated 2/9/15 and 5/11/15 indicated Patient1's functional status in Activities of Daily Living Assistance in: Bed mobility, Transfer, Walk in room, Walk in corridor, Locomotion on unit, Locomotion off unit had deteriorated from supervision and setup help only to limited assistance and one person physical assist.Review of the care plan dated, 7/31/14 for problem of agitation and restlessness M/B (manifested/by) attempts to elope indicated under the Nursing approaches : "visual checks at least Q (each) 1-2 hour. " Review of the care plan dated 2/1/13,for fall with update dates of 1/14/14, 2/18/14, and 5/8/14, indicated: 1) Patient1 had "Fall history on 1/17/13, 9/5/13; Elopement episode on 1/14/14, 5/8/14." 2) Nursing approaches included " Hourly rounds to be done on residents for pain, toileting and personal needs. " During an interview on 6/10/15 at 11:10 am, the Director of Staff Development (DSD) acknowledged there was no documented evidence for the hourly or two hourly visual checks before 4/18/15 when the elopement took place.During a telephone interview on 6/11/15 at 8:20 am, the Registered Nurse (RN) 1 stated that she was surprised to receive telephone call from the ER (emergency room) at the General Acute Care Hospital (GACH) on 4/18/15 saying that Patient1 was brought into the ER S/P (Status post: after)a witnessed fall. It was the first time she heard it (Patient1 is missing from the facility); it was around 7:30-7:35 pm. Patient1 was not wearing a wanderguard at the time. Patient1 was supposed to wear one as she had previous attempt of elopement, but she had broken so many of them, it costs $100 each.She also stated that the alarm on the front door was not on. RN 1 checked it after she received that call from ER. She also said things could be better if the door alarm and wanderguard were on. At least she would pay attention to the front door every time the alarm sounds. Because it was on a Saturday and in the afternoon, a lot of family members came to visit. RN 1 stated, " The alarm would be turned off sometimes. Some of the CNAs (Certified Nursing Assistant) go out to smoke at that time too, thinking they are back soon, sometimes they would turn the alarm off as well. "During a telephone interview on 7/8/15 at 3:45 pm, Certified Nursing Assistant (CNA) 1 stated: 1) On that day (4/18/15), there were a lot of visitors came in to help out with the dinner as it was weekend. 2) No wanderguard was on her on that day. She removed it all the time. 3) When the charge nurse told me that Patient1 was missing, I checked the front door alarm. It was turned off. I turned it on straight away. The nurse said Patient1 was already in the hospital." During a telephone interview on 7/23/15 at 2:05 pm, CNA 2 stated that the last time he saw Patient1 on 4/18/15 was at around 5:30 pm when he removed the dinner tray. Record review of Nurse's Notes, dated 4/18/15, indicated: " At 19:30 pm, GACH ER called ... Patient1 fell, sustained right facila abrasion, right knee abrasion, right facial bluish discoloration and swelling below right eye." Review of ED (Emergency Department) Provider Notes from the GACH , dated 4/19/15, indicated Patient1 had diagnoses of "head injury and facial contusion."Review of Short Term Care Plan, dated 4/19/15, indicated Patient1 had impaired skin integrity R/T (related to): right knee abrasion, right below eye abrasion, right below eye swelling, right below eye skin discoloration (contusion). Review of the Nurse's Notes, dated 4/23/15, at 6:00am, indicated "still noted right face discoloration and swelling d/t (due to) fall...."Review of the facility Policy on Wandering, Unsafe Resident, with revised date of 1/21/15, indicated that for residents who were at risk for elopement, "Interventions to try to maintain safety will be included in the resident's care plan (Including the use of wander guard). Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior.""The facility is equipped with security measures: the front door's alarm goes off every time the doors are open; the front entrance/exit is also equipped with wander guard sensor which is activated when a Patient wearing a wander guard bracelet gets within five (5) feet of the front entrance/exit. "Therefore, the facility failed to provide adequate supervision to prevent the elopement of one Patient(Patient1) when: 1. there was no documented evidence for the one to two hourly visual checks before 4/18/15 when the elopement took place. 2. failed to ensure that the front door alarm was turned on to alert staff when the door was opened. This deficient practice had resulted in Patient1's emergency room admission to treat head injury and facial contusion related to a fall outside the facility after she eloped on 4/18/15. This deficient practice had a direct relationship to the health, safety, or security of patients. |
| 230000802 |
Country Crest Post Acute |
230008979 |
B |
14-Feb-12 |
NZIP11 |
1916 |
A 064 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. Based on interview and record review, the facility failed to report to the Department of Public Health within 24 hours of an abuse altercation that occurred on 1/8/12 between two residents. This action had the potential to negatively impact the residents' physical and emotional well being. On 1/10/12 at 9:51 am, the facility sent a faxed notification to the Department confirming that a suspected abuse altercation had occurred on 1/8/12. On 1/13/12 at 3:45 pm, Administrative (Admin) Nurse A stated that during the evening shift on 1/8/12 at 5:30 pm, Resident 1 slapped Resident 2 on the face while they were seated at a table. Resident 1 was admitted to the facility on 10/24/08, with diagnoses that included dementia (a progressive impairment of intellectual functions) with behavioral disturbances. A Minimum Data Set, an assessment tool-dated 12/27/11, indicated that Resident 1 was unable to correctly state the current day, month, or year. It further indicated the patient was non-ambulatory and required extensive assistance from the staff to transfer her from her bed or wheelchair.A Nurses Note, dated 1/8/12 at 5:30 pm, read that Resident 1 had slapped Resident 2 across the face thinking that the other patient was reaching for her food during the dinner meal. On 1/13/12 at 5:30 pm, Admin Nurse A confirmed that the abuse altercation between Residents 1 and 2 was reported late and not within the required 24 hours. The facility reported the abuse altercation to the Department 40 hours following the incident. Therefore, the facility failed to report to the Department of Public Health within 24 hours of the abuse altercation that occurred on 1/8/12 between Patients 1 and 2. |
| 230000351 |
Copper Ridge Care Center |
230008989 |
B |
16-Mar-12 |
O8BN11 |
5172 |
F 323 483.25(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. Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was free from a hazardous accident, that caused injury, when four toes on his left foot and one toe on his right foot, sustained second degree burns (a burn that extends through the surface of the skin down to just above the fat layer) on the hot surface of the baseboard heater in his room.On 1/3/12, Resident 1 was admitted to the facility with diagnoses that included a stroke, weakness, and diabetic neuropathy (loss of feeling in hands and feet). The Minimum Data Set, (MDS-an assessment tool-dated 1/16/12), reflected that Resident 1 had memory and recall difficulties. On 1/27/12 at 8:30 am, Resident 1 was interviewed. Resident 1 stated that his feet had slipped off the left side of his bed and were resting on the baseboard heater. Resident 1 stated that his bed had been moved closer to the heater to facilitate the installation of a transfer pole at the request of his physical therapist to assist him with getting out of bed. He stated that he had fallen asleep with his feet on the heater and when his nurse assistant woke him up "a few hours later," his toes had been burned. Resident 1 stated that because of his diabetic neuropathy, he could not feel how hot the heater was and had not realized that he had been burned. A review of Resident 1's Nursing Progress Notes, dated 1/17/12, reflected that Resident 1 was discovered at midnight with his feet hanging off the side of his bed and were resting on the heater. Resident 1 had suffered burns to four of the toes on his left foot and one toe on the right foot. He was sent immediately to the emergency room. Resident 1's Skin Integrity Report, dated 1/17/12, revealed that he had burns with "missing skin layers" to the left big toe, third, fourth, and fifth toes and on the right big toe.A Physical Therapy Weekly Progress Report on Resident 1, dated 1/26/12, indicated that, "He is markedly weaker after he burned his toes," and weight bearing is limited on both lower extremities, and required continued physical therapy to return to his prior level of functioning. An observation and concurrent interview was conducted with Maintenance Staff (MS) A on 1/27/12 at 11 am. The facility currently had baseboard heaters in four rooms: Rooms 19B, 31B, 37B, and 49B. MS A stated that when the facility had been remodeled, those rooms were not getting adequate heat from the central heating unit, so the baseboard heating was left in place.The following information was identified with MS A during an observation of the rooms that contained baseboard heaters: 1. Patient 1's previous room, Room 31B, was warm. The thermostat on the wall read 70 degrees. The bed was parallel to the wall heater and measured 29 inches from the heater. The heater ran along the baseboard of the wall and had a protective metal cover over it that was five feet long and seven inches wide. The cover that Resident 1 had rested his feet on, was hot to the touch. The temperature of the metal was taken and found to be 199.7 F degrees, which was confirmed by MS A.2. Room 19B's thermostat read 68 degrees and the baseboard heater's metal cover was 152 degrees, which was confirmed by MS A. 3. Room 37B's thermostat was on "low" and the baseboard heater's cover was cold to the touch. 4. Room 49B's thermostat read 75 degrees and the baseboard heater's metal cover was 280 degrees, which was confirmed by MS A. MS A stated that Resident 1's night stand had been removed from the area between the bed and the heater and that the bed had been moved closer toward the heater to accommodate a transfer pole. Without the night stand in place, MS A stated Resident 1's bed was about 14 inches from the heater, which allowed him to be close enough to rest his feet on the metal cover of the heater. On 1/27/12 at 2 pm, an observation of Resident 1's feet and concurrent interview with the Assistant Director of Nurses (ADON) was conducted. The following burned areas contained no skin layer, were yellowish white in color with dark pink edges, and the burned areas measured:1. Resident 1's left third toe measured approximately one half by one half inch, 2. Resident 1's left fourth toe measured approximately one half by one half inch, 3. Resident 1's left fifth toe measured approximately one inch by two inches, and 4. Resident 1's left big toe measured approximately one half by one inch.5. Resident 1's right big toe had a fluid filled blister with pink edges that measured approximately one by two inches.Therefore, the facility failed to ensure that Resident 1 was free from a hazardous accident, that caused injury, when four toes on his left foot, and one toe on his right foot sustained second degree burns on the hot surface of the baseboard heater in his room.The violation of this regulation had a direct relationship to the health, safety, or security of residents. |
| 230000279 |
Crystal Ridge Care Center |
230009209 |
A |
17-Jan-14 |
KCBM11 |
15697 |
F 309 483.25 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. The facility failed to provide Patient 1 the necessary care and services to prevent and treat worsening congestive heart failure (CHF, failing heart that has lost ability to pump enough blood to the body's tissues) for Patient 1 by failing to: Recognize Patient 1's weight gain, edema (excess fluid in the lungs and tissues), wheezing (whistling air passageway narrowing from excess fluid), and shortness of breath as signs and symptoms of worsening CHF; Review, revise, and implement Patient 1's CHF, Nutrition, and Chronic Kidney Disease (CKD, concurrently causes excess fluid) care plans; andNotify Patient 1's physician of Patient 1's worsening signs and symptoms of CHF (weight gain, edema, wheezing and shortness of breath), prior to discharging her home on 2/7/12.These failures permitted Patient 1's unrecognized decline in clinical status. After discharge home on 2/7/12, Patient 1 died of Cardiac Arrest and CHF the following morning on 2/8/12.Patient 1 was admitted to the facility on 1/9/12, following an acute care hospitalization on 1/6/12 for acute respiratory failure secondary to acute CHF exacerbation (increase in signs, symptoms and severity). The facility's minimum data set (an assessment tool), dated 2/7/12, described her as able to make her own health care decisions.The acute care hospital's admission documentation for Patient 1, dated 1/6/12, showed she was treated for acute CHF exacerbation (worsening), had a history of CKD, weighed 159.5 pounds (lbs) on admission, and the plan was to aggressively diurese her (diuretic medication that eliminates excess fluid buildup through urine excretion), prior to discharge on 1/9/12. On discharge from the acute care hospital, Patient 1's weight was down to 153 lbs and she was breathing better.Patient 1's admission orders, dated 1/9/12, showed an order for the diuretic hydrochlorothiazide at 25 milligrams daily. Her February 2012 medication administration record showed she had received the daily hydrochlorothiazide. There was no physician's order for a loop diuretic found in Resident 1's record. Patient 1's nutritional care plan, dated 1/11/12, was not completed. The boxes for the identified problems of diuretic use and fluid restriction were left unchecked. The nutritional care plan goal for Patient 1 to maintain her weight was not filled in or checked.A "Care Plan," dated 1/18/12, showed Patient 1 was at risk for shortness of breath, edema, and anxiety related to CHF. The care plan's approaches showed that nursing would evaluate and report effectiveness of Patient 1's medications (diuretics), assess for fluid excess (weight gain,...shortness of breath,...wheezing, edema, worsening of edema...), and monitor and report signs of respiratory distress (rapid or difficult breathing). Patient 1's care plan for her CKD, dated 1/18/12, also showed that the facility would assess for excess fluid. The care plan's approach showed that nursing would notify MD E of respiratory distress and significant weight gain. On 3/2/12 at 8:50 am, Family Member (FM) G was interviewed. FM G stated that she attended a care conference with facility staff on or about 1/25/12, and was told by facility staff that Patient 1 had gained 11 lbs in 2 weeks. FM G stated that when she said the 11 lb weight gain was not good for Patient 1, the facility staff did not respond to her. FM G stated that on 2/6/12 (the day before Patient 1's discharge), when she told Social Services Director (SSD) F that Patient 1 was not feeling well, not breathing well, and should not be sent home, SSD F told her that the facility staff had checked Patient 1's lungs and heart and that, "She was fine." FM G stated that Patient 1 seemed almost as sick as when she had previously entered the acute care hospital on 1/6/12 for acute CHF exacerbation.Reviewed on 3/2/12, the facility's January 2012 weekly weight reports documented Patient 1's weights as follows: 153 lbs on 1/9/12, admission date; 157 lbs on 1/16/12 (4 lbs in 7 days); 164 lbs on 1/23/12 (7 lbs in 7 days); 168 lbs on 1/30/12 (4 lbs in 7 days), a total of 15 lbs in 21 days. In a Nutritional Progress Note for Patient 1, dated 1/19/12, registered dietician (RD) D documented that Patient 1 gained 4 lbs in one week, that her weight should not exceed 160 lbs, and was eating 50 to 75 % of her meals. RD D documented that Patient 1 was hyponatremic (excess fluid volume and low sodium levels) and might benefit from a fluid restriction (limited fluid intake). An entry on 1/26/12, showed that RD D recommended a fluid restriction a second time and that the facility would request a physician's order for it. An entry on 2/2/12 (23 days after admission), showed that Patient 1 had gained 15 lbs in three weeks, that the facility was waiting for a response from the physician to start the previously requested fluid restriction, would suggest the fluid restriction again, and that Patient 1 had stated her legs were "puffy" (edema). Patient 1's nurse notes showed that fluids were encouraged (rather than restricted) to her on 1/11, 1/12, 1/15, 1/21, 1/22, 1/27, 1/30, and 1/31/12. Patient 1's nurse notes reflected the following signs and symptoms of fluid overload (causes heart to work very hard to pump the excess fluid volume, which can worsen heart failure, cause shortness of breath, weight gain, and edema of the feet or legs): On 2/4/12 at 4:10 pm, Patient 1 had 2+ pedal edema (significant fluid buildup in feet/ankles that leaves a dent in skin when pressed with thumb, sign of fluid overload in CHF); On 2/4/12 at 7:15 pm Patient had 1 to 2 + edema and a cough; On 2/5/12 (no specified times noted), Patient 1 was tachypnic (rapid breathing, normal respiration rate 12-20 breaths per minute) at 24 breaths per minute during the morning and afternoon shifts; and On 2/7/12 at 4 am (the day of her discharge), she was anxious, complained of being short of breath, and was wheezing and at 12:50 pm, no shortness of breath was noted. Patient 1's daily nurse notes, dated from 1/9 to 2/7/12, showed there was no documentation that Patient 1's continuous weight gain totaling 15 lbs, 2+ pedal (foot) edema, tachypnea, shortness of breath or wheezing had been recognized as signs and symptoms of CHF exacerbation. There was no documentation indicating that Patient 1's physician (MD E) had been notified of her signs, symptoms, or cumulative weight gain since admission.Patient 1's Rehabilitation Skilled Therapy Progress Note, dated 2/2/12, showed that she complained of right calf swelling (edema) and that the therapist notified nursing. Patient 1's signed physician telephone orders, dated 2/4/12, showed that on 2/4/12 (3 days prior to discharge) the facility obtained Resident 1's 1500 milliliter (ml) fluid restriction and discharge orders for 2/7/12.On 3/2/12 at 9:52 am, Administrative (Adm) Nurse B stated that nursing staff was responsible for assessing the resident to determine if they were medically cleared for discharge from the facility. Adm Nurse B stated the facility policy was that nursing staff was to communicate this information to the physician and ask for the discharge order.On 3/2/12 at 3:25 pm, the nursing services documentation portion of the "Final Summary of the Patient's Status" section of Patient 1's Interdisciplinary Discharge Summary, dated 2/7/12, showed she had a 15 lb weight increase since admission and was concurrently reviewed with Adm Nurse C. Adm Nurse C confirmed that he had completed the nursing portion of the form. Adm Nurse C stated that he was not aware of Patient 1's shortness of breath and wheezing (signs and symptoms of CHF fluid overload), noted by nursing at 4 am on 2/7/12, the day of Patient 1's discharge. Adm Nurse C stated that he had not noted Patient 1's 15 lb weight gain as a sign of fluid overload at the time of her discharge assessment.The American Medical Directors Association (AMDA) 2010 clinical practice guidelines for Heart Failure in the Long-Term Care Setting, showed that fluids should be restricted in patients who are hyponatremic, that patients with signs of fluid overload (edema) should receive a loop (type of diuretic that stops sodium/water from reentering the body) diuretic medication (for example, Lasix) to decrease fluid overload, and be monitored for condition and response to treatment. The guideline specified that if patients did not achieve explicit goals, the reasons should be documented and the care plans should be modified. On 3/2/12 at 2:05 pm, Adm Nurse B, confirmed she had not contacted MD E about the ineffectiveness of Patient 1's diuretic, her edema, or her breathing problems, as directed in her heart failure care plan. On 3/30/12 at 11:30 am, MD E was interviewed about Patient 1's care at the facility. MD E stated that she was not made aware of Patient 1's weight gain until she received the Weight Variance Report and request for fluid restriction, that indicated a 7 lb weight gain, which was not significant in and of itself. MD E stated she was not contacted by the facility about Patient 1's 15 lb weight gain, edema, shortness of breath or wheezing. MD E stated that when the facility contacted her to discharge Patient 1, she understood Patient 1's condition was "super stable." When asked what she expected the facility's nursing staff to do when monitoring weight gain in CHF patients, MD E stated it should be similar to outpatients, who are educated to contact their physician for a two to three lb weight gain over several days.On 4/3/12 at 2 pm, during a concurrent record review and interview, RD D's progress note, dated 2/2/12, showed that Patient 1 had gained 15 lbs in the previous three weeks. RD D confirmed she had completed a Weight Variance Report on 1/19/12 that included a request to Patient 1's physician to place her on a fluid restriction and had given it to nursing to fax to MD E. RD D stated that she had advised the nursing staff to obtain a physicians order for fluid restriction on 1/19/12 and that nursing was responsible for notifying the MD E of Patient 1's weight and getting the order for the fluid restriction. RD D stated the facility was to follow up her recommendations by contacting the physician, if they had not received a response within 72 hours. RD D confirmed that she again requested the fluid restriction for Patient 1 on 1/26 and 2/2/12. RD D stated that as of 2/2/12, Patient 1 had gained 15 lbs in three weeks and had stated that her legs were "puffy."On 4/3/12 at 2:10 pm, Adm Nurse A (Patient Care Coordinator) stated he was not able to provide documentation or verify that Patient 1's physician was contacted on 1/19 or 1/26/12, about her 15 lb weight gain or RD D's request for the fluid restriction order. Adm Nurse A confirmed that on 2/3/12, MD E was faxed Patient 1's 1/26/12 Weight Variance Report that showed a 7 lb weight gain, as part of the request for the fluid restriction order. Adm Nurse A confirmed that Patient 1's actual cumulative weight gain on 2/3/12 had been 15 lbs, not the 7 lbs indicated on the Weight Variance Form which had been dated 1/26/12 (8 days earlier). Also, that Weight Variance Form reported only the 7 lbs gained in the he prior week, not the full 11 lbs cumulative weight gained by 1/26/12.There was no evidence found in Patient 1's record that MD E was notified of her significant 15 lb weight change or her respiratory problems that were noted in her 2/5 and 2/7/12 nursing notes.On 4/3/12 at 3:15 pm, when Adm Nurse A and B were concurrently asked how MD E was able to effectively decide to discharge Patient 1, based on the inaccurate weight gain they had provided to her on 2/3/12 and the lack of communication about Patient 1's edema, shortness of breath, and wheezing (all signs of worsening heart failure), neither Adm Nurse A or B was able to answer.On 4/3/12 at 3:20 pm, Adm Nurse B confirmed the facility had not used their assessments to update or implement Patient 1's heart failure care plan, when they did not report the weight gain, edema, or breathing problems to MD E. Adm Nurse B confirmed that Resident 1 did not receive a loop diuretic and that her nutritional care plan was not updated for diuretic use or the 1500 ml fluid restriction.On 4/3/12 at 3:35 pm, Adm Nurse B confirmed Patient 1's physician was not immediately notified following each documented weekly weight gain.The AMDA 2010 clinical practice guideline for Acute Change of Condition in the Long-Term Care Setting" showed that edema in a resident with heart and/or kidney disease, should be reported to the practitioner immediately when it is sudden, accompanied by sudden onset of shortness of breath, or has sudden onset of edema in one leg. This guideline showed that gradually progressive edema accompanied by weight gain should be reported to the practitioner on the next office day.Patient 1's record did not show any documentation that MD E had been notified about her signs and symptoms of worsening congestive heart failure: edema, cough, tachypnea, shortness of breath or wheezing (as recorded in the nurses notes from 2/4/12 through 2/7/12). There was no documentation that MD E was notified about Patient 1's weight gain prior to 2/3/12. The weight gain reported to MD E on 2/3/12 was misleading, indicating only a 7 lb weight gain over the prior 7 days (as measured 8 days earlier), rather than the full 15 lb cumulative weight gained in the 3 weeks since admission (as measured on 1/30/12).On 4/3/12 at 3:35 pm, Adm Nurse B confirmed Patient 1's physician was not immediately notified following each documented weekly weight gain. Adm Nurse B confirmed the facility did not have a nursing policy for management of heart failure patients. Adm Nurse B was not able to verbalize when nursing would be expected to contact a physician about a patients worsening heart failure signs and symptoms. Adm Nurse B was not able to explain why Patient 1's physician was not notified of her 15 lb weight gain in three weeks, the presence of edema, or her wheezing and shortness of breath the morning of discharge 2/7/12, all indications of fluid overload and worsening heart failure. Resident 1's certified death certificate, dated 4/10/12, in the "Cause of Death" section, listed the following: "(A) Cardiac Arrest(B) Congestive Heart Failure."Therefore, the facility failed to provide Patient 1 the necessary care and services to prevent and treat worsening congestive heart failure (CHF, failing heart that has lost ability to pump enough blood to the body's tissues) for Patient 1 by failing to: Recognize Patient 1's weight gain, edema (excess fluid in the lungs and tissues), wheezing (whistling air passageway narrowing from excess fluid), and shortness of breath as signs and symptoms of worsening CHF;Review, revise, and implement Patient 1's CHF, Nutrition, and Chronic Kidney Disease (CKD, concurrently causes excess fluid) care plans; and Notify Patient 1's physician of Patient 1's worsening signs and symptoms of CHF (weight gain, edema, wheezing and shortness of breath), prior to discharging her home on 2/7/12.These failures permitted Patient 1's unrecognized decline in clinical status. After discharge home on 2/7/12, Patient 1 died of Cardiac Arrest and CHF the following morning on 2/8/12.These violations presented an imminent danger of death or serious harm to the patient or a substantial probability that death or serious physical harm would result. |
| 230000802 |
Country Crest Post Acute |
230009326 |
B |
06-Jul-12 |
U6OD11 |
4306 |
F 223 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion 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. Based on interview and record review, the facility failed to ensure that Resident 1 was free from verbal abuse when Licensed Nurse (LN) A spoke harshly to Resident 1 and demanded that she use the toilet instead of the bed pan, as the resident had requested. The staff to resident interaction resulted in psychological distress for Resident 1.Findings: On 4/28/12 at 9:31 pm, the Department received a report of Suspected Dependent Adult/Elder Abuse notification explaining that on 4/28/12 at 4 pm, LN A had spoken harshly to Resident 1 and said the nurse was "snotty and didn't have the right attitude towards me. Now I'm afraid of her because now I don't know what she will do."Resident 1's record disclosed that she had been admitted to the facility on 4/16/12 with diagnoses that included after care following a surgical hemiarthroplasty (replacement of the femoral head with a metal ball held in place by a stem extending into the shaft of the femur) repair of her right hip fracture. The 73 year old female's Minimum Data Set (a resident assessment tool), dated 5/18/12, showed that she had no cognitive impairments, had anxiety and depression, and required extensive assistance with one person when transferring and total assistance with toileting.Resident 1's admission orders included an order to have physical and occupation therapy evaluate and provide services that included, the use of an abductor pillow while sitting and when lying in bed, and permit only 50 percent (partial) weight bearing to her right leg. An Interdisciplinary Progress Note entry, written by a nurse and social worker, dated 4/30/12, gave details of an incident of alleged verbal abuse directed at Resident 1 by LN A who had been the charge nurse for that evening.On 5/16/12 at 1:25 pm, Resident 1 was interviewed. She stated she had requested the bedpan and LN A demanded that she was to use the raised toilet seat in the bathroom. During her transfer from the bed to the wheel chair and then to the toilet, Resident 1 described LN A's voice as being irritated and loud. Resident 1 said she tried to explain to LN A that she was partial weight bearing and was instructed not to remove the wedge (that protects and used for proper alignment of the hip as it heals) between her legs while in bed or sitting in a chair. LN A stated there was no reason she could not use the bathroom and proceeded to transfer her from the bed to the wheel chair after removing the wedge. After the transfer Resident 1 said she was afraid of LN A and was not sure what the nurse might do to her next.On 5/16/12 at 1:35 pm, Resident 1's roommate (Roommate B) had confirmed she had overheard LN A telling Resident 1 that she knew what she was doing in a loud voice and demanded that Resident 1 needed to use the bathroom toilet instead of the bedpan. Roommate B said that Resident 1 started to cry when she was made to get out of bed.On 5/16/12 at 2 pm in an interview, LN C stated that she had been notified that Resident 1 was upset and crying in her room. Shortly after the incident at 4:30 pm, LN C found Resident 1 in bed crying and shaking. She then explained that LN A had made her get up and use the bathroom toilet. She said she did not want to get out of bed, but only to use her bedpan. Resident 1 said she was afraid of what LN A might do to her and expressed that she wanted to run away and go back home.During an interview on 5/16/12 at 2:30 pm, LN A admitted that she had insisted that she remove the wedge between Resident 1's legs and use the raised toilet seat in the bathroom, instead of the bedpan.Therefore, the facility failed to ensure that Resident 1 was free from verbal abuse when Licensed Nurse (LN) A spoke harshly to Resident 1 and demanded that she use the toilet instead of the bed pan, as the resident had requested. The staff to resident interaction resulted in psychological distress for Resident 1. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000802 |
Country Crest Post Acute |
230009327 |
B |
19-Feb-14 |
ZIZL11 |
5701 |
F223 483.13 (c )(1)(i) Free from abuse/involuntary seclusion The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to protect two female residents, Residents 1 and 2, from sexual and verbal abuse by Resident A, by not following their written care plan to closely supervise him. The facility staff was to provide one to one (1:1; one staff member to one resident) visual checks by staff for Resident A while he was awake, as a protection for the female residents in the Memory Villa Unit, which housed male and female residents with dementia.On 5/9/12 the Department received a Suspected Dependent Adult/Elder Abuse form that reported that Resident A had inappropriately touched a female resident. On 5/11/12 the Department received a second Suspected Dependent Adult/Elder Abuse form that reported that Resident A had his pants down and pushed a female resident's face down to perform oral sex.On 5/16/12, a review of Resident A's record disclosed that the 86 year old male was admitted to the facility on 6/23/11 with diagnoses that included dementia, depression, and a stroke.A Minimum Data Set (MDS-a resident assessment tool), dated 5/14/12, disclosed Resident A had difficulty making decisions, could usually understand others, and had short and long term memory problems. Resident A's behaviors included physical (hitting, kicking, and sexually abusing others) and other behavioral symptoms such as, public sexual acts and disrobing in public. The resident required limited to extensive assist with his activities of daily living and required standby assistance when ambulating with a walker.A care plan, dated 10/26/11, indicated that Resident A exhibited inappropriate sexual behavior. One of the interventions to prevent sexual behavior with female residents was to provide continuous 1:1 visual checks.The following were examples of Resident A's sexual behaviors in the Memory Villa Unit: 1. An entry documented in an interdisciplinary progress note (IDT) on 10/26/11 described an incident of Resident A's sexual inappropriate behaviors. Resident A was found naked from the waist down lying on the floor with an unidentified female resident sitting beside him.2. On 5/6/12 at 1 pm, a licensed nurse entry in the nurse's notes indicated that Resident A beckoned an unidentified female resident to masturbate him while sitting in the living room. The residents were separated. 3. On 5/7/12 at 1:40 pm, License Nurse (LN) 3 had documented that Resident A had three episodes that morning shift of verbal and sexual behavior towards the female residents in the Memory Villa Unit. A weekly summary report, written by LN 3 on 5/8/12, disclosed Resident A had 37 inappropriate verbal and sexual behaviors during the week of 5/1 to 5/8/12.4. On 5/17/12 at 3:25 pm in an interview, CNA G confirmed that on 5/8/12 at 3:35 pm while she was in the kitchen getting a drink for another resident and returned to the common area, she observed Resident A with his pants unzipped with his genitals exposed outside of his clothing and that had his hand down Resident 1's blouse when she separated both Resident A and Resident 1. CNA G's assigned duties included 1:1 visual checks for Resident A that evening shift. CNA G stated she was not sure if Resident A was supposed to be on 1:1 continuous observation.Resident 1, a 79 year old female, had been admitted to the facility on 8/12/09 with dementia. The MDS, dated 4/29/12 disclosed that she had severe cognition problems with long and short time memory loss. She also needed extensive help with her daily care and used a wheelchair for mobility.5. On 5/8/12 at 1 pm, LN 3 documented that Resident A had continually disrobed, exposed, touched himself, along with making ten sexual statements towards Resident 2 throughout the day and "at one point resident was fondling himself".The staff had difficulty detouring Resident A away from the female residents that day due to his angry outbursts towards them.Resident 2, an 81 year old female, had been admitted to the facility on 10/12/10 with Alzheimer's disease with behaviors. 6. On 5/10/12 at 6:45 pm, the facility's Janitor F was cleaning the day room on the Villa Memory Unit when he witnessed Resident A telling Resident 2 to perform oral sex on him. On 5/17/12 at 3:25 pm, Janitor F was interviewed. He stated he was cleaning the day room when he witnessed and overheard Resident A tell Resident 2 to perform oral sex by stating twice "suck my d*ck, b*tch". He had been too embarrassed to continue to watch and went for help as there were no staff present in the area. Janitor F stated Resident A had grabbed Resident 2 by the back of her hair and was trying to force her down to his exposed genitals. Janitor F returned with CNA H within three minutes, who then separated the two residents. On 5/17/12 at 3:15 pm, LN 3, who was on duty the morning shift on 5/8/12, was interviewed. She stated that she had reported to the evening shift nurse that Resident A had increased inappropriate sexual behaviors on the day shift. On 5/18/12 at 4 pm, LN 4 confirmed that Resident A's incident on 5/8/12 involving Resident 1 and the 5/10/12 incident involving Resident 2 could have been prevented with continuous 1:1 visual checks by staff instead of sporadic supervision that was ineffective in keeping Resident A from abusing female residents. The violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 230000802 |
Country Crest Post Acute |
230009369 |
B |
06-Jul-12 |
F5KB11 |
3598 |
F 223 483.13(b), 483.13(c)(1)(i) Free From Abuse/Involuntary Seclusion 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. Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was free from verbal abuse. This failure had the potential to cause psychological harm to Resident 1.Findings: On 3/18/12 at 3:42 pm, the Department received a report of Suspected Dependent Adult/Elder Abuse notification explaining that on 3/17/12 at approximately 7 pm, Resident 1 had complained that Licensed Nurse (LN) B was rude to her. She claimed that when LN B had found her walking alone in her room without an assistive device, the nurse tried to redirect her with a rude approach. The faxed report disclosed that this staff to resident interaction caused "emotional distress" to Resident 1.Resident 1's record was reviewed on 3/22/12. The 72 year old female was admitted to the facility on 3/14/12 with diagnoses that included diabetes, a history of sepsis (a serious blood infection) and depression.An initial nursing assessment, dated 3/14/12 at 7:42 pm, indicated that Resident 1's cognitive skills were "independent," and alert with short term memory problems. It additionally assessed her as requiring assistance for transfers, ambulation, and personal hygiene from one staff member.During an interview on 3/22/12 at 5:30 pm, Resident 1 stated she recalled the incident with LN B. She identified LN B as the nurse working and passing medications. She stated she could not remember exactly what LN B had said to her but, "I remember how it made me feel." She stated LN B's tone made her cry and feel worthless. She additionally stated that LN B made sure to let her know that, "...she was in charge and I had no say in my life." She additionally stated she was crying because LN B spoke to her like a child, and was, "...verbally abusive." On 3/22/12 at 2:40 pm, LN B recalled that she entered Resident 1's room and found the resident walking by herself and without her cane on 3/17/12. She said that she informed Resident 1 that, "You know you're supposed to use your call light for assistance from staff." She stated Resident 1 had an angry look on her face, and told LN B that she did not like the way she had spoken to her. An interview was conducted with certified nursing assistant (CNA) C on 3/22/12 at 3:05 pm. She recalled that around dinner time on 3/17/12, she had entered Resident 1's room and found the resident with reddened eyes and crying while sitting in her chair. CNA C stated she reported what the resident told her to LN B. She stated that when she was outside Resident 1's room, shortly after the incident, she overheard LN B tell Resident 1 that the resident's safety came first and Resident 1 responded by saying she did not like LN B's tone of voice. On 3/23/12 at 12:40 pm, Administrative (Admin) Nurse D provided an undated "Resident Rights" policy. The policy disclosed that residents would be treated with respect and be free from abuse, humiliation, and intimidation. Admin Nurse D stated she had disciplined LN B after the incident about the harsh approach she had used with Resident 1. Therefore, the facility failed to ensure that Resident 1 was free from verbal abuse. This failure had the potential to cause psychological harm to Resident 1. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000802 |
Country Crest Post Acute |
230009704 |
B |
17-Dec-13 |
YLG311 |
2589 |
F 224 CFR483.13(c) Neglect The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to ensure that Resident 1 was free from neglect when Certified Nurses Assistant (CNA) A failed to follow the facility's policy regarding the use of gait belts (belt put around the waist of the resident and held onto by staff to provide support during transfers). This resulted in a cut to Resident 1's right leg that required stitches. On 1/11/13, Resident 1's record was reviewed. Resident 1 was an 82 year old female who was admitted to the facility on 3/21/12, with diagnoses of diabetes, dehydration, and muscle weakness that required rehabilitation in order to return to home. Resident 1's minimum data sheet (MDS) a resident assessment tool, dated 12/27/12, disclosed that she required extensive (two person) assist with transfers and used a wheelchair. Resident 1's plan of care, dated 10/19/12, indicated that Resident 1 required extensive assistance with her daily care and was a high risk for falls.The facility's investigative report, dated 1/9/13, indicated that, on 1/4/13, Resident 1 sustained a laceration as a result of transfer from a Beauty Salon chair to a wheelchair. The injury required a visit to the Emergency Department where eight stitches were applied. The report further read, "The result of our investigation indicates there there was in fact, resident neglect on the part of CNA A. The CNA failed to follow facility procedures regarding the use of gait belts, as well as facility policy concerning two person transfers of residents." During an interview on 1/11/13 at 3 pm, CNA A stated she had been trained and oriented to the facility's policy on the use of gait belts but did not use one when she transferred Resident 1 because she was in too much of a hurry. CNA A also stated she did not request assistance from another CNA. The facility's policy titled "Gait belts," dated 11/2006, indicated that gait belts were to be used during transfers and ambulation to prevent injuries and discomfort, while providing support and a sense of security. Resident 1 was not transferred with the use of a gait belt and two persons, as required by facility policy and Resident 1's physical condition. As a result, Resident 1's leg was caught in the wheel of her wheelchair and she suffered a cut to her right leg that required stitches. The violation of this regulation had a direct relationship to the health, safety, or security of the residents. |
| 240000023 |
Calimesa Post Acute |
240008903 |
B |
12-Jan-12 |
OE9Y11 |
4153 |
REGULATION VIOLATION: Title 22 72311 Nursing Services-General and 72301 Required Services 72311 (a) Nursing services shall include, but not be limited to, the following: (2) Implementation of each patient's care plan according to the methods indicated. Each Patient's care shall be based on this plan. And 72301 (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 Patient A's care plan and doctor's orders for placement of a lap buddy were consistently implemented. On August 17, 2010, Patient A fell from her wheelchair after being left alone by staff without her lap buddy in place. As a result she sustained a right orbital fracture and 11 sutures to her right eye.Patient A was an 89 year old female, originally admitted to the facility on June 10, 2004, with the most recent readmit April12, 2008. She had diagnoses that includes acute renal failure (failure of the kidneys), dementia (a serious illness affecting a person's brain and memory), generalized weakness, and osteoporosis (a bone disease where bones become porous, break easily and heal slowly). Patient A was described by the nursing staff as being totally dependent for all activities of daily living.On August 17, 2010 at approximately 9:45 AM, as documented in the licensed nurses' progress notes, Patient A was seen by nursing staff on the floor of her room. She was noted to be on her left side in front of her bed and in front of her wheel chair. She had lacerations on the right side of her face starting at the outside of her right eye and ending at the inside corner. She also sustained a bump to her forehead, laceration to her left pointer finger and her fourth left knuckle. Patient A's physician was notified and ordered for her to be sent to the general acute care hospital. On August 17, 2010 at approximately 10:15 AM, Patient A was taken to the general acute care hospital for treatment after her fall. The report from the emergency room showed that she suffered 1) Right facial laceration, 2) Left finger laceration superficial, 3) Blunt head trauma 4) Orbital blowout fracture-small. Review of Patient A's care plan titled, "Safety Deficit: FALLS" revealed the intervention, "Do not leave unattended after removal of lap buddy" dated August 13, 2009. Falls were noted on this care plan on August 13, 2009 and August 17, 2010. Review of Patient A's care plan titled, "SAFETY DEVICES" revealed the use of a lap buddy with the intervention "Lap buddy when up in w/c, may remove when in dining room for meals, activities or in direct supervision of nursing."Physician Orders for Patient A dated April 23, 2010 stipulated, "Lap buddy while up in wheel chair for poor trunk control", with an informed consent form with verbal consent from Patient A's conservator on June 15, 2008. Interdisciplinary Team Review Notes regarding this event dated August 19, 2010, showed that the contributing factor to this fall was, "lap buddy not applied appropriately." During an interview with the DON on September 15, 2010 at 10:58 AM, she stated that Patient A was found in her room on the floor. Patient A had been in her wheelchair without her lap buddy on. During an interview with the facility administrator on September 15, 2010 at 11:05 AM, she stated she didn't know what to say; "the lap buddy wasn't on." She said, "that's what worries me too." During a telephone interview with LVN 1 on September 28, 2010 at 4:08 PM, she stated that on the day that Patient A was injured she was the nurse on duty. She stated that Patient A had fallen out of her chair. She did not have her lap buddy on. LVN 1 stated that when Patient A is up in her chair without her lap buddy on she is absolutely supposed to have someone with her. She stated that no one was with Patient A at the time of her fall. The failure of the facility to consistently implement the care plan and to follow the physician's orders was the direct cause of Patient A's injuries. The violation of the above regulation had a direct relationship to the health, safety, or security of patients. |
| 240001032 |
Cedar Mountain Post Acute |
240008915 |
A |
17-Jan-12 |
77F311 |
20816 |
REGULATION VIOLATION: Title 22 72315 Nursing Services-Patient Care, 72301 Required Services, and 72523 Patient Care Policies and Procedures 72315 (m) Patients call signals shall be answered promptly. 72301 (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The facility failed to promptly respond to Patient A's pressure pad alarm (a device used to detect pressure/movement over a specific area to alert the staff of patient's movement) on the afternoon of January 29, 2011.The facility failed to follow policy and procedures and accurately complete the neurological assessment following Patient A's fall on January 29, 2011 at 1:30 PM. Patient A fell on January 29, 2011 at approximately 1:30 PM. The facility did not identify injuries to the patient's right elbow and right hip until 11:15 PM on January 29, 2011. Patient A arrived at the acute care hospital emergency room on January 30, 2011 at approximately 12:49 AM with fractures (broken bones) to the right elbow and right hip which required surgical interventions and hospitalization. On March 9, 2011, Patient A's medical record was reviewed. Patient A, 88 years of age, was admitted to the facility on January 17, 2011. Diagnoses included pneumonia (infection of the lung), urinary tract infection (UTI, an infection of the bladder), urosepsis (complicated bloodstream infection that are caused from UTI's) and dementia (a condition in which there is a gradual loss of brain function. The main symptoms are usually loss of memory, confusion, problems with speech and understanding, changes in personality and behavior and dependent on others for the activities of daily living). The Minimum Data Set (MDS, a comprehensive assessment of the patient) completed on January 21 and 29, 2011, indicated that Patient A required extensive assistance for toileting with two persons physical assist for transfer and limited assistance of one person assist for ambulation in the room.The admission nursing assessment dated January 17, 2011 at 3:35 PM, indicated that Patient A was alert and disoriented (not aware of) to time and place. Patient A was at risk for falls due to diagnoses of dementia, antihypertensive drugs (medications used to treat high blood pressure), and inability to transfer self, incontinent of urine, infection of the bladder, confusion and impaired gait/balance (difficulty walking with poor balance). A review of the care plan titled, "Safety deficit falls", dated January 17, 2011 included the following: "Actual safety deficit, at risk for falls related to: cognitive deficit, decreased safety awareness, impaired sitting and standing balance, abnormal gait (not steady on feet while walking), incontinence/bathroom urge and adjusting to environment". Interventions on January 17, 2011 included: "Clip mobility alarm (a box type alarm device connected to a cord with a clip. The clip is connected to a part of the resident clothing and the box is attached to the chair/furniture. When the cord gets disconnected from the box, it alarms and alerts the staff to the patient's movement). Pressure pad alarm, provide a low bed, assist with ambulation, frequent fall program (or falling leaf program is designed to increase staff awareness of residents who are at highest risk for falls and to implement team-oriented approaches to help reduce falls)." A review of the licensed nurses progress notes dated January 19, 2011 at 5:30 AM indicated that Patient A fell out of bed and was observed on the floor with a skin tear to her right elbow. A review of the care plan titled "Actual fall dates: January 19, 2011" included the following: a. No injuries, b. Poor safety awareness, c. Low bed, d. Safety mat, and e. Reduce environment obstacles." A review of the Interdisciplinary team (IDT) meeting dated January 19, 2011 included the following: "a. Fall with skin tear, very thin skin, b. Confused, got out of bed without calling for assistance, c. Impact mat placed on floor beside bed, d. Low bed e. Pressure pad with alarm placed under patient." A review of the licensed nurses' progress notes dated January 23, 2011 at 6:30 AM indicated that Patient A was found on the floor. The patient stated that she hit her head, was confused and complained of a headache. Patient A was transferred to the acute care hospital emergency room for evaluation.According to the documentation reviewed, this was Patient A's second fall in five days. A review of the medical record showed no documented evidence that a fall care plan was initiated or that the IDT met following the fall on January 23, 2011. A review of the licensed nurses progress notes' dated January 29, 2011 at 1:30 PM indicated, "Resident was attempting to use the restroom without assistance and lost her balance; eyes reactive to light; able to move all extremities freely and without pain; bilateral hand grasp even and strong, respiration even and unlabored. 4 centimeters (cm) laceration (cut) noted to right elbow, cleaned with NS (normal saline, a solution) and dressed with steri strip. Daughter notified and faxed nurse advice to inform. All needs met and call light use explained and placed in the patient's hand." A review of the licensed nurses' progress notes showed no documented evidence of an assessment completed on Patient A on January 29, 2011 between 2:45 PM until 9:44 PM. A review of the licensed nurses progress notes' dated January 29, 2011 at 9:45 PM indicated that the patient was alert, verbally responsive, and able to make needs known. Documentation further showed the patient fell with no changes in LOC; the patient required extensive assistance for transfer and toileting. However, there was no documented evidence that the following areas were assessed per facility's policy: pain at rest or with movement, new limitation in ROM (Range of Motion), active or passive, any swelling, redness or skin discoloration, or the condition of the skin tear to the right elbow.A review of the licensed nurses progress notes' dated January 29, 2011, at 11:15 PM indicated, "CNA reported at 10:30 PM that patient was limping on right leg. On assessment, the patient was noted to have bruise to right hip and leg is externally rotated (rotated outwards). Right elbow noted to have large bruise and skin tears x 2, positive swelling noted. Orders obtained to send patient to hospital for evaluation." Documentation showed that the injuries were identified 9 hours after the fall had occurred. Patient A arrived at the acute care hospital ER on January 30, 2011at 12:49 AM, 11 hours after the fall had occurred. On March 9, 2011, the facility's investigative report dated January 31, 2011 was reviewed. The report showed that Patient A fell in her room while attempting to go to the bathroom unassisted. The patient did not complain of pain at the time but was walking with a limp 2 hours later. On evaluation, the right hip was noted to have purplish discoloration. The patient was sent to the acute care emergency room (ER) for evaluation. The facility's policy titled, "Fall management program", version June 9, 2009 stipulated, under the post-fall assessment and treatment section, that after a fall, a nurse will: "1. Immediately check the resident for injury by assessing for: Bleeding, Change in level of consciousness, Change in vital signs, Pain at rest or with movement, New limitation in range of motion, active or passive, Swelling, Redness or other skin discoloration, Open areas such as skin tears or lacerations." 13. "Enter the resident's information on the 24-hour report to initiate 72-hour charting. All shifts should continue documenting assessments, monitoring for injury and interventions for increased risk of falls during the 72-hour post-fall period." 14. "Update the care plan after each fall". 15. "Members of the IDT will review fall reports, review contributing risk factors, and investigate as needed to assist in revising the plan of care to reduce the risk of further falls". On March 9, 2011 at approximately 12:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a care plan was not initiated after the fall on January 23, 2011 because the fall was witnessed. The DON confirmed that the IDT did not meet following the fall on January 23, 2011. The DON acknowledged that the facility did not follow the facility's fall management program by failing to update the fall care plan and the IDT not meeting following the fall on January 23, 2011. The DON, Administrator and the Social Worker were asked the status of Patient A. The Administrator stated that the patient was admitted to the acute care facility on January 30, 2011. The facility was unsure of the admitting diagnosis and had no documentation from the acute care hospital regarding the patient. On March 11, 2011, Patient A's acute care hospital record was reviewed. The record indicated that the patient arrived at the acute care hospital ER at 12:49 AM on January 30, 2011; Eleven hours after the fall occurred in the facility. Assessment conducted in the ER described the patient's swollen and deformed right elbow. The assessment noted the patient's limited range of motion (ROM the inability to move joint freely) to right elbow due to pain. The right hip was shorter than the left hip with internal rotation (the hip was turned inwards). There was tenderness to palpation (touch) in the right inguinal area (groin area) and attempts at rotating (turning) the hip resulted in pain. Patient A underwent surgical procedures to repair the fractures to the right elbow and right hip on January 31, 2011. On March 14, 2011 at 12:50 PM an interview was conducted with LVN 1. LVN 1 was responsible for Patient A's care at the time of the fall on January 29, 2011. LVN 1 stated that she was in the 200 hallway passing medication when Patient A's pressure pad alarm was activated. LVN 1 stated that she responded to the alarm and observed the patient sitting on the side of the bed. Patient A stated that she wanted to go the bathroom. LVN 1 stated that she told the patient lie back down and she would send the Certified Nursing Assistant (CNA) in to assist the patient. LVN 1 stated that she notified CNA 2, who was assigned to provide care for Resident 1 on the day shift on January 29, 2011 that the patient needed assistance.LVN 1 stated that approximately 4-5 minutes later, Patient A's pressure pad alarm was activated for the second time. LVN 1 stated that she reminded CNA 2 to check on the patient. LVN 1 stated that she continued to pass medications and did not check on the patient at that time. LVN 1 stated that about 5-7 minutes later, Patient A's pressure pad alarm was activated for the third time. LVN 1 stated that when she responded to the alarm, she observed Patient A lying on the floor. Patient A was alert and stated that she wanted to use the bath room. LVN 1 stated that she was surprised when Patient A's alarm was activated for the third time because she thought that CNA 2 had assisted the patient earlier.LVN 1 was asked, "What was the purpose of the pressure pad alarm?" LVN 1 responded, "The pressure pad alarm was used to alert the staff of the patient's movement". LVN 1 stated that staff should have responded right away and assisted Patient A to the bathroom. LVN 1 acknowledged that that Patient A was confused and needed assistance to go to the bathroom per the plan of care. On March 14, 2011 at 1:00 PM, a subsequent interview was conducted with LVN 1. LVN 1 was asked if she was aware that Patient A suffered fractures to her right elbow and right hip on January 29, 2011. LVN 1 responded that those injuries were not observed on assessment of Patient A following the fall on January 29, 2011. LVN 1 stated that the patient denied hitting her head or pain.LVN 1 stated, "Patient A's hand grips were strong and equal; the patient moved her legs and feet without complaints, both legs were in good alignment; no bruising was observed to the patient's body; a 4 centimeters (cm) skin tear was noted to the outside of the patient's right elbow. Patient A ambulated to the bathroom with the assistance of CNA 2 after the fall assessment was completed with no complaints or difficulty walking". LVN 1 stated that she could not explain why Patient A did not show signs and symptoms of injuries to her right elbow or to the right hip during the assessment that she had performed following the fall. The physician orders dated January 29, 2011, included, monitor level of consciousness (LOC) per protocol. (LOC measures how a person is arouse and/or respond to stimulation from the environment). The facility's policy titled, "Fall management program", version June 9, 2009 under "Post - fall assessment and treatment" included the following documentation: "Perform a neurological assessment if the fall was un-witnessed or there is suspected injury to the head. Neurological assessment includes: Checking the LOC if alert and oriented (patient is aware of his/her name, time and place), lethargic (not alert, drowsy), stupor (stunned or confused and slow to react) or comatose (not conscious; lacking awareness and the capacity for sensory perception as if asleep or dead). The movements of the extremities are determined to be voluntary (movement on command) or involuntary (not able to control movement). The pupils of the eyes are observed for equality of dilation, reactivity to light, and ability to accommodate)". The minimal frequency for repeating neurological checks is: Every 15 minutes times 4. Every 30 minutes times 4. Every shift times 72 hours. On March 14, 2011, Patient A's neurological assessment log was reviewed. The section under LOC on the neurological assessment was blank from 1:30 PM on January 29, 2011 when the log was initiated through the last entry at 8:30 PM on January 29, 2011. The facility failed to complete neurological assessments as written in their policy and failed to follow physician orders regarding monitoring the patient's LOC. An interview was conducted on April 8, 2011 at approximately 12:00 noon with CNA 1 who was responsible to provide care for Patient A at the time of the fall on January 29, 2011. CNA 1 stated that LVN 1, the charge nurse notified him that Patient A needed assistance to the bathroom. CNA 1 stated that he told LVN 1 that he was toileting another patient (high risk for fall) and could not leave the patient at that time. CNA 1 stated that LVN 1 returned a second time and notified him that Patient A needed assistance. CNA 1 stated that he told LVN 1 for the second time that he was still toileting the patient. CNA 1 stated that a short time later he was called to Patient A's room.When he entered Patient A's room, the patient was sitting in a wheel chair and he assisted Patient A to bed. CNA 1 stated that he did not assist Patient A to the bathroom.An interview was conducted on March 14, 2011 at 2:10 PM with Registered Nurse (RN) 1. RN 1 worked the night shift (11:00- 7:30 AM) on January 29, 2011. RN 1 stated that at 11:15 PM on the night of January 29, 2011, CNA 2, who was assigned to Patient A on the PM shift (3:00 PM - 11:30 PM) on January 29, 2011, asked, "Will you come and check this patient?" RN 1 stated that she went to Patient A's room with RN 2, the PM supervisor who was responsible for the assessment of Patient A on January 29, 2011 on the PM shift.RN 1 stated that she was not sure of the status of Patient A because she had just started the night shift (11:00 PM - 7:30 AM). RN 1 stated that Patient A's right arm was swollen and discolored, the right hip was swollen and the right leg was turned outward. RN 1 stated that Patient A's injuries required immediate attention. RN 1 stated that Patient A was transferred to the acute care ER for evaluation and treatment.An interview was conducted on March 14, 2011 at 3:05 PM with CNA 2 who was responsible for Patient A's care on the PM shift on January 29, 2011. CNA 2 stated that she did not remember the incident. An interview was conducted on March 14, 2011 at approximately 3:20 PM with RN 2, the PM shift supervisor who was responsible for the assessment of Patient A on January 29, 2011. RN 2 stated that she could not give any further information than what she had documented in the licensed nursing notes dated January 29, 2011 at 11:15 PM. RN 2 stated that when the CNA notified her that there was a problem, she assessed the patient. RN 2 had no response as to why Patient A's injuries were not identified earlier on the PM shift or why at 10:30 PM when CNA 2 reported that Patient A was limping on the right leg, there was no documentation of an assessment completed at 10:30 PM.An interview was conducted with Patient A's daughter on April 7, 2011 at approximately 9:55 AM. The daughter stated that when she visited her mother on the afternoon of January 29, 2011, staff informed her that Patient A had fallen while ambulating un-assisted to the bathroom after lunch. The daughter stated, "My mother was lying in bed and was she was very agitated and edgy (restless), she did not say anything to me. Normally when she is feeling well, she would be calm, even with her confusion. I thought that she was tired since she was so sick with the pneumonia, the bladder infection and the fall, I did not stay".An interview was conducted with the DON on April 27, at approximately 10:30 AM. The clinical record and the investigation findings were reviewed. The DON was asked, "What was the purpose of the bed pressure pad alarm?" The DON responded, "To alert staff of the patients' movement." The DON was asked, "What was the facility's policy for responding to the pressure alarm?" The DON responded, "Any staff in the building should respond to the alarm as they do for the call light and then get the appropriate staff to assist the resident". The DON was asked to explain why the staff did not respond and assisted Patient A to the bathroom on the first or the second times when the alarm was activated. The DON responded, "I have no explanation as to why the charge nurse did not assist Patient A to the bathroom the first time the alarm was activated. The charge nurse was aware that the CNA was busy. Charge nurses can answer lights too." The DON confirmed that Patient A's pressure pad alarm was used in place of the call light because the patient was too confused to use the call light and that staff should have responded right away to the alarm. The DON was asked if Patient A's fall was preventable. The DON responded, "Based on your investigation and the information you presented, the fall on January 29, 2011 was preventable."The DON was asked why Patient A's injuries were not identified until 11:15 PM when the fall occurred at 1:30 PM in the afternoon. The DON stated that she had no explanation as to why Patient A's injuries were not identified earlier. The DON stated that she saw Patient A about an hour after the fall and that she did not observe any injuries to the patient. The DON responded that she did not complete a physical assessment of Patient A. The DON acknowledged that Patient A's injuries were not identified early and that treatment was delayed for the patient. On April 27, 2011, Patient A's neurological assessment log was reviewed with the DON. The section under LOC on the neurological assessment was blank from 1:30 PM on January 29, 2011 when the log was initiated through the last entry at 8:30 PM on January 29, 2011. The DON confirmed that the staff did not follow the physician order for monitoring the LOC or the facility's post fall neurological assessment on patient A. The DON stated that if the licensed staff followed the post-fall assessment policy, they should have noted limitations to Patient A's right elbow and right leg, swelling or discoloration to the affected areas.Therefore, the facility failed to ensure that staff followed Patient A's plan of care by promptly responding to the pressure pad alarm and providing the care needed, on the afternoon of January 29, 2011. In addition, the licensed nurses failed to follow the facility's policy that addressed timely and accurate assessments, of Patient A following the fall. These failures resulted in Patient A falling, sustaining fractures to the right elbow and right hip which were not identified in a timely manner and resulted in delayed in diagnoses, surgical interventions and hospitalization. The violation of the above regulations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240001896 |
CASA #4 |
240009033 |
B |
22-Feb-12 |
VP7I11 |
7121 |
REGULATION VIOLATION: 483.420 (d) Staff treatment of clients (1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of a client AND (d) Staff treatment of clients (2) The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator and to other officials in accordance with State law through established procedures. The facility failed to implement its written policy and procedure for "Prevention of Abuse, Neglect and Mistreatment, and Change of Condition" by not reporting a bruise of unknown origin on one of six clients (Client A) immediately, and by allowing the employee (DCS 1) to continue working after abuse had been suspected.The facility failed to report the allegation of abuse to Client A to the Administrator for 3 days and to the required regulatory agencies for 5 days. This had the potential to result in additional injuries to go unreported; therefore, placing all six clients at risk for abuse.Patient A was a 16 year old male admitted to the facility on February 23, 2005. His diagnoses included: severe mental retardation (an IQ in the 20-34 range), panhypopituitaryism (a condition of decreased pituitary hormone), and Bell's palsy on the left side (pain and paralysis of facial nerve), bilateral hearing loss from chronic obits media (ear infections), fetal alcohol syndrome (mother's consumption of alcohol during pregnancy caused mental and physical delays), cerebral palsy (trauma before or during birth caused mental and physical disabilities) seizures, visual defects, and a gastrostomy tube (tube inserted through abdominal wall through which nourishment and medications can be given).Client A was ambulatory and overall non-verbal. However, he could answer "yes", "no", say a few isolated words and used American sign-language, or pointing, to make his needs known. There were no documented behaviors for this client. He was described by both the staff at the home and his high school as being, "friendly, all smiles, compliant, and interacts well with peers and staff." On April 9, 2011 at approximately 6:00 AM, documentation indicated the facility manager (FM) was relieving the night direct care staff (DCS 1) and noted a discoloration on the right side of Client A's forehead. The FM went outside to ask DCS 1 what had caused the injury since it had not been reported at their change of shift. DCS 1 told the FM, "I thought it was a pimple". No change of condition report was filled out by the FM. On April 10, 2011, DCS 2 asked Client A what had happened to his forehead; the client said, "[the name of DCS 1]." Documentation showed Client A became progressively anxious and aggressive, including throwing his plate of food at staff. On April 13, 2011, LVN 1 returned to work her scheduled shift. When Client A returned from his school, she noted "a small area of dark discoloration on right forehead, approximately 1 inch below hairline." Documentation by LVN 1 showed Client A had no bleeding, no edema, no complaint of pain, and no signs of complication. LVN 1 documented the mark as being approximately 1/2 inch in length and 1/4 inch in width.LVN 1 documented, "How it occurred was not observed..." LVN 1 initiated the notification of the administrator, qualified mental retardation professional (QMRP), regulatory agencies, and the police. The "Change of Condition" form described the wound as linear. On April 26, 2011 at 8:50 AM, during the investigation of Client A's injury, DCS 3 provided a tour of his room. There were no sharp corners or objects for the client to strike noted during the observation. During an interview with the QMRP at 8:40 AM, she stated, "[Client A] did not have behaviors, so when I was shown his injury and told about him naming DCS 1, and becoming aggressive, LVN 1 and I implemented our abuse policy and procedure, and DCS 1 was suspended." A review of the facility policy and procedure titled, "Prevention of Abuse, Neglect, and Mistreatment, and Change of Condition", undated, stipulated the following, "All direct care staff are instructed on procedures for reporting any individual injury, observed marks or bruises and also receive information regarding abuse/neglect/mistreatment during their initial orientation."A review of the employee file for DCS 1 showed she had been employed since April 4, 2004. A review of the employee file for the FM showed she had been employed since September 26, 2003. Both employee files reflected initial and ongoing abuse training. Neither file had documented evidence that action had been taken to address their failure to implement the procedure for reporting the injury. In addition, there was no documented evidence of DCS 1's suspension. During an interview with the FM on April 26, 2011 at 9:55 AM, she could not explain why she had not followed the facility policy. During an interview with QMRP on April 26, 2011 at 10:30 AM, she was asked if DCS 1 had worked after the FM had suspected she was responsible for the mark on Client A. She stated that "[DCS 1] did work the night shift on April 9, 2011, and then was off because she only works on Friday and Saturday. I didn't find out until Wednesday and that's when she was suspended."The QMRP confirmed that the abuse policy had not been followed as indicated, "In the event that an employee has been accused of abuse/neglect/mistreatment, the administrator is to be informed immediately by the individual witnessing, reasonably suspecting and/or receiving the allegation. The accused employee is suspended...pending an investigation." During an interview with LVN 1on April 26, 2011 at 12:30 PM, she was asked what made her suspect possible abuse when she returned to work. She stated that when she saw the mark on Client A when he returned home from school, the FM told her what had happened. "He had acted strangely around DCS 1 before, but I thought it was because she was so loud. Then I noted he always runs to greet everyone at the door, but when she came, he sat in a chair and covered his face. There wasn't a mark then and nothing to report. I even looked to see what might have caused the mark since no one had witnessed anything. When I heard that he had become aggressive, and was more anxious, I just followed the procedure and notified everyone." The facility failed to implement its own policy and procedure for abuse prevention by not reporting a bruise of unknown origin on Client A, and by not suspending the accused staff member to protect the client pending investigation. This placed all clients for the potential of mistreatment or abuse. The facility failed to ensure that when abuse was suspected, the administrator and other regulatory agencies were notified. This failure had the potential for future injuries to occur and be dismissed as behaviors, instead of investigated to prevent reoccurrences. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000058 |
Country Villa Healthcare |
240009036 |
B |
23-Feb-12 |
0RL911 |
5611 |
REGULATION VIOLATION: Title 22 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse.The facility failed to ensure Patient A's rights included being free from verbal abuse. On February 8, 2011, CNA 1 was overheard yelling at Patient A while providing care to the patient.The facility failed to implement their Abuse prevention policy and procedure by failing to immediately remove CNA 1 from caring for Patient A.On February 17, 2011, at 10:10 AM, an unannounced visit was made to the facility to investigate an entity reported incident involving an allegation of verbal abuse by CNA 1 to Patient A that occurred on February 8, 2011. On February 17, 2011 the medical record for Patient A was reviewed. Patient A was a 52 year old female admitted to the facility on November 14, 2010, with diagnoses that included muscle weakness, pressure ulcer (an area of the skin that breaks down when constant pressure is placed against the skin), pneumonia (infection of the lung), renal failure (when the kidneys stop working), hypertension (high blood pressure), CHF (congestive heart failure- a condition where the heart is unable to pump enough blood to the body), and diabetes mellitus type II (when blood sugar is too high). A review of the MDS (minimum data set - a comprehensive tool used to assess the patient), date December 1, 2010, revealed that Patient A had clear speech and was able to make herself understood and had the capacity to understand others. Patient A had adequate hearing without the use of a hearing aid. On February 24, 2011, at 10:10 AM, an interview was conducted with the facility administrator. The Administrator stated that she was informed by RN 1 on February 8, 2011 that CNA 2 heard CNA 1 yelling at Patient A, in Patient A's room. The Administrator confirmed CNA 1 was not removed from providing care to Patient A the remainder of the day, nor was she suspended during the facility's investigation of the incident. On February 18, 2011, at 10:18 AM, an interview was conducted with CNA 2. She stated on February 8, 2011, she was sitting at the nurse's station when she heard yelling from Patient A's room. She walked to her room and heard CNA 1 say, "Why did you put your call light on...why are you crying you're not a baby, only babies cry." CNA 2 stated Patient A said "I'm always in trouble, she's [CNA 1] always mean to me." CNA 2 stated she went and reported the incident to RN 1. On February 24, 2011, at 11:40 AM, an interview was conducted with the charge nurse (RN 1). RN 1 stated on the morning of February 8, 2011, CNA 2 reported that she overheard CNA 1 yelling at Patient A. RN 1 stated she entered Patient A's room and found her "upset" and "crying." RN 1 stated, "She [Patient A] was talking fast, I asked her to calm down." RN 1 asked Patient A what happened. Patient A told RN 1 that she had her call light on, CNA 1entered the room, and said "Why did you press your call light when a CNA is already in the room?" RN 1 asked Patient A if she had any problems with CNA 1 and Patient A denied a problem with CNA 1, but RN 1 stated "she [Patient A] was not in a calm state." RN 1 stated she reported the incident to the DON (Director of Nurses) and called the Administrator via telephone.RN 1 confirmed CNA 1 continued her shift providing care to Patient A on 2/8/2011 and was not immediately suspended from the facility at that time. A review of the facility's form titled, "Change In Condition Assessment" dated 2/10/11 at 9:30 AM, written by RN 1, showed the following under the section "Additional Comments." "Resident alleged that she was verbally abused by a staff member last 2/8/11." On February 8, 2011 at 10:00 AM, an interview was conducted with the facility's Recreation Director (RD 1). She stated that she interviewed Patient A after the incident on February 8, 2011. RD 1 stated, "She [Patient A] told me that she was talked to harshly by a CNA [CNA 1] and that she [Patient A] is afraid of her [CNA 1.]" A review of RD 1's document interview of Patient A, dated 2/8/11, indicated, "On 2/8/11 Patient A told RD 1 that a CNA told her "Stop crying you're too old for that and stop pushing your call light, your CNA is right here and why do you keep pushing your call light?"The facility's policy titled "Abuse Investigation", dated February 1, 2000, stipulated, "In a case where possible abuse to a resident is observed or reported, the facility provides a safe environment for resident(s), as indicated by the situation...If the suspected perpetrator is an employee, remove the employee immediately from providing care to the resident. Depending on circumstances, employee may be removed from care of other residents. The employee may be suspended during the investigation, in accordance with personnel policies."The facility failed to ensure that staff followed the abuse policy, by failing to immediately remove the CNA from providing care to the patient. In addition, the facility failed to ensure Patient A's rights included freedom from verbal abuse.The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the patient. |
| 240000841 |
Clock House |
240009284 |
B |
09-May-12 |
O5PE11 |
5323 |
REGULATION VIOLATION: California Welfare and Institutions Code Section 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. (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.Based on interview and record review the facility failed to ensure that Client A was consistently free from harm. On March 16, 2011, Client A sustained an injury and fractured toe secondary to an unsafe transfer. On March 23, 2011 at 2:20 PM, a visit was made to the facility for the purpose of investigation of a self reported incident that Client A sustained a fracture of his toe. A review of the clinical record, conducted on March 23, 2011, revealed that the client was admitted to the facility on March 31, 2009 with diagnoses that included cerebral palsy, severe mental retardation and paraplegia. An interview was conducted with the Facility Manager (FM) on March 23, 2011 at 2:25 PM. He stated that the client was being transported back from the physician's office. The facility's investigation revealed that Client A caught his foot on the lift during transport.A review of the facility's investigation revealed that the Direct Care Staff (DCS 1) wrote an explanation of the incident stating, "When arrived from Dr. appt. (appointment) @ 2:25 PM, staff took (Client A's name) to bedroom and took off braces and sock and shoes and noticed Rt (right) foot - big toes and toe next to the Lt (left) bleeding. Big toe has a medium size cut. Call FM @ 2:27 PM, RN (name) @ 2:30 PM, (name) QMRP @ 2:35 PM." Action Taken: "To ER to get checked out". A review of the FM's investigative document revealed, "On March 16th, 2011 Client was taken to ED due to bloody foot. On March 17, 2001 as daylight came I went to look at the van lift to see how this could have happened, it appeared to me that his foot was caught between the lift and the bumper... Staff will be re-oriented for using the van lift again to prevent any further accidents." A review of the ED documents dated March 16, 2011, revealed discharge information provided for a fractured toe. There was a hand written note that showed, "In ER, x-rays of right foot and ankle were performed and fracture of distal (further away) first and second digits (toes) was found cleaned wound and applied xeroform (dressing). Protective split (splint) was applied." A review was conducted of the training given to the DCS regarding driving and loading safety. The training was given by the FM and signed by DCS 1. The orientation training instructed the staff to load the client facing the street.The FM was interviewed on March 23, 2011 at 3:10 PM, regarding the loading of the client. He stated that DCS 1 loaded the client forward and that was how his foot became caught between the bumper and the lift. He stated that DCS 1 gave him no explanation for loading the client facing the van. He stated that he discovered how the client was injured and that DCS 1 did not tell him that she loaded the client in the van incorrectly. DCS 1 was interviewed on March 23, 2011 at 3:20 PM. She stated that she always loaded clients facing the street "except this one time". She confirmed that was how the client's foot was caught and she did not notice. She offered no explanation for loading the client improperly. She stated that she knew she should have loaded the client facing the street. She stated that Client A did not act any different until his socks and shoes were taken off and she noticed that his foot was bleeding. An observation was conducted on March 23, 2011 at 4:10 PM of Client A's right foot. The foot was red from the mid foot to the end of all 5 toes. The top, posterior (back) portion of the great toe and the 2nd toe had an area of black discoloration about 1/2 dime size. The two effected toes were bent forward at approximately 90 degree angle at the end joint. There was a laceration on the proximal (close to the start of the toe) portion of the great toe approximately 2 centimeters long and 1/2 centimeters wide. The foot was moderately swollen from mid foot to the end of the toes. In an interview with the Qualified Developmental Disability Professional (QMRP) on March 23, 2011 at 4:20 PM, he stated that the client would have to stay out of his day program until the open lesions on the toes have healed. The QMRP stated that this would be difficult for the client because he loved going to his day program. On April 19, 2011 at 8:30 AM, an interview was conducted with the FM. He stated that Client A had not returned to his day program. He stated that the client was scheduled to return on May 5th. The facility's failure to ensure that the client's right to be free from harm resulted in a fracture of two toes that prevented the client from attending his day program for over one month. This violation had a direct relationship to the health, safety, or security of patients. |
| 240001831 |
Cole Home |
240009286 |
B |
11-May-12 |
NZBV11 |
5477 |
REGULATION VIOLATION: Title 42 483.420 (d) Standard: Staff treatment of clients. (3) The facility must have evidence that all alleged violations are thoroughly investigated.The facility failed to provide documented evidence of an investigation into an injury of unknown source. On April 18, 2012, Client A was observed with a bruised right eye. Client A was a 45 year old female admitted to the facility on March 30, 2001. Her diagnoses included: Mild mental retardation (IQ 50-70); mild cerebral palsy (birth trauma resulting in mental or physical limitations), behavior problems (self- injurious), and recurrent lymphadenitis in axilla (lymph nodes in the armpit swell). In March 2012, bipolar disorder (a fluctuating mood disorder where the person experiences extreme highs (manic phase) followed by extreme lows (suicidal depression), was added to her list of diagnoses. Client A was documented as being alert and oriented. Client A was able to walk with a walker but refused and preferred to self-propel in her wheelchair. Client A frequently reviewed her medical record and then would get upset over what had been written. Client A was very articulate and had recall of recent and remote events. Client A had a legal guardian but no conservator.Client A had a documented history of calling 9-1-1 to take her to the hospital. She was always sent back to the home. On January 23, 2012, Client A was seen by the facility physician (MD) and he documented, "Still manipulative, faked choking episode at the day program (DP). Sent to the ER (emergency room) and released."During observation of Client A at 8:30 AM on April 23, 2012, she was noted to be well groomed, sitting up in her wheelchair with her lap belt on. An approximately 4 cm (1 inch =2.54cm), dark ecchymotic (bruise) area was noted under Client A's right eye, just above her cheek bone. Additional ecchymosis was noted at the crease of the right eyelid and a faint discoloration was observed up to the brow. During initial contact, Client A shied away from talking indicating "shhh" by putting her index finger to her mouth. When asked if she wanted to talk later at her day program she nodded, "yes". On April 23, 2012, review of the clinical record was done from 8:40 AM until approximately 10:00 AM. During a review of all nurses' notes, direct care staff (DCS), care plans and qualified mental retardation professional (QMRP) notes, there was no documentation regarding the cause of the client's bruised eye. There was no documented evidence of an investigation into the injury. During an interview with direct care staff 1 (DCS 1) at 9:45 AM, staff stated," [used Client A's name] was upset because I wouldn't change something fast enough in her log book for range of motion. She got mad and started hitting herself in the face". When asked where he had documented this incident, he was unable to show any documentation. A review of the facility policy and procedure (P&P) titled, "System to Prevent Abuse/Neglect/Mistreatment and Resolve Complaints", undated, under "Procedures #1 indicated, "Staff will complete a Change of condition/Incident report form for any physical injury, observed, mark or bruise...Both an RN(registered nurse) and the Administrator will review all Change of Condition/Incident reports and will provide and document any follow up information on the Change of Condition /Incident Report Follow Up form." During an interview with the QMRP at 11:40 AM, she said, "We didn't chart anything because she will want to see the chart and then she gets mad. The nurse didn't see any bruise when she came out on Thursday." There was no documented evaluation of Client A by the licensed nurse. During the same interview with the QMRP, when asked to see the change of condition report and facility investigative report, the QMRP was not able to provide one. The QMRP stated, "We didn't do one." A visit was made to the day program (DP) to interview Client A at 12:30 PM. During an interview with the DP Director at 12:35 PM, she stated, "[Client A] was not at the DP as scheduled due to illness." "She has not been here since last Wednesday. I thought it was odd because she never misses shopping trips on Friday." When asked, the DP Director stated she was unaware of the black eye that Client A had sustained. She confirmed the behaviors listed on Client A's most recent individual service plan (ISP) and acknowledged that they did not include making false allegations or hitting herself in the face. Client A's behaviors were as follows: a. Curses and threatens staff, yells. b. Hits others using her balled up fist. c. Hits hand on counter, walls, wheelchair, and bites herself. d. Verbally and sexually inappropriate towards males. e. Refuses to eat, or eats and then vomits. During an interview with Client A at 1:45 PM, she was asked how she got the black eye. She stated, "I hit myself because I was so angry at the staff. I put ice on it but my eye hurts." When asked if her eye had been checked by the licensed nurse or MD, Client A stated, "No." When asked why she had not gone to the day program she stated, "I'm embarrassed about my eye." The facility failed to conduct an investigation of the bruise around Client A's right eye. This had the potential for future injuries to occur and be dismissed as maladaptive behaviors. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000031 |
Creekside Care Center |
240009505 |
B |
20-Sep-12 |
SZRT11 |
6707 |
REGULATION VIOLATION: Title 22 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to protect Patient A from staff abuse by failing to ensure that the staff followed the facility's abuse policy and Patient A's plan of care. On April 16, 2011, a licensed staff witnessed CNA 1 verbally abusing and threatening Patient A.On June 28, 2011, Patient A's medical record was reviewed. Documentation showed that the patient was admitted to the facility on February 16, 2011, and discharged to another facility on April 21, 2011. Diagnoses included dementia (loss of memory, confusion, problems with speech and understanding, changes in personality and behavior and dependent on others for the activities of daily living), hypertension (high blood pressure), and depressive disorder (an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things) and anxiety (distress or uneasiness of mind caused by fear of danger or misfortune). The Minimum Data Set (MDS, a comprehensive assessment of the resident) completed on March 1, 2011, indicated that Patient A had long and short term memory loss. The patient's cognitive skills for daily decision making were moderately impaired. Patient A was independent with ambulation, transfer and activities of daily living. The facility's investigative report dated April 20, 2011, indicated that during a period of agitation, Patient A threw an accucheck device (a small hand held device used to monitor blood glucose) at CNA 1. CNA 1 was told to walk away several times from the patient but she refused. CNA 1 stated, "You're lucky I'm on the clock, you old hag, get away from me." Patient A did not recall the incident due to her dementia. On June 28, 2011, the licensed nurses' progress notes (LNPN) dated April 16, 2011 at 10:20 PM was reviewed. Documentation showed that when CNA 1 tried to redirect Patient A from the entrance/exit door of the facility, the patient became agitated (upset) and began to yell and swear at CNA 1. CNA 1 was advised by the Licensed Vocational Nurse (LVN) 1, to walk away from the patient who was becoming more agitated. CNA 1 disregarded LVN 1 advice and continued to exchange words with Patient A. This increased the patient's agitation. Patient A took the accucheck machine off the medication cart at the nursing station, and threw it at/and hit CNA 1 on the shoulder. CNA 1 became irritated at the patient. The charge nurse told CNA 1 not to say anything to Patient A and to go and wait in the dining room until the patient was redirected to her room. CNA 1 began shouting at Patient A, "Shut up old lady, you old hag. You're lucky I'm on the clock." CNA 1 would not stay away from Patient A. Patient A was later redirected to her room. CNA 1 was told to clock out and leave the facility. A review of the care plan titled, "Behavior problems," initiated on March 9, 2011, noted that Patient A had a history of verbally disrupted behavior; was verbally abusive with inappropriate behaviors at times. Intervention included to remove the patient from the stimulus setting as needed. A review of the facility policy titled, "Walk-Away Policy and Procedure," revised October 20, 2010, included the following: "It is the policy of this facility that any staff member who becomes frustrated when assisting a resident, visitor or other staff members must walk away from the situation, absent an emergency, and request assistance so as to prevent a resident from being subjected to verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion or misappropriation of a resident's money or other property." A review of CNA 1's separation notice dated April 18, 2011, indicated that she was terminated for verbal threat to Patient A. CNA 1 was a hired on March 21, 2011. On July 7, 2011 at 12:04 PM, an interview was conducted with LVN 1 who was responsible for the supervision of Patient A's care at the time of the incident on April 16, 2011. LVN 1 stated that Patient A was confused; one minute the patient was nice and the next minute the patient was awful to staff. Patient A did not like African American (AA) staff and would swear at them and curse them out. Patient A had a history of trying to leave the facility and was at the entrance door to the facility when CNA 1, an AA staff tried to redirect the patient from the door. Patient A got very upset and started to yell and swear at CNA 1. LVN 1 was asked where she was while this incident was taking place. LVN 1 stated that she was sitting behind the nursing station, charting. Patient A and CNA 1 were in front of the nursing station. LVN 1 stated that she told CNA 1 to come behind the nursing station, away from Patient A. CNA 1 refused to move away from the patient and continued to argue with the patient. This increased Patient A's anger which escalated the situation. CNA 1 was told again to come behind the nursing station. CNA 1 came behind the nursing station but continued to make comments at Patient A. Patient A walked over to the medication cart that was in the hallway, removed an accucheck machine from the cart and threw it at CNA 1. The accucheck machine struck CNA 1 on her shoulder. CNA 1 got very upset at Patient A and called the patient, "Old hag, get out of my face". LVN 1 stated at that point she got between Patient A and CNA 1 and redirected Patient A back to her room.LVN 1 stated that CNA 1 escalated the situation and was definitely verbally abusive with Patient A. LVN 1 was asked why she did not intervene earlier since she had observed the incident from the beginning. LVN 1 responded, "I was busy trying to get my charting done." LVN 1 was asked what she could have done differently. LVN 1 responded, "I should have stepped in and redirected the patient back to her room once CNA 1 did not move away from the patient when I told her to." LVN 1 failed to follow Patient A's plan of care by failing to redirect the patient away from CNA 1 before the situation escalated out of control.On August 9, 2011 at approximately 9:30 AM, an interview was conducted with the Administrator and the findings were discussed. The Administrator confirmed that CNA 1 did not follow the facility's "Walk away" policy and LVN 1 did not intervene and redirect the patient back to her room until after the situation got out of control.The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the patient. |
| 240000093 |
COMMUNITY CONVALESCENT CENTER OF SAN BERNARDINO |
240009556 |
B |
18-Oct-12 |
PKUL11 |
9014 |
REGULATION VIOLATION: Title 42 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 ensure Patient 1 received the care needed to maintain the patient's highest physical and psychosocial well-being. The facility failed to consistently provide care as written on the patient's plan of care. Patient 1 had a documented behavior of decannulizing herself (when the tracheotomy tube is disconnected from the ventilator, (a machine that gives air to a person) from the ventilator. The patient's plan of care included providing "close supervision" to avoid adverse effects from decannulation. This failure resulted in Patient 1 decannulizing herself, going into cardiac arrest and being transferred to the acute care hospital for intensive care. On December 14, 2011at 2:30 PM, an unannounced visit was made to the facility to investigate a complainant reported incident. Review of Patient 1's admission face sheet noted that the patient was a 17 month old female admitted to the facility on October 13, 2010, with diagnoses which included Tracheotomy and ventilator dependent. An interview was conducted on December 14, 2011 at 3:00 PM, with certified nurse assistant (CNA 1). CNA 1 stated that Patient 1 was very active and was always playing with her hands and hitting herself. CNA 1 stated Patient 1 liked to smile and watch television. An interview was conducted on December 14, 2011 at 2:45 PM, with the Director of Nurses (DON). The DON stated that on December 7, 2011 at approximately 9:30 PM, Licensed Vocational Nurse (LVN 1) heard the pulse oxygen alarm (a machine that alarms when the heart rate or oxygen concentration is below normal limits) going off in Patient 1's room. The DON stated that when LVN 1 heard the alarm, she went to Patient 1's room immediately. The DON stated that when LVN 1 entered Patient 1's room, Patient 1's tracheotomy cannula was observed disconnected from the ventilator and Patient 1 was non responsive. The DON stated that Patient 1 did not respond to Cardio Pulmonary Resuscitation and Emergency Medical Systems (EMS) was called. The DON stated that Patient 1 was transferred to the acute hospital at approximately 10:00 PM. Another interview was conducted on December 14, 2011 with LVN 1. LVN 1 stated that on December 7, 2011 at approximately 9:30 PM, she heard the pulse oxygen alarm going off in Patient 1's room. LVN 1 stated that she went to Patient 1's room immediately and saw that Patient 1's tracheotomy cannula was out and Patient 1 was non responsive. LVN 1 stated that she called another Registered Nurse (RN) and the RT (respiratory therapist) to Patient 1's room and both responded immediately. LVN 1 stated that the RT was able to reconnect the tracheotomy cannula. LVN 1 stated that once the tracheotomy cannula was reconnected, Patient 1 continued to be non responsive. LVN 1 stated that cardio pulmonary resuscitation (CPR) was started at approximately 9:45 PM. LVN 1 stated that EMS (emergency medical services) was called and Patient 1 was transferred to the acute care hospital at 10:00 PM. LVN 1 stated that the last time she was in Patient 1's room prior to the incident was at approximately 9:00 PM, during medication administration. LVN 1 stated that at that time, Patient 1 was laughing and alert. An interview was conducted on December 14, 2011 at 5:10 PM, with the RT assigned to Patient 1. The RT stated that on December 7, 2011 at 7:30 PM, she was in Patient 1's room giving a sprinting therapy (when the tracheotomy cannula is disconnected from the ventilator to check for patient/resident toleration). The RT stated that Patient 1 was only able to tolerate being disconnected from the ventilator for ten minutes. The RT stated that Patient 1 does not always tolerate sprinting therapy. The RT stated that the last time she was in Patient 1's room was at 7:30 PM; the RT was administering sprinting therapy and breathing treatments. The RT stated that Patient 1 had a history of decannulation. The RT stated that each time she decannulated (disconnects her tracheotomy cannula) herself, the incident was to be documented on the decannulation log. Another interview was conducted on December 14, 2011 at 4:15 PM, with the DON. The DON stated that Patient 1 had a history of decannulizing herself. The DON stated that when decannulation happened with any patient, the decannulation incident was placed on the decannulation log. A review on December 14, 2011 of the facility's "decannulation log" was conducted. The decannulation log showed that Patient 1 had decannulized herself a total of 6 times between the months of November, 2011 and December, 2011, prior to the incident of decannulizing herself on December 7, 2011. The log showed the following incidents: 1. November 7, 2011 at 6:30 PM 2. November 13, 2011 at 8:20 AM 3. November 13, 2011 at 10:40 AM 4. November 21, 2011 at 7:45 AM 5. December 2, 2011 at 12:40 PM 6. December 2, 2011 at 4:10 PM A review was conducted on December 14, 2011, of Patient 1's plan of care developed on July 7, 2011 titled "Trach Decannulation." The plan of care stipulated, [Patient 1] "Would not develop adverse effects from decannulation".The plan of care included, "[Patient 1] would be monitored closely to prevent patient from pulling out her Tracheotomy tube." However, there was no documented evidence that the facility staffs were checking on Patient 1 more frequently. There was no evidence that the plan of care was updated to reflect new interventions when Patient 1 decannulized herself on November 7, 2011. There was no evidence that the plan of care was updated to reflect new interventions when Patient 1 decannulized herself on November 13, 2011 at 8:20 AM. There was no documented evidence that the plan of care was updated to reflect new interventions when Patient 1 decannulized herself on November 13, 2011 at 10:40 AM. There was no documented evidence that the plan of care was updated to reflect new interventions on November 21, 2011, when Patient 1 decannulized herself. There was no evidence that the plan of care was updated to reflect new interventions on December 2, 2011 at 12:40 PM, when Patient 1 decannulized herself. There was no documented evidence that the plan of care was updated to reflect new interventions on December 2, 2011 at 4:10 PM, when Patient 1 decannulized herself. A review was conducted on December 14, 2011 of the "Emergency room admission smart chart" from the acute care hospital. The admission chart showed that Patient 1 arrived to the emergency room at 10:06 PM. The chart showed that upon picking up the resident from the facility, Patient 1 was being "Bagged" and was "Non-responsive." The chart showed the resident's admitting diagnosis as, "Status post cardiopulmonary arrest." The emergency room smart chart showed that Patient 1's admitting vital signs were, heart rate of 165 (normal value 60-110) a blood pressure of 87/57 (normal value 100/60) and respirations which were not accessible secondary to Patient 1 being bagged. The chart further revealed that Patient 1 was stabilized and then transported to a higher level of care. The chart showed that Patient 1 was transferred at 10:49 PM. A review was conducted on December 15, 2011 at 9:00 AM of Patient 1's admission history and physical completed December 8, 2011 at the acute care hospital. The admission history and physical included the following, "Upon arrival to the facility, [Patient 1] was not interactive and was not spontaneously opening her eyes or moving around. The estimated down time (minutes without oxygen) was 10-15 minutes." Another review was conducted on December 15, 2011 of Patient 1's Electroencephalogram (EEG) (a test that determines brain function) completed December 8, 2011. The EEG final result showed, "EEG moderately abnormal, revealing generalized slowing of the background suggestive of diffuse cerebral dysfunction or encephalopathy." Another review was conducted on December 15, 2011 of Patient 1's most recent nursing assessment notes dated December 14, 2011. The nurse's assessment noted that Patient 1 was now only active to painful stimuli and does not move or open her eyes. A review was conducted on December 15, 2011 of the acute care hospitals "Discharge Summary" for Patient 1. The discharge summary showed that Patient 1 was discharged on ventilator support and transferred to a different skilled nursing facility on December 16, 2011. The facility's failure to implement and revise the patient's plan of care pertaining to decannulation, contributed to the resident's inability to maintain her highest practicable physical and psychosocial well being. These failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000031 |
Creekside Care Center |
240012736 |
B |
9-Nov-16 |
CJ3L11 |
5579 |
REGULATION VIOLATION 72311(a)(2) Nursing Services-General (a)Nursing service shall include, but not be limited to, the following: (2)Implementing of each patient's care plan according to the methods indicated. Each patient's care should be based on this plan. FINDINGS: The facility failed to implement the care plan by not providing a two person assist for safety precautions during a toileting care for Patient 1. On December 28, 2015 Patient 1 was being transferred from the Hoyer lift e-z stand (equipment used to lift a resident to assist with transfers) to the bedside commode by Certified Nursing Assistant (CNA 1) and (CNA 2), when suddenly the CNA noticed the Hoyer lift battery needed to be replaced. CNA 1 left Patient 1 and CNA 2 to get batteries. CNA 2 continued providing care for Patient 1 by changing Patient 1's adult brief by herself, Patient 1 began to fall forward to the floor and fell on her knees. Patient 1 sustained a fracture to her left knee. Patient 1 was admitted to the facility on June 28, 2011 with diagnoses which included cerebral vascular accident (stroke-blood flow to brain blocked), hemiplegia (unable to move lower or upper part of body) and chronic back pain. A review of Patient 1's quarterly Resident Assessment Instrument (RAI, a tool used to assess a resident from head to toe) completed on December 5, 2015 indicated under transfers that Patient 1 was totally dependent on staff and required a two person assist for transfers. The plan of care for Patient 1, developed on June 9, 2014, documented that Patient 1 required a two person assist with turning and repositioning. In an interview with the Administrator (Admin), on January 5, 2016 at 9:45 AM, the Admin stated on December 28, 2015 Patient 1 was being transferred from the Hoyer lift e-z stand to the bedside commode by Certified Nursing Assistants (CNA 1) and (CNA 2). The Admin further stated that while Patient 1 was being transferred CNA 1 left to go retrieve batteries for the Hoyer lift e-z stand. The Admin stated that when CNA 1 left Patient 1's room to get batteries, CNA 2 was left with Patient 1 and during that time Patient 1 fell to the floor. In an interview with CNA 1, on January 5, 2016 at 10:30 AM, CNA 1 stated on December 28, 2015 she and CNA 2 were assisting Patient 1 to the bedside commode with the e-z stand Hoyer lift. Suddenly the Hoyer lift began to blink indicating that batteries were needed. CNA 1 stated Patient 1 was partially positioned on the bedside commode. CNA 1 stated she left the room to retrieve new batteries. CNA 1 stated when she returned she saw Patient 1 halfway on the lift with lower half of body sitting on the floor. During an interview with CNA 2 on January 5, 2016 at 10:45 AM, CNA 2 stated on December 28, 2015 at 10:00 AM, she and CNA 1 were assisting Patient 1 to the bedside commode. CNA 2 stated Patient 1 required a Hoyer lift for transfers. CNA 2 stated Patient 1 required two people to transfer. CNA 2 stated that while transferring Patient 1 to the bedside commode, the Hoyer lift started to blink indicating new batteries were needed. CNA 2 stated that Patient 1 had gotten on the bedside commode, but was not securely positioned all the way back on the commode. CNA 2 stated CNA 1 left to go retrieve batteries for the Hoyer lift. CNA 2 stated she attempted to change Patient 1's adult brief by herself; Patient 1 began to fall forward. CNA 2 stated Patient 1 fell forward to the floor and fell on her knees. CNA 2 stated that she should have waited for CNA 1 to return before she attempted to change Patient 1. CNA 2 stated Patient 1 should have been secured on the bedside commode before CNA 1 left the room to retrieve batteries to ensure a safe transfer occurred. In an interview with Licensed Vocational Nurse 1 (LVN 1), on January 5, 2016 at 11:00 AM, LVN 1 stated she assessed Patient 1 after a fall from the easy stand Hoyer lift. LVN 1 stated Patient 1 had two lacerations (cuts to skin) to the right knee. LVN 1 stated that the physician was notified and Patient 1 was assisted back to bed. LVN 1 stated that on December 31, 2015 (three days after the fall incident), Patient 1 was complaining of severe left knee pain. LVN 1 stated Patient 1 had a pain score of 8 out of 10 (pain scale 0-10, 0 is no pain, 10 is severe pain). LVN 1 stated the physician was notified and orders were received to obtain an x-ray (picture of bone) of Patient 1's left knee. Review of the x-ray report from December 31, 2015 revealed that Patient 1 had a non-displaced fracture of the left knee. During an interview with the Administrator on January 5, 2016 at 11:15 AM, the Admin stated that it was the policy of the facility that staff follows the plan of care for all patients to ensure patients safety would not be affected. The facility failed to implement the care plan by not providing a two person assist for safety precautions during a toileting care for Patient 1. On December 28, 2015 Patient 1 was being transferred from the Hoyer lift e-z stand (equipment used to lift a resident to assist with transfers) to the bedside commode by Certified Nursing Assistant 1 (CNA 1) and (CNA 2), when suddenly the CNA noticed the Hoyer lift battery needed to be replaced. CNA 1 left Patient 1 and CNA 2 to get batteries. CNA 2 continued providing care for Patient 1 by changing Patient 1's adult brief by herself, Patient 1 began to fall forward to the floor and fell on her knees. Patient 1 sustained a fracture to her left knee. These violations had a direct relationship to the health, safety or security of the patient. |
| 240000038 |
Citrus Nursing Center |
240012846 |
A |
27-Dec-16 |
MMGO11 |
6185 |
REGULATION VIOLATION Regulation: Title 22 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement their ?Accident and Incident prevention? policy. Patient 3 required a fall precaution due to cognitive impairment , orthostatic hypotension (postural hypotension - a form of low blood pressure that happens when you stand up from sitting or lying down causing dizziness), hemiplegia (weakness/ paralyzed on one side of the body), and unsteady gait. On November 27, 2015, Patient 3 was left in the bathroom unattended, sustained a fall and a left hip fracture which required a surgical intervention at the hospital. A review of Patient 3?s medical record revealed that Patient 3 was admitted to the facility on xxxxxxx with diagnoses that included hemiplegia , late effect of stroke , diabetes mellitus (high blood sugar in the blood) and anemia (blood lacks enough healthy red blood cells contributing to dizziness). A review of the Admission and Transfer Summary from the hospital, dated November 22, 2015, documented Patient 3 was at risk for falls due to impaired balance and decreased strength. Furthermore, the documentation indicated that Patient 3 had orthostatic hypotension. The History and Physical dated November 23, 2015, documented that Patient 3 needed skilled care for physical therapy. The note indicated that Patient 3 required fall precautions. A review of the physician's order dated November 23, 2015, indicated an order for physical therapy that included a gait training exercise. A review of the medical record for Patient 3 indicated that on November 27, 2015, at 9:00 PM Patient 3 required to go to the bathroom. CNA (Certified Nursing Assistant) 1 assisted Patient 3 to the bathroom. At that time, the wife of Patient 3 roommate?s asked CNA 1 to call the charge nurse for her husband. As the CNA was walking back from calling the charge nurse, she heard Patient 3 push the door and fall to the floor, without calling for assistance or activating the call light. When CNA 1 opened the bathroom door, she saw Patient 3 lying on the left side on the bathroom floor. The record also revealed that upon assessment, Patient 3 complained of pain to his left hip after the fall. A further review of nurses? notes dated November 28, 2015, at 2:50 PM, that Patient 3 continued to complain about left hip pain. The physician gave an order to transfer Patient 3 to the acute hospital for evaluation. Patient 3 was transferred to the hospital by ambulance on November 28, 2015 at 2:50 PM for evaluation. A review of the History and Physical, dated December 7, 2015, documented that Patient 3 was discharged from the hospital on December 5, 2015 for the treatment of left hip fracture ORIF (An open reduction and internal fixation (ORIF), a type of surgery used to fix broken bones), status post fall. In an interview with CNA 1 on February 3, 2016 at 3:15 PM, CNA 1 stated she knew Patient 3 from admission, and said Patient 3 could not walk by himself, he required assistance. CNA 1 stated Patient 3 was in the bathroom on November 27, at 8:30 PM, and she was waiting outside the bathroom door. CNA 1 further stated that while she was waiting, a visitor asked her to go call the charge nurse. CNA 1 stated that she left Patient 3 in the bathroom unattended. CNA 1 stated when she returned, she found Patient 3 was lying on the bathroom floor. CNA 1 stated that she should have not left Patient 3 in the bathroom unattended. A review of the care plan dated November 24, 2015 documented Patient 3 had short and long term memory impairment. A review of the care plan titled "Fall," dated November 24, 2015, documented Patient 3 required assistance with all transfers and ambulation. A review of the CNA flow sheets dated November 23, 2015 through November 27, 2015, documented Patient 3 required staff assistance with toileting and transfers. During an interview with the Registered Nurse (RN 1) on February 18, 2016 at 2:10 PM, she stated she heard about Patient 3's fall in the bathroom on November 27, 2015. RN 1 stated Patient 3 should not be left alone in the bathroom, "Even if they (the residents) are alert, and oriented for safety reasons." A review of the physical therapy notes dated November 23, 2015 through November 27, 2015, documented that Patient 3 was at fall risk, with unstable knees during transfers. During an interview with the physical therapist (PT 1) on February 18, 2016 at 2:20 PM, she stated Patient 3 was on physical therapy for gait training exercise. PT 1 stated prior to Patient 3's fall incident, Patient 3 was on ?contact guard assist.? PT 1 stated that contact guard assist required Patient 3 to have staff supervision at all times during ambulation and transfers, which included toileting. PT 1 stated, "Don't leave the resident to walk alone; don't leave the resident alone... He (Patient 3) needed to be watched when doing transfer. His balance was not good enough to be left alone." A review of the facility's policy and procedure, titled, "Accident and Incident Prevention", dated September 2007, indicated: ?It is the policy of this facility...to prevent accidents and incidents to eliminate preventable occurrences, practices...which negatively impact residents and/or resident care and environmental hazards whenever possible." The facility failed to implement their ?Accident and Incident Prevention ? policy and procedure. Patient 3 required a fall precaution due to cognitive impairment, orthostatic hypotension (postural hypotension - a form of low blood pressure that happens when you stand up from sitting or lying down causing dizziness), hemiplegia (weakness/ paralyzed on one side of the body) and unsteady gait. On November 27, 2015, Patient 3 was left in the bathroom unattended. Patient 3 sustained a fall which resulted in a left hip fracture and required a surgical intervention at the hospital. These violations 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. |
| 240000031 |
Creekside Care Center |
240013314 |
B |
26-Jun-17 |
NSB611 |
6169 |
REGULATION VIOLATION:
Title 22 72657 Mechanical Systems
Heating, air conditioning and ventilating systems shall be maintained in normal operating conditions to provide a comfortable temperature and shall meet the requirements of section T17-105, Title 24, California Administrative Code.
The facility violated the above regulation by failing to:
Ensure comfortable and safe temperatures for 13 patients who resided on the 200 hallway (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13), and nine patients (Patients 14, 15, 16, 17, 18, 19, 20, 21 and 22) who resided on the 300 hallway, when the air conditioning unit failed.
During the initial tour on May 23, 2017 between 6:00 PM and 6:14 PM, the Nurses? Station, where three patients (Patient 14, 22 and 23) were gathered, felt hot and uncomfortable. The temperature was taken with the surveyor's laser thermometer gun and was determined to be 87 degrees Fahrenheit (F) and verified with the Licensed Vocational Nurse (LVN 1 and 2).
Also during the initial tour, observation revealed no facility staff had been observed to be passing hydration to clients affected by the elevated temperatures in the building. The facility's maintenance personnel were not on site, and no work was being completed on the air conditioning unit.
During an observation while conducting the initial tour on May 23, 2017 at 6:06 PM, two patients (Patients 1 and 2) were observed in their room (Room XXXXXXX). They were visibly sweating, and complained of the excessive heat in their room. Their room temperature was 91 degrees F, using the surveyor's laser thermometer gun and verified with Patient 1 and Patient 2, who complained of the elevated temperature. The Director of Staff Development (DSD) was also present to verify the elevated temperature of 91 degrees F.
During an observation on May 23, 2017 at 6:19 PM, the hydration cart (cart with fluids available to independently serve individuals in the facility) had been observed in the dining room, unavailable to any patients who were unable to get out of bed independently, or to self-propel in their wheelchair.
During additional observations, on May 23, 2017, between 6:00 PM and 7:04 PM, the following area's temperatures were taken with the surveyor's laser thermometer gun, and verified with the DSD.
a. Nurses' Station: 87 degrees F.
During an interview with Patient 14 on May 23, 2017 at 6:20 PM, she stated, "I'm [I am] hot," indicating she had been uncomfortable in the common area located by the nurses' station. The temperature in the common area where Patient 14 was sitting was taken with the surveyor's laser thermometer gun and was 87 degrees F, verified with LVN 1 and 2.
b. Room 201: 92 degrees F.
During an interview with Patient 3, on May 23, 2017 at 6:19 PM, she stated, "I'm [I am] hot; it's [it is] always hot [in my bedroom]." The temperature in Room 201 was taken with the surveyor's laser thermometer gun and was 90 degrees F, verified with Patient 3, and the DSD. Patient 3 stated the facility had not provided any means of comfort since the air conditioning unit failed to operate.
c. Room 202: 91 degrees F.
During an interview with Patient 1 on May 23, 2017 at 6:14 PM, he stated, "It's [it is] hot, and has been since yesterday [in our room]." Patient 1 stated the air conditioning does not work and the fan is "Blowing hot air." The temperature was 91 degrees F, taken with the surveyor's laser thermometer gun, verified with Patient 1 and the DSD.
During an interview with Patient 2 on May 23, 2017 at 6:16 PM, he stated, "I'm [I am] hot [in our room], and the [facility's] air conditioning never works." Patient 2 stated, "The heat works just fine, but it is always hot [in our room]." The temperature was 91 degrees F, taken with the surveyor's laser thermometer gun, verified with Patient 2 and the DSD.
d. Room 303: 90 degrees F.
During an interview with Patient 15 on May 23, 2017 at 6:23 PM, he stated, "90 degrees [Fahrenheit] is too warm [in room XXXXXXX]." The temperature in Room 303 was 90 degrees F and was taken with the surveyor's laser thermometer gun, verified with Patient 15, and the DSD.
During an interview with the Director of Staff Development (DSD) on May 23, 2017 at 6:42 PM, she stated the air conditioning was not working and had not worked since yesterday (May 22, 2017). The DSD stated, "The air conditioner repair person will not repair the air conditioner until tomorrow (May 24, 2017)." The DSD stated, "I don't [do not] know, why the repairs are not being done." The DSD confirmed the maintenance personnel and the air conditioning unit repair person were not at the facility.
During an interview with the Director of Maintenance (DM) on May 23, 2017 at 7:22 PM, he stated the air conditioning was not working when he had left the facility today (May 23, 2017). The DM stated the air conditioner repair person was not scheduled to come back here until tomorrow (May 24, 2017). The DM confirmed that he called the air conditioning unit repair person to come to the facility, after the surveyor arrived on site.
A review of the facility's policy and procedure titled, "Policy," (undated), indicated, "It is our policy to keep the room temperatures between 72 and 81 degrees [Fahrenheit]... If the situation cannot be addressed in a timely manner, more aggressive steps must be taken..."
A review of the facility's policy and procedure titled, "Maintenance Service," (undated), indicated, "2. Functions of maintenance personnel include...d. Maintaining the heat/cooling system...f. Establishing priorities in providing repair service..."
The facility?s failure to repair the air conditioning unit had the potential to impact 13 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13) occupying five rooms in the 200 hallway, and nine patients (Patients 14, 15, 16, 17, 18, 19, 20, 21 and 22) who occupied five rooms in the 300 hallway by placing them at risk for heat related illnesses.
This violation had a direct or immediate relationship to the health, safety or security of long term healthcare facility patients or Patients. |
| 250000598 |
COVEY QUAIL HOUSE |
250009661 |
B |
12-Dec-12 |
VIR011 |
5080 |
CITATIONClass "B" Citation Welfare and Institution Code 4502 (h) The right to be free from harm The facility failed to take steps to prevent patient abuse and harm:The facility failed to ensure that Patient B was free from harm and protected from Patient A, (Patient A had a known history of being aggressive towards his peers). The facility failed to address Patient A's escalating aggressive behavior by not updating the ISP objective interventions and care plan related to Patient A's aggression.As a result Patient B sustained a head laceration that required seven staples, after being pushed by Patient A and hitting his head against the fire place.Record review was done for Patient B on July 25, 2008. Patient B was admitted to the facility on May 24, 1999, with diagnoses which included profound mental retardation, and was legally blind.The "Change of Condition Report," dated July 16, 2008, at 7:51 p.m., indicated that Patient B lost balance, fell backwards and hit his head on the edge of the fireplace, when he was pushed by Patient A. Patient B sustained an open wound two inches long and one centimeter wide.A Special Incident Report, dated July 17, 2008, at 7:51 p.m. was completed by the facility QMRP. The report indicated that the police arrived to assess the situation and remained at the facility until the paramedics arrived. The paramedics transported Patient B to the hospital, where treatment was rendered. Patient B required seven staples to the head laceration. The QMRP documented in her report that Patient B's injury was caused by Patient A's behavior.Patient A's record was reviewed on July 24, 2008. Patient A was admitted to the facility on March 26, 2007, with diagnosis which included Profound Mental Retardation. A psychological evaluation, dated March 4, 2008, identified that Patient A "was experiencing some stress and anxiety which is expressed through physical aggression directed towards others. On average he is showing aggression towards others approximately 86 times per month...Staff adjustments to the home presented changes to his immediate environment. Often times these transitions create anxiety that is difficult to handle. Creating and establishing new relationships with people in the home can be a daunting process." Patient A's annual Individual Service Plan (ISP), dated March 12, 2008, indicated that Patient A needed to decrease incidence of aggression towards others. The ID team objective/plan implementation was, "Patient A will decrease incidences of aggressive towards others to 42 times per month." Patient A had a nursing care plan for "Behavior," dated March 17, 2008. The behavior care plan did not address aggressive behaviors towards peers as a problem. The monthly Nursing Evaluation for May 2008, dated June 6, 2008, indicated that Patient A's "behaviors have been elevating on a daily basis during the end of March and first part of April." The RN further documented that Patient A was physically aggressive towards others, and continued to need a great deal of supervision. The behavior care plan was not updated with interventions to address the behavior problems addressed in the monthly nursing summaries for April and May 2008. There was no behavior care plan implemented for aggressive behaviors towards peers. The objective data collection for objective #1(Patient A will decrease incidence of aggression to 42 times per month), dated June 2008, documented the following incidents; June 1, 2008 - Hitting and kicking peers June 6, 2008 - Slapped another patient on the face 2x June 9, 2008 - Slapped another patient across the chest June 12, 2008 - Pushed another patient to the floor from the sofa June 13, 2008 - Hit another patient 2x on the head. June 29, 2008 - Hitting walls, peers...kicking, spitting, slapping, pushing June 30, 2008 - Hit client 1x The monthly Nursing Evaluation for June 2008, dated July 1, 2008, Patient A had a "potential for violence r/t mental disorder. (Patient A's name) continues to need a great deal of supervision. (Patient A's name) behavior have been elevating on a daily basis towards the end of June. He has gotten increasingly aggressive, and has hit caregivers on more than one occasion." The RN did not care plan the aggressive behaviors directed towards peers nor addressed Patient A' assaults on his peers in her monthly nursing evaluation. The facility was aware that Patient A had a history of being aggressive towards his peers, and failed to ensure that Patient B was free from harm from Patient A.The facility failed to protect Patient B from Patient A, and as a result Patient B sustained a head laceration that required seven staples, after being pushed by Patient A and hitting his head against the fire place.The facility failed to protect Patient B from Patient A's escalating aggressive behavior by failing to update the care plan and ISP objective interventions related to Patient A's aggression. The above violations, either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety, or security. |
| 250000079 |
Centinela Grand, Inc. |
250010018 |
B |
25-Jul-13 |
KQ1M11 |
2992 |
HSC 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. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On January 2, 2013, an unannounced visit and investigation was conducted at the facility for an entity reported incident. The facility failed to report the allegation of abuse of Resident 1 by Staff 1, which occurred on November 23, 2012, at 2:41 a.m., to the California Department of Public Health (CDPH) immediately, or within 24 hours. The facility initially reported the alleged incident of abuse to the CDPH office on November 29, 2012, at 3:04 p.m. (157 hours after the incident). Resident 1 was readmitted to the facility on September 5, 2012. The History and Physical, dated September 6, 2012, indicated Resident 1 "has the capacity to understand and make decisions."The Licensed Nurse Record, for the 3 p.m. to 11 p.m. shift, dated November 23, 2012, indicated Resident 1 was alert, oriented, awake and able to actively participate in decision making, and had no mood and behavior patterns. The Licensed Nurse Record documentation, for the 11 p.m. to 7 a.m. shift, dated November 23, 2012, indicated in a note written at 2:15 a.m., Resident 1 called the police. Resident 1 was "...place[d] on monitor[ing] for allegation that he was attack[ed] by staff..." The Licensed Personnel Progress Notes, dated November 23, 2012, at 2:36 a.m., indicated Resident 1 "was on the phone... [with] police officer reported that he was attacked by the charge nurse."The Licensed Personnel Progress Notes, dated November 23, 2012, at 4 a.m. and 7 a.m., indicated the incident was reported to the social services director and the administrator. On January 2, 2013, at 9:45 a.m., the Administrator was interviewed. The Administrator stated the facility had called him and told the him about the incident. The Administrator stated, "The incident was he [Resident 1] was out of control with the LVN (licensed vocational nurse), not that he [Resident 1] felt threatened by the nurse. The Administrator stated he talked with Resident 1 the next day. The Administrator stated Resident 1 reported "he felt threatened" by LVN 1 on Monday (November 26, 2012).The facility failed to report the allegation of abuse, which occurred on November 23, 2012, at 2:41 a.m., to the California Department of Public Health (CDPH) immediately, or with 24 hours. The facility initially reported the alleged incident of abuse to the CDPH Office on November 29, 2012, at 3:04 p.m. (157 hours after the incident). Therefore, the facility failed to report the allegation of abuse of Resident 1 by staff to the Department within 24 hours. These failures placed all residents at the facility in potential danger due to the risk for abuse.These violations had a direct relationship to the health, safety, or security of the residents. |
| 250000033 |
CALIFORNIA NURSING & REHABILITATION CENTER |
250010518 |
B |
06-Mar-14 |
PTL811 |
3672 |
F224 483.13 (c)(1)(i) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to protect the rights of Resident A from the misappropriation of the resident's property by CNA 1 (Certified Nursing Assistant) when money was deliberately used without the resident's consent. On July 19, 2013, the facility reported that CNA 1 had been accused of stealing money from Resident A. CNA 1 was arrested by the [name of city] Police Department (PD) on July 19, 2013. On August 6, 2013, an unannounced visit was made to the facility to investigate the entity-reported event regarding the alleged misappropriation of Resident A's funds by CNA 1. Administrator 1 was interviewed at 10:55 a.m., and indicated a call was received on July 18, 2013, from an officer of the PD. It was reported that the PD was investigating the financial abuse of Resident A by CNA 1. The PD officer scheduled an interview with the resident for July 19, 2013, at 7:30 a.m. An investigation of the incident was then initiated by the facility. On July 24, 2013, the police report regarding the above allegation was faxed to the Department. The following was documented under Summary: "Suspect [CNA 1]...used [Resident A's] ATM debit card and wrote out several checks without [Resident A's] permission. All the transactions totaled $14,919.58." The Narrative Report indicated CNA 1 had written nine checks to himself, made four electronic debits and one pre-authorized debit. The report further indicated that Resident A's friend, who had Power-of-Attorney over the resident's finances, had gone to the bank and was told "the account had been frozen" due to "suspected possible fraud". Discrepancies were noticed within the account statements from April 26, 2012, to July 12, 2013 - "ATM transactions and several checks written out for large amounts". This was then reported to the police department on July 15, 2013. The report further indicated the PD officer interviewed Resident 1's roommate, Resident B who provided a witness statement. Resident B reported that he had never seen Resident A write a check to CNA 1 and that Resident A had a bad habit of leaving his checkbook on top of his nightstand. The PD officer then waited in the facility's parking lot for the arrival of CNA 1. Upon arrival, CNA 1 was approached and asked whether Resident A had given him money or checks. Per the report, CNA 1 stated,...he had been "suffering from financial hardship... [Resident A] had offered to help him and gave him the checks...all the checks and had signed them all on the same day." The report indicated CNA 1 was then arrested for fiduciary elder abuse and forgery. The record for Resident A was reviewed on August 6, 2013. Resident A, age 83, was admitted to the facility on November 14, 2012. Diagnoses included dementia. The attending physician documented, July 12, 2013, that the resident was incompetent in making personal and financial decisions. The facility failed to protect Resident A from the misappropriation of the resident's funds by CNA 1 when money, totaling $14, 919.58, was deliberately used without the resident's consent. This failed practice placed Resident A and other residents at risk for abuse by CNA 1. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, and/or other emotional trauma to Resident A with the potential to affect the safety of other residents. |
| 250001435 |
CHAPALA HOUSE |
250010607 |
AA |
11-Apr-14 |
J7GB11 |
10937 |
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.(c) Class "AA" violations are violations that meet the criteria for a class "A" violation and that the state department determines to have been a direct proximate cause of death of a patient or resident of a long-term health care facility. Except as provided in Section 1424.5, a class "AA" citation is subject to a civil penalty in the amount of not less than five thousand dollars ($5,000) and not exceeding twenty-five thousand dollars ($25,000) for each citation. In any action to enforce a citation issued under this subdivision, the state department shall prove all of the following:(1) The violation was a direct proximate cause of death of a patient or resident.(2) The death resulted from an occurrence of a nature that the regulation was designed to prevent.(3) The patient or resident suffering the death was among the class of persons for whose protection the regulation was adopted.If the state department meets this burden of proof, 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.Except as provided in Section 1424.5, for each class "AA" citation within a 12-month period that has become final, the state department shall consider the suspension or revocation of the facility's license in accordance with Section 1294. For a third or subsequent class "AA" citation in a facility within that 12-month period that has been sustained, the state department shall commence action to suspend or revoke the facility's license in accordance with Section 1294.4502. 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). The right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. California Code of Regulations T-22. Social Security Act Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies 76918. Client?s Rights. (a) Each client shall have these rights as specified in Section 4502 through 4505 of the Welfare and Institutions Code Sections 50500 through 50550 of Title 17 of the California Code of regulations. 76875. Health Support Services-Nursing Services (a) Facilities shall provide registered nursing services in accordance with the needs of the clients for the purpose of: (2) Development and implementation of a written plan for each client to provide for nursing services as a part of the individual service plan, consistent with diagnostic, therapeutic, and medication regimens. The facility failed to ensure Client A was free from neglect and protected from self-injurious behavior, that led to Client A?s suicidal death on November 24, 2012. The facility failed to ensure the nursing care plan entitled, ?Alteration of harmful words to others and self during behaviors?, was implemented. Staff left Client A alone in his room during a behavioral outburst of repeated verbalizations that he wanted to die. Client A intentionally stuffed a wash cloth, left within reach by staff, down his throat in an effort to choke himself. When staff discovered Client A, he was cyanotic (skin blue in color due to lack of oxygen), unresponsive and had a wash cloth stuffed in his mouth. Cardio-pulmonary resuscitation (CPR) was unsuccessful. On November 26, 2012, the facility reported the death of Client A that occurred on November 24, 2012. Client A was lying on a mat after self-induced vomiting. Staff cleaned the client and left the area. A wash cloth was left within reach of the client. After eight to ten minutes, staff returned and noticed the wash cloth in Client A?s mouth. Client A was cyanotic. CPR was initiated and 911 was called. Client A was taken to an acute hospital where he died. On November 29, 2012, at 11:55 a.m., an unannounced visit was made to the facility to investigate the entity-reported event regarding the death of Client A. The Qualified Intellectual Disabilities Professional (QIDP 1) was interviewed and stated, ?Client put washcloth, left in room, down his throat.? Client A?s record was reviewed. Client A, 25 years of age, was admitted to the facility on January 13, 2009. Diagnoses included traumatic brain injury related to a bicycle/motor vehicle accident in 1991, severe intellectual disability, cerebral palsy (physical/motor impairment due to an abnormality of the brain), spastic quadriplegia and bipolar disorder (a mental disorder causing extreme depressive and manic episodes). Client A had a history of self-injurious behavior and attempts to injure others. The nursing care plan entitled, ?Alteration of harmful words to others and self during behaviors?, dated October 29, 2010 and updated through September 6, 2012, included the following: ?Plans of Care:?Staff will report to RN (Registered Nurse) and QMRP (Qualified Mental Retardation Professional) as well as documenting behavior type with comments of harm. Call RN & QMRP ASAP (As Soon as Possible). Staff will remove all objects around resident when he has a behavior to avoid harm to self and others. Staff will sit resident up right or by him to his side to prevent any form of aspiration (the introduction of foods or fluids into the lungs) or choking during any form of inducing of vomiting during his behavior?? Further review of Client A?s record revealed RN Notes, dated November 24, 2012, indicating the following: ?Notified by the QMRP that [Client A] was at the [acute hospital] due to [choking] from a behavior and was not able to survive after resuscitation. The facility was called immediately and information from [facility] staff stated that [Client A] had a behavior and was helped to lay down on his mat on the floor, [Client A] did not tell staff the reason for his behavior after being asked a couple of times. Staff stated she had wiped him clean after an episode of vomiting?At about 3:45 p.m., staff observed [Client A] [cyanotic] and non-responsive?The para-medics were notified immediately and CPR was commenced. Para-medics arrived at about [3:50 p.m.] and took over the resuscitation and [Client A] was sent to the [acute hospital]?Follow up call made to the hospital after informed that [Client A] had passed, stated that [Client A] was in full arrest?until he passed?? A Special Incident Report was faxed to the Department on November 26, 2012. A review of the ?Special Incident Report? under ?Description of Incident?, indicated the following notations in the record: ?On the 24th of November, 2012 at approximately 3:30 p.m., [Client A] was observed with behavior of self-induced vomiting twice while lying on his exercise mat in his room. In the process of cleaning him, the staff inadvertently dropped one of the wash cloth[s] within reach. At approximately 3:40 p.m., while passing by [Client A?s] room, facility staff observed [Client A] faced (sic) up with a wash cloth in his mouth which she immediately removed and began CPR; 911 was immediately notified. [Client A] was transported to the Emergency Room at the [acute hospital] via the Paramedics?It was reported by hospital personnel that [Client A]?could not be resuscitated at approximately 4:40 pm same day on arrival at the hospital.? Further review of the RN Notes in Client A?s record (documented by the facility?s assigned RN) and dated October 22, 2012, indicated the following notations: ?Notified by the RN on call that [Client A] had a [behavior] trying to [gouge] his eye and re-open an old?scar.? Client A?s psychiatrist documented the following notation in Client A?s record on October 22, 2012: ?He pokes at his eye but doesn?t damage.? Additional notations by the psychiatrist, dated September, 26, 2012, indicated the following: "(Client A) attempted to choke himself with his hand ? tantrums and is very impatient.? Review of documentation by the Deputy Coroner in the ?Coroner Investigation? report, dated December 20, 2012, set forth under, ?Cause of Death? the following: ?suicide, asphyxia with towel ? intentially stuffed towel in throat.? The ?Coroner Investigation? report, dated December 20, 2012, included the following notations regarding the Deputy Coroner?s review of Client A?s record: ?[Client A had] several prior incidents of attempted suicide and self- injury. The last episode of self-injury was two days ago.? The Deputy Coroner also documented under the section entitled, ?Supplementary Information?, [Name of a caretaker] employed [name of Client A?s facility/home], ?stated [Client A] had been consistently acting out for the past two days?demonstrated by his poking at his eyes and also poking at his old [Gastric Tube] site.? (A site where a tube leading to the stomach had been surgically placed for feedings.) ?He was easily agitated and not easily calmed.? Therefore the facility failed to ensure the following: that staff reported to the RN and QMRP/QIDP, ASAP, Client A?s ongoing behavior of self-induced vomiting and stating that he wanted to die on November 24, 2012; that staff removed all objects around resident when he had the repeated behavior of self-induced vomiting and stating he wanted to die on November 24, 2012; that staff sat resident upright or by him to his side during the episode of repeated self-induced vomiting behavior on November 24, 2012. Therefore, the facility failed to ensure Client A was free from neglect and protected from the self-injurious behavior that led to Client A?s suicidal death on November 24, 2012; when Client A stuffed a wash cloth in his throat. Facility staff left Client A alone in his room during a behavioral outburst of repeated verbalizations that he wanted to die. Subsequently Client A intentionally stuffed a wash cloth, left within reach by staff, down his throat in an effort to choke himself. When staff discovered Client A, he was cyanotic, unresponsive and had a wash cloth stuffed in his mouth. Cardio-pulmonary resuscitation (CPR) was unsuccessful. This act of neglect led to the suicide death of Client A. This failed practice presented an imminent danger to Client A and was a direct proximate cause of death of the client. |
| 250000033 |
CALIFORNIA NURSING & REHABILITATION CENTER |
250010858 |
B |
10-Jul-14 |
P8E211 |
2653 |
B CITATION 483.13 (c)(1)(i) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure Resident A was protected from the misappropriation of the resident's property when checks were deliberately taken from Resident A's purse and cashed without Resident A's consent by CNA 1 (Certified Nursing Assistant). On July 24, 2013, the facility reported that CNA 1 had been accused of stealing and cashing three checks taken from Resident A's purse. Copies of the checks were provided to Administrator 1 by Resident A on July 22, 2013. A follow-up telephone interview with Administrator 1 on July 24, 2013, indicated the checks totaled $1300.00. Check #505 for $500.00 and dated July 11, 2013, check #506 for $400.00 and dated July 15, 2013 and check #507 for $400.00 and dated July 18, 2013. The checks were written out to CNA 1's mother. The resident was provided with the Potential Identity Theft Notification Letter. The [name of city] Police Department (PD) was notified. On August 6, 2013, an unannounced visit was made to the facility to investigate the entity-reported event regarding the alleged misappropriation of Resident A's funds by CNA 1. Administrator 1 was interviewed at 10:55 a.m., and indicated a call was received on July 18, 2013, from an officer of the PD. It was reported that the PD was investigating the financial abuse of another resident by CNA 1. An investigation of the incident was then initiated by the facility and it was discovered that three other residents (including Resident A) had reported thefts. CNA 1 had been arrested by the PD on July 19, 2013, for fiduciary elder abuse and forgery against another resident. The record for Resident A was reviewed on August 6, 2013. Resident A, age 65, was admitted to the facility on November 29, 2012. Resident A was discharged from the facility on July 30, 2013. Therefore, the facility failed to ensure Resident A was protected from the misappropriation of the resident's funds by CNA 1 when checks, totaling $1300.00, were deliberately taken from Resident A's purse and cashed without Resident A's consent. This failed practice placed Resident A and other residents at risk for abuse by CNA 1. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, and/or other emotional trauma to Resident A with the potential to affect the safety of other residents. |
| 250000553 |
CONNER RESIDENCE |
250010882 |
B |
30-Jul-14 |
GPU711 |
3261 |
W&I 15610.30. (a) (1) "Financial abuse" of an elder or dependent adult occurs when a person or entity does any of the following: (1) Takes, secretes, appropriates, or retains real or personal property of an elder or dependent adult to a wrongful use or with intent to defraud, or both. The facility failed to ensure Personal and Incidental (P&I) funds were protected from misappropriation.The facility failed to ensure eleven clients P&I funds were not misappropriated on/by February 22, 2012. On March 16, 2012 at 9:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged financial abuse. The clients at the facility were admitted with developmental and mental disabilities.On March 16, 2012, at 9:30 a.m., an interview was conducted with Qualified Mental Retardation Professional (QMRP)/Qualified Intellectual Disability Professional (QIDP). The QMRP/QIDP stated on February 22, 2012, she asked to see the ledger documenting the clients' Personal and Incidental (P&I) funds. The Facility Manager (FM) told her that the ledger was locked in a drawer with the funds and only one Direct Training Staff (DTS) had the key. The QMRP/QIDP thought the FM had the key and was helping the DTS with the ledger.The QMRP/QIDP further explained that the clients kept from twenty to thirty dollars in their pouch. She indicated that for the clients who bought their lunch the ledger was balanced each time. For the clients who did not buy lunch there was no checking of the ledger.The QMRP/QIDP then had the lock cut off the drawer containing the clients' P&I funds. She stated when she looked at the pouches she noticed only coins, no bills. The QMRP/QIDP along with other administrative staff, counted the monies. The QMRP/QIDP stated she found a total of $189.58 missing from eleven clients. The QMRP/QIDP stated there was no policy regarding who should have the key to the drawer containing the clients' P&I funds at the time of this incident. The Special Incident Report, dated February 24, 2012, indicated eleven clients were missing varying amounts of money from their P&I funds. The missing amounts ranged from $4.49 to $27.84 on February 22, 2012. The employee file for the DTS indicated she had not received the Department of Justice training (training that includes financial abuse) within the last year. The DTS had been due for the training since September 2011. The facility policy, "Policy on Client's Personal & Incidental Funds," updated January 12, 2012 indicated, "...3. The FM will maintain an Individual Petty Cash form for each individual, and balance it on daily basis."There was no policy regarding which staff members should have access to the key to the drawer containing the clients' P&I funds.The facility failed to ensure clients' trust funds were protected from misappropriation when: 1. Eleven clients lost a total of $189.58. 2. The facility failed to implement their policy and procedure concerning daily reconciliation of the clients' petty cash funds. 3. The facility did not have a policy regarding the designated staff who kept the key to the drawer containing the clients' P&I monies.These violations had a direct relationship to the health, safety, or security of the clients. |
| 250000045 |
Corona Health Care Center |
250011934 |
B |
07-Jan-16 |
Q8M811 |
3256 |
72529 Safeguards for patients? Monies and Valuables (a) Each facility to whom a patients? monies or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients? monies or valuables with that of the licensee or the facility. Patients? monies and valuables shall be maintained separate, intact, and free from any liability that the licensee incurs in the use of the licensee?s or the facility?s funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of the patients? monies or valuables as theft, as defined by Section 484 of the Penal code. The facility failed to ensure patients? monies were not co-mingled with facility funds. On March 25, 2015 at 2 p.m., an unannounced monitoring visit was made to the facility as part of the ongoing investigation regarding an allegation of bankruptcy of the facility.On March 25, 2015 at 3 p.m., an interview was conducted with the Business Office Manager (BOM 1), who stated all money from the patients' trust would go into one trust account. BOM 1 stated the facility ledger would reflect separate accounting records for each patient. The bank statement for the dates of January 31, 2015 through February 27, 2015, provided by BOM 1, was reviewed on March 25, 2015. The bank statement indicated a balance of $24,871.90 in the Patient Trust Account. The ledger maintained by the business office and dated February 28, 2015, was reviewed and indicated the balance of the Patient Trust Account was $72,300.78. BOM 1 was unable to explain the different balances between the bank statement and facility ledger. On March 31, 2015, the California Department of Health Care Services, Audits and Investigations Unit, Financial Audits Branch, conducted an audit of the Patient Trust Account for the period of January 1, 2014 through March 31, 2015. On August 4, 2015, the auditors' report from that investigation was reviewed. The auditors found the facility maintained a separate patient trust account. However, the licensee co-mingled the patients' monies with that of the facility. In May 2014, the licensee transferred $50,000 from the patient trust account to the facility corporate account. In addition, $35,000 of patient funds were transferred to the facility corporate account during the months of September and October 2014.On August 4, 2015 at 11:47 a.m., an interview was conducted with the facility Administrator (ADM). When asked if he knew about the co-mingling of the patient trust accounts, the ADM stated the previous owners insisted on having the patient trust funds handled the way there were handled. He stated BOM 1 was not able to do anything to change the facility practice. On August 4, 2015 at 11:55 a.m., an interview was conducted with the current Business Office Manager (BOM 2), who stated she knew nothing about any previous handling of the patient trust funds. The facility failed to ensure that, between May 2014 and October 2014, a total of $85,000 from the patient trust accounts were not co-mingled with the facility corporate account. The above violations jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of patients. |
| 250000045 |
Corona Health Care Center |
250011940 |
B |
07-Jan-16 |
Q8M811 |
2418 |
72529 Safeguards for Patients? Monies and Valuables (a) Each facility to whom patients' monies or valuables have been entrusted shall comply with the following: (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. The facility failed to ensure that an accurate record of patients' monies and a detailed inventory was maintained. On March 25, 2015 at 2 p.m., an unannounced monitoring visit was made to the facility as part of the ongoing investigation regarding an allegation of bankruptcy of the facility.On March 25, 2015 at 3 p.m., an interview was conducted with the Business Office Manager (BOM 1), who stated all money from the patients? trust would go into one trust account. BOM 1 stated the facility ledger would reflect separate accounting records for each patient. On March 31, 2015, an audit of the Patient Trust Account for the period of January 1, 2014, through March 31, 2015, was conducted by the California Department of Health Care Services, Audits and Investigations Unit, Financial Audits Branch. On August 4, 2015, the auditors? report from the investigation was reviewed. The auditors found the licensee did not submit the deposit receipt for two patients' pension checks (Patient 28 and Patient 66) totaling $914.00 for April 2014. In addition, the auditors found the licensee did not submit patients' detailed inventory for Patient 28 and Patient 66.On August 4, 2015 at 11:47 a.m., an interview was conducted with the Administrator(ADM). When asked what he knew about the handling of patient funds, ADM stated the previous owners insisted on having the patient funds handled a certain way. He stated BOM 1 was not able to do anything to change the facility practice. On August 4, 2015, at 11:55 a.m., an interview was conducted with the current Business Office Manager (BOM 2), who stated she knew nothing about any previous handling of the patient trust funds. The facility failed to safeguard the patient trust funds; two deposits for two patients (Patient 28 and Patient 66), totaling $914.00, were not deposited. The above violations either jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of patients. |
| 250000045 |
Corona Health Care Center |
250011941 |
B |
07-Jan-16 |
Q8M811 |
2923 |
72529 Safeguards for Patients? Monies and Valuables (a) Each facility to whom patients' monies or valuables have been entrusted shall comply with the following: (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance. All of these records shall be maintained at the facility for a minimum of three years from the date of transaction. At no time may the balance in a patient's drawing account be less than zero. The facility failed to maintain accurate records of patients' monies including maintaining supporting receipts for withdrawals. On March 25, 2015 at 2 p.m., an unannounced monitoring visit was made to the facility as part of the ongoing investigation regarding an allegation of bankruptcy of the facility.On March 25, 2015 at 3 p.m., an interview was conducted with the Business Office Manager (BOM 1), who stated all money from the patients' trust would go into one trust account. BOM 1 stated the facility ledger would reflect separate accounting records for each patient. On March 31, 2015, an audit of the Patient Trust Accounts for the period of January 1, 2014 through March 31, 2015, was conducted by the California Department of Health Care Services, Audits and Investigations Unit, Financial Audits Branch. On August 4, 2015, the auditors? report was reviewed. The auditors found the licensee withdrew $16,636 in March 2015 from the patients' trust account. The auditors found no receipt to support the reason for this withdrawal. On August 4, 2015 at 11:47 a.m., an interview was conducted with the Administrator (ADM). When asked what he knew about the handling of patient funds, ADM stated the previous owners insisted on having the patient funds handled a certain way. He stated BOM 1 was not able to do anything to change the facility practice. On August 4, 2015 at 11:55 a.m., an interview was conducted with the current Business Office Manager (BOM 2), who stated she knew nothing about any previous handling of the patient trust funds. The facility failed to maintain accurate records for patient trust funds and failed to maintain receipts to support a withdrawal from the patients' trust fund, totaling $16,636. The above violations either jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of patients. |
| 250000045 |
Corona Health Care Center |
250011942 |
B |
07-Jan-16 |
Q8M811 |
3297 |
72529 Safeguards for Patients? Monies and Valuables (a) Each facility to whom patients' monies or valuables have been entrusted shall comply with the following: (3) Patients' monies not kept in the facility shall be deposited in a demand trust account in a local bank authorized it do business in California, the deposits of which are insured by the federal deposit Insurance Corporation, or in a federally insured bank or savings and loan association under a plan approved by the department. If a facility is operated by a county, such funds may be deposited with the county treasurer, if a facility is operated by the State, such funds may be deposited with the State treasurer. All banking records related to these funds, including but not limited to deposit slips, checks, cancelled checks, statements and check registers, shall be maintained in the facility for minimum of two years from the date of transaction. Identification as patient trust fund account shall be clearly printed on each patient's trust account checks and bank statements. The facility failed to clearly identify all banking records including deposits for patient trust fund accounts, resulting in an inability to locate $47,992. On March 25, 2015 at 2 p.m., an unannounced monitoring visit was made to the facility as part of the ongoing investigation regarding an allegation of bankruptcy of the facility. On March 25, 2015 at 3 p.m., an interview was conducted with the Business Office Manager (BOM 1), who stated all money from the patients? trust would go into one trust account. BOM 1 stated the facility ledger would reflect separate accounting records for each patient. On March 31, 2015, an audit of the Patient Trust Account for the period of January 1, 2014 through March 31, 2015, was conducted by the California Department of Health Care Services, Audits and Investigations Unit, Financial Audits Branch. On August 4, 2015, the auditors? report was reviewed. The auditors found the licensee's patient trust fund account was identified as ?Debtor in Possession?, however, the checks for that account were identified as a patient trust account. In addition, the auditors were unable to determine where the licensee deposited $47,992 in patient trust funds that were not deposited in the Patient Trust Account. On August 4, 2015 at 11:47 a.m., an interview was conducted with the Administrator (ADM). When asked what he knew about the handling of patient funds, the ADM stated the previous owners insisted on having the patient funds handled a certain way. He stated BOM 1 was not able to do anything to change the facility practice. On August 4, 2015 at 11:55 a.m., an interview was conducted with the current Business Office Manager (BOM 2), who stated she knew nothing about any previous handling of the patient trust funds. The facility failed to safeguard the patient trust funds in separate accounts, which caused a total of $47,992 of patient funds to not be deposited into the patient trust account. The facility failed to clearly identify all banking records for patient trust funds, including where a patient trust deposit for $47,992 was placed. The above violations either jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of patients. |
| 250000045 |
Corona Health Care Center |
250011943 |
B |
07-Jan-16 |
Q8M811 |
2791 |
72529 Safeguards for Patients? Monies and Valuables (a) Each facility to whom patients' monies or valuables have been entrusted shall comply with the following: (8) Upon discharge of a patient, all money and valuables of that patient which have been entrusted to the licensee and kept within the facility shall be surrendered to the patient or authorized representative in exchange for a signed receipt. Monies in a demand trust account or with the county treasurer shall be made available within three normal banking days. Upon discharge, the patient or authorized representative shall be given a detailed list of personal property and a current copy of the debits and credits of the patient's monies. The facility failed to promptly return patient funds after discharge for five patients (Patients 1, 20, 25, 26, and 39), and failed to return any funds after discharge for seven patients (Patients 12, 27, 42, 46, 54, 60, and 68). On March 25, 2015 at 2 p.m., an unannounced monitoring visit was made to the facility as part of the ongoing investigation regarding an allegation of bankruptcy of the facility. On March 25, 2015 at 3 p.m., an interview was conducted with the Business Office Manager (BOM 1), who stated all money from the patients' trust would go into one trust account. BOM 1 stated the facility ledger would reflect separate accounting records for each patient. On March 31, 2015, an audit of the Patient Trust Account for the period of January 1, 2014 through March 31, 2015, was conducted by the California Department of Health Care Services, Audits and Investigations Unit, Financial Audits Branch. The auditors found the facility refunded funds to five discharged patients (Patients 1, 20, 25, 26, 39), from 70-376 days after their discharge date. There were 7 patients (Patients 12,27,42,46,54,60,68) who were discharged and no refunds were issued for a total of $5,990. In addition, the licensee applied $4,725 of patient funds in the facility's Accounts Receivables instead of refunding the amount to the patients who had rights to those monies.On August 4, 2015 at 11:47 a.m., an interview was conducted with the Administrator(ADM). When asked what he knew about the handling of patient funds, ADM stated the previous owners insisted on having the patient funds handled a certain way. He stated BOM 1 was not able to do anything to change the facility practice. On August 4, 2015 at 11:55 a.m., an interview was conducted with the current Business Office Manager (BOM 2), who stated she knew nothing about any previous handling of the patient trust funds. The facility failed to ensure patient funds were returned within three banking days after discharge for five patients, and failed to ensure seven patients received any refunds after discharge totaling $5,990. |
| 250000043 |
COMMUNITY CARE AND REHABILITATION CENTER |
250012229 |
B |
09-May-16 |
KB3B11 |
6815 |
482.13 (c) (2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including the State survey and certification agency). 482.13 (c) (3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. During a complaint investigation, initiated on June 23, 2015, it was determined that the facility failed to ensure that an allegation of suspected sexual abuse was thoroughly investigated by the facility and that the facility reported the allegation of sexual abuse to the Department of Public Health (CDPH) Licensing and Certification, within 24 hours. This failed practice placed a universe of 136 residents at risk for lack of a thorough investigation by the facility staff for alleged abuse. On June 23, 2015, an unannounced visit was made to the facility for the investigation of one complaint of alleged suspected sexual abuse towards Resident 1. On June 23, 2015, at 8:45 a.m., the Facility Administrator (FA) was interviewed. The FA stated a detective had recently visited the facility and spoke with some night shift employees regarding a resident (Resident 1), that had been transferred to a local emergency room with diagnoses that included altered level of consciousness. Resident 1 had been a long term care resident of the facility with frequent hospitalizations. The FA stated, "The detective advised me that he (the detective) would contact him if there was cause for concern." The FA stated that he had also spoken with the acute care hospital Social Worker regarding the allegation of sexual abuse and was advised that she (the Social Worker) would be filling out an SOC 341 (form for reporting suspected Dependent Adult/Elder Abuse). The FA stated, "I did not report the allegation to the CDPH or investigate the allegation because it was being handled by the police department and they have a higher authority. The PD (police department) supersedes me." The FA stated he did not document his phone calls with the detective or the hospital Social Worker. The FA stated no internal investigation was done by the facility staff because the resident was no longer at the facility, and a police investigation was conducted. On June 23, 2015, at 1:15 p.m., the facility Social Worker (SW) was interviewed. The SW stated she was contacted by telephone by the hospital's Social Worker who informed her of the emergency room findings of a vaginal tear indicative of sexual assault to Resident 1. The SW stated, "Within minutes I reported the information to the Administrator who is also the Abuse Coordinator." The SW did not have any notes documenting her phone call with the hospital social worker, or her conversation with the Administrator.The clinical record for Resident 1 was reviewed. Resident 1 was a long term care resident of the facility with diagnoses that included level of consciousness changes necessitating frequent hospitalization (most recent 6/3/15 - 6/8/15) and resolving pneumonia. Resident 1 required moderate to maximum assist with all areas of activities of daily living and was nonverbal. Resident 1 did not have the capacity to understand and make own decisions. On the evening of June 10, 2015, Resident 1 was transferred to the local emergency room with altered level of consciousness. The document titled, "Emergency Patient Record," dated June 10, 2015, at 8:25 p.m., indicated, "Upon insertion of Foley (catheter inserted into the bladder to drain urine), noted blood and skin tears on interior vaginal wall. At 8:33 p.m., "Charge nurse made aware of possible sexual assault." On June 11, 2015, at 5:33 a.m., "Called Riverside PD... stated they will send an officer to file a report." At 6:15 a.m., "PD arrived. Report of incident given. PD taken to the patient. Suspicious incident report in chart." The hospital document titled, "History and Physical," dated June 11, 2015, indicated, "In the ER, the patient is not able to urinate, so a Foley catheter was placed. When the nurse tried to put in the Foley catheter, the nurse found some vaginal bleeding and showed bruising in her vaginal area. Sexual abuse was suspected. The patient was seen by Riverside Police Department, but they cannot investigate because the patient is not able to give any reliable history..." The hospital document titled, "OB-Gyn (Obstetrics and Gynecology) Consult Note - Brief," dated June 11, 2015, at 7:12 p.m., indicated, "Severe atrophic (wasting) vulvovaginitis (inflammation of the vagina and vulva). Unable to fully assess vaginal canal due to poor patient tolerance..." The hospital document titled, "Case Management Report," dated June 11, 2015, at 3:16 p.m., indicated the hospital SW phoned the FA. The FA stated he had no knowledge of sexual assault/trauma and did not know why Riverside PD was at the skilled nursing facility that morning investigating. The facility policy and procedure titled, "Reporting Allegations of Abuse," revised March 2013, was reviewed. The document indicated "Policy Statement - It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc. to promptly report any incident or allegation of resident neglect or abuse, including injuries of unknown origin, and theft or misappropriation of resident property to the facility management... 6. The Administrator or designee will notify Law Enforcement, LTC (Long Term Care) Ombudsman, and the CDPH (California Department of Public Health) Licensing and Certification by telephone immediately or as soon as practicable and in writing (SOC 341) within twenty-four (24) hours of alleged physical abuse which does not result in serious bodily injury). Physical abuse includes: assault, battery, sexual assault, unreasonable physical constraint, improper use of a physical or chemical restraint or psychotropic drug)." The facility policy and procedure titled, "Abuse Investigations," revised March 2013, was reviewed. The document indicated, "Policy Statement - All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management...1. Should an incident or allegation of resident abuse, mistreatment, neglect or injury of unknown origin be reported, the Administrator, or his/her designee, will initiate an investigation immediately."The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1, and placed all residents within the facility at risk for abuse. |
| 250000043 |
COMMUNITY CARE AND REHABILITATION CENTER |
250012716 |
B |
10-Nov-16 |
4ECX11 |
6870 |
Code of Federal Regulations 483.25 (h) (2) Accidents The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents. During a complaint investigation initiated on July 19, 2016, it was determined that the facility failed to ensure Resident A received adequate supervision to prevent accidents. As a result, Resident A had a fall, suffered hip and ankle pain which required transfer to an acute hospital for further evaluation and treatment. Resident A?s treatment required surgical treatment to stabilize the left hip fracture. Resident A?s record was reviewed. Resident A, a 78 year old female, was admitted to the facility on May 14, 2016, with diagnoses which included fracture of right upper end of the arm. Resident A?s history and physical dated May 16, 2016, indicated Resident A, on admission, had the capacity to understand and make decisions. Resident A?s physician indicated fall precautions for one of the plans of care. The document titled, ?Fall Risk Assessment,? dated May 14, 2016, indicated Resident A had a score of 10. The document indicated a score of 10 or greater was considered a high risk for potential fall. Resident A?s care plan related to risk for falls/injury, dated May 14, 2016, indicated, ?Goals: Will have no Falls or injuries x (times) 90 days?Interventions?Assist with mobility and transfer?Keep call light within Reach and answer promptly?Observe frequently for safety?? The document titled, ?OT (occupational therapy) Initial Evaluation,? dated May 16, 2016, was reviewed. The document indicated Resident A?s cognition (process of understanding) was mildly impaired in safety awareness (being aware of safety issues) and judgement (person?s problem- solving ability). Resident A?s occupational notes, dated May 19, 2016, indicated Resident A needed moderate assistance in toileting (how resident uses toilet room, transfers, and on and off toilet). A review of Resident A?s, ?Nurses? Notes,? indicated the following: a. On May 22, 2016, at 8 a.m., Resident A was noted to have increased confusion stating she was seeing people in her room trying to take her pictures down. Resident A did not even want to stay in her room and had agreed on moving to another room; b. On May 22, 2016, at 8:30 a.m., Resident A was moved from Room 312 to Room 309 (room was farther from the nursing station); and c. On May 22, 2016, at 3:15 p.m., Resident A was found on the bathroom floor, lying on her back, beside the toilet and partially underneath the bathroom sink counter. On May 22, 2016, at 3:30 p.m., Resident A was transferred to the acute hospital after the physician was notified of the condition of the left lower extremity which was outwardly rotated and leg crossing midline of the body. During an interview on July 19, 2016, Licensed Vocational Nurse (LVN) 1 stated staff was expected to stay inside the room if a resident had been assisted to the bathroom to ensure the resident?s needs for help would be heard immediately by the staff. During an interview on July 19, 2016, the Director of Nursing (DON) stated any resident who needed assistance going to the bathroom should not be left unsupervised. The DON stated the staff should be close by to ensure help would be provided as soon as possible for the resident inside the bathroom. During an interview on July 19, 2016, LVN 2 stated Resident A was confused and should not be left unsupervised while at the bathroom because of safety issues. During an interview on July 19, 2016, a Certified Nursing Assistant (CNA) 1 stated she was told Resident A was alert on May 22, 2016. She stated she assisted Resident A to the bathroom and left her with a call light to use. CNA 1 stated she left the room to get a disposable diaper for Resident A. She stated she was an estimated 20 steps way from the entrance to the resident?s room. CNA 1 stated when she came back the call light was already on, and she found Resident A on the bathroom floor. She stated Resident A said she saw plastic coming out of the toilet so she got up and fell. During an interview on July 19, 2016, CNA 2 stated she had taken care of Resident A prior to acute care transfer. She stated Resident A had confusion and required help in transfer and ambulation. CNA 2 stated Resident A should not be left unsupervised while in the bathroom or else she would get up on her own. During an interview on August 17, 2016, an Occupational Therapy Assistant (OTA) stated a resident who needed moderate assistance (50 %-percent performance of the resident and 50 % physical assistance) in toileting should not be left unsupervised while in the bathroom. Resident A?s history and physical dated May 23, 2016, at the acute hospital, indicated, ??The patient presents following fall?Family reports pt. (patient) has hallucinations while on Dilaudid (pain medication) and was scared by hallucinations and proceeded to fall?Physical examination?LLE (left lower extremity) is shortened and externally rotated with tenderness at hip?? Resident A?s radiological (X-ray) report of the hip on May 22, 2016, at the acute hospital indicated an impression of acute intertrochanteric (between the upper end and the shaft of the femur) fracture of left proximal femur (left hip fracture). The hospital document titled, ?Consult Orthopedic Surgery,? dated May 24, 2016, indicated, ??Assessment/Plan?She (Resident A) has an unstable left femur intertrochanteric fracture?recommend surgical treatment with a intramedullary rod (device used to treat broken bones of the long bones) to stabilize the fracture? would recommend holding off on right shoulder surgery? believed this would be too much surgery for her (Resident A) in one setting and there will be an increased risks of postoperative complications for the right shoulder with rehabilitation from her left femur intertrochanteric fracture?? The above hospital document indicated Resident A had one additional surgery which was for the fractured left hip instead of the previously scheduled right shoulder surgery. Resident A?s hospital discharge summary dated May 27, 2016, indicated Resident A had undergone ORIF (open reduction internal fixation- surgical procedure to fix a severe bone fracture, or break) of the left hip. Therefore, the facility failed to ensure adequate supervision was provided to prevent an accident and injury for Resident A. As a result, Resident A fell and suffered hip and ankle pain that required transfer to an acute care hospital where it was determined Resident A had sustained a broken (fractured) left hip. The fracture required surgery to repair the left hip fracture and delayed the resident previously scheduled surgical procedure to repair the fractured right upper arm bone. The violation of this regulation has a direct relationship to the health, safety, or security of the resident. |
| 250000019 |
COMMUNITY CARE ON PALM |
250012847 |
B |
5-Jan-17 |
F6MZ11 |
13344 |
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, in accordance with the comprehensive assessment and plan of care. On December 31, 2014, at 11:25 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Patient A sustaining a fall on December 26, 2014, which resulted in the patient suffering a left hip fracture, a left wrist fracture, and a laceration to her left eyebrow requiring sutures. It was determined that the facility failed to ensure Patient A was provided with necessary care and services to maintain her highest physical well-being by failing to evaluate the patient's increased weakness and decline in physical mobility; failing to identify specific interventions and implement fall prevention interventions after multiple falls occurred; failed to provide frequent monitoring of the patient due to high risk for falls; and failed to update/revise care plan to provide adequate safety measures resulting in Patient A attempting to ambulate to the bathroom without staff assistance and was found on the floor with injuries. A review of the facility's investigation report dated December 26, 2014, indicated Patient A was found on the floor on December 26, 2014, at approximately 5:10 a.m. Patient A was lying next to her bed. She was bleeding from a laceration to her left eyebrow, and complained of pain to her left arm and left leg. Patient A stated she had gotten up from bed to go to the bathroom and fell. Patient A was then transferred to the hospital where X-rays later confirmed a left hip fracture, and left wrist fracture, and laceration to the left eyebrow requiring sutures. Upon further review, the facility's investigation report indicated Patient A was last checked by a Certified Nursing Assistant (CNA 4) at 2 a.m. (3 hours and 10 minutes prior to being found on the floor). The record for Patient A was reviewed on December 31, 2014. She was admitted to the facility on XXXXXXX, with diagnoses including senile dementia (loss of intellectual abilities involving impairment of memory, judgment, and thinking), paranoid schizophrenia, (chronic mental illness in which a person loses touch with reality), and osteoporosis (reduction in bone mass). A review of the most recent Minimum Data Set (MDS, a comprehensive assessment tool of the resident), dated December 10, 2014, indicated Patient A had cognitive and memory impairments with disorganized thinking process. Patient A required extensive assistance of one staff for bed mobility, transferring, walking, and hygiene. Patient A was also continent (having voluntary control) of bowel and bladder, and needed extensive assistance of one staff for toileting. A review of the acute hospital form titled, "History of Present Illness," dated December 26, 2014, indicated Patient A had advanced dementia, confusion, and did not have the capacity to make decisions. A review of the facility form titled, "Progress Notes" indicated the following documentation made by the licensed nurses showing a decline in the patient's health and cognitive status: a. On December 8, 2014, at 11:01 p.m., the patient was alert and confused, had unsteady gait, required assistance of one staff for ambulation, and was weak. b. On December 9, 2014, at 6:32 a.m., the patient was alert with confusion. "General decline in condition noted. General weakness noted." c. On December 10, 2014, at 12:32 a.m., the patient was being monitored for general weakness. "Resident (Patient A) noted weak and increased confusion unsteady gait during ambulation increased assistance required..." d. On December 11, 2014, at 4:38 a.m., the patient had "General decline in condition noted. Resident (Patient A) requires increased assist with ADL's (activities of daily living)." e. On December 12, 2014, at 3:35 a.m., the patient was "Assisted to BR (bathroom) by 1 CNA (Certified Nursing Assistant). Generalized COC (change of condition), weakness." f. On December 14, 2014, at 2:06 p.m., the patient was continuing to be monitored for generalized weakness and required maximum assistance with all ADLs. g. On December 26, 2014, at 6:21 a.m., the nurse was notified by Patient A's roommate that Patient A was on the floor. Patient A was assessed by the nurse and noted to be bleeding from a left eyebrow skin laceration, and complaining of pain to her left shoulder, left wrist, and left hip. Patient A was immediately transferred to the hospital. There was no documented evidence that facility staff attempted to determine the cause of Patient A's decline in health and cognitive status, or that the physician was made aware. Further review of the nursing progress notes indicated Patient A was readmitted back to the facility on XXXXXXX at 8:33 p.m. Patient A sustained a left hip fracture, left radius (wrist) fracture, her left lower forehead had five stitches, and her left upper arm had bruises as a result of the fall. No surgical interventions were done to repair the bone fractures. Review of the hospital records indicated Patient A had an orthopedic consult on December 26, 2014. The consult indicated Patient A was high risk for intraoperative complications due to her diagnosis of osteoporosis, and Patient A's family elected for no surgery to be performed. Review of Patient A's care plan titled, "Fall/Injury Risk," initiated December 20, 2013 (one year prior to most recent fall and fractures), indicated the resident was at increased risk for falls related to wandering, psychoactive medications, vision deficit, osteoporosis, and dementia. The care plan was last updated on June 22, 2014, with ongoing interventions to check Patient A's safety periodically due to wandering behavior, handle patient gently, prevent falls, and modify risk factors. There were no interventions listed as to how staff were supposed to "Prevent falls" specific to Patient A. There was no indication that the staff identified and updated the patient's care plan for fall risk around December 8, 2014, when Patient A starting displaying increased confusion, increased weakness, unsteady gait, and general decline. A short-term care plan titled, "Fall," dated October 7, 2014, was reviewed. The care plan interventions were for staff to monitor Patient A for adverse side effects from the fall, monitor for pain, and notify the physician of any change in condition. There were no fall prevention interventions initiated specific to Patient A's condition to ensure her safety and prevent further falls. The facility's form titled, "Post Fall Assessment," dated December 26, 2014, indicated the patient did not have any "Tab Alarm" (a device that alarms to alert the staff when a patient is getting up unassisted). The patient's bed was in a low position, her bed rails were down, and she had no restraint devices. There were no staff witnesses to the fall. Documentation on the form also indicated Patient A was alert with confusion, complaining of pain to her left shoulder, pain to her left hip, and a laceration to her left eyebrow area. The form did not list any new interventions or recommendations made by the Interdisciplinary Team (IDT) in attempt to prevent further falls from occurring. Review of the Post Fall Assessment dated June 2, 2014, indicated, "Pt (Patient A) was walking and tripped on her other foot. Pt fell and hit her left side of her face...Abrasion noted on left face. Mild pain noted on right knee..." The form did not list any new interventions or recommendations made by the IDT in an attempt to prevent further falls from occurring. Review of the fall/injury risk care plan dated December 20, 2013, and updated every three months after by the IDT, did not list any new fall prevention interventions. Review of the Post Fall Assessment dated August 20, 2014, indicated, "Resident (Patient A) slip while trying to leave dining room. Resident stand up by herself and before staff got to her, stated she was going to restroom...ST (skin tear) to right elbow (measuring) six centimeters (cm) by three cm. Patient A also fell on October 7, 2014, with no injuries. The form did not list any new interventions or recommendations made by the IDT in an attempt to prevent further falls from occurring. Review of the fall/injury risk care plan dated December 20, 2013, and updated every three months after by the IDT, did not list any new fall prevention interventions. During observation and interview with Patient A on December 31, 2014, at 12:28 p.m., she was lying in bed with a healing laceration to her left eyebrow. She could not recall the events of her fall on December 26, 2014, due to her confusion. When Patient A was asked if she was in pain, she stated she had bruises on her shoulder and placed her right hand on her left shoulder. Patient A stated she hurt when she moved around. In an interview with the Director of Nurses (DON) on December 31, 2014, at 12:45 p.m., she stated the CNA (CNA 4) who was assigned to care for Patient A at the time of the fall on December 26, 2014, had last checked on the resident at 2 a.m. The DON stated, "The CNA should be doing rounds (checking residents) every two hours." In an interview with Licensed Nurse (LN 4) on December 31, 2014, at 12:47 p.m., he stated the patient's roommate alerted CNA 4 that Patient A had fallen around 5 or 5:10 a.m. the morning of December 26, 2014. LN 4 stated he went to assess the patient and the patient was found lying on the floor between her bed and the door. LN 4 stated the patient was attempting to go to the bathroom. LN 4 stated Patient A was very quiet and the roommate would let staff know if Patient A needed help. LN 4 further stated Patient A did not have any device such as an alarm to alert staff when she was getting out of bed unassisted. A second visit was made to the facility on January 8, 2015, at 10:15 a.m. In an interview with LN 1 on January 8, 2015, at 10:55 a.m., she stated Patient A's health was declining prior to the fall with injuries, had poor gait, poor balance, and required staff assistance due to history of falls. In an interview with LN 2 on January 8, 2015, at 11 a.m., she stated Patient A needed assistance for ambulation (walking), her balance was impaired, and the patient had a general decline in health. LN 2 stated, "We (licensed nurses) made sure there's someone to assist her (Patient A) to the dining room, for toileting, and all other ADLs (activities of daily living)." In an interview with CNA 1 on January 8, 2015, at 11:25 a.m., she stated, "...(Patient A) became weak. When she walk she was unstable...The CNA take her to the bathroom. She cannot go to the bathroom by herself." In an interview with Restorative Nurses Aide (RNA 1) on January 8, 2015, at 11:33 a.m., he stated, "She's been declining...she required assistance for ambulation...she needed assistance to go to the bathroom...CNAs check patients every 2 hours." In an interview with CNA 3 on January 8, 2015, at 11:50 a.m., she stated, "... We preferred to help her since she was declining. We assist her. She was unsteady. Her feet was like shuffling. She would trip..." In a second interview with the DON on January 26, 2015, at 11:15 a.m., she stated "...(CNA) did not go in every 2 hours (to check Patient A). We expect them (CNAs) to make every 2 hour check..." The facility's policy titled, "Falls and Fall Risk, Managing," dated August 10, 2009, was reviewed. The policy indicated: "Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's (patient's) specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls...6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling... Components of Fall Prevention Program ...6. Employees are constantly making safety rounds to ensure patients (residents) are safely positioned or that the environment remains free of hazards...8. Re-assessment of patients who are showing functional declines is performed..." The facility policy titled, "Care Plans," dated March 29, 2011, was reviewed. The policy indicated, " ...Policy Interpretation and Implementation...6. Each resident's comprehensive care plan has been designed to: a) Incorporate identified problem areas;...d) Reflect treatment goals and objectives in measurable outcomes; e) Identify the professional services that are responsible for each element of care; f) Aid in preventing or reducing declines in the resident's functional status and/or functional levels..." Therefore, the facility's failed practice placed Patient A at continued high risk for falls, injuries, and pain. The violations of the above regulation presented either imminent danger or serious harm would result or a substantial probability that death or serious harm would result. |
| 250000619 |
CHERRY VALLEY HEALTHCARE |
250012954 |
B |
1-Mar-17 |
P4RB11 |
10806 |
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.
An unannounced visit was made to the facility on December 22, 2015, at 9:15 a.m., to investigate Patient 1's fall with head injuries.
It was determined that the facility failed to ensure one patient (Patient 1) was free from falls and injuries when the facility did not implement care plan interventions of a perimeter mat (safety cushion device made of soft padding that absorbs and decrease the force of impact during a fall) on the floor beside the bed, and did not ensure a working bed alarm (a warning device that produces a high pitch sound to alert staff when a resident moves around or gets out of bed). The facility also failed to assess and investigate Patient 1's fall for possible causes.
These failures resulted in Patient 1 falling from her bed to the floor and sustaining a laceration to her left eyebrow with bleeding and swelling. Patient 1 also had a significant change in her mental cognition with decreased level of awareness, and required hospitalization for a subdural hematoma (bleeding and increased pressure on the brain).
A review of Patient 1's record indicated she was admitted to the facility on XXXXXXX 2015, with diagnoses that included diabetes mellitus (high blood sugar), physical debility (weakness), and syncope (passing out/fainting).
A review of Patient 1's incident report summary dated November 28, 2015, indicated Patient 1 was found on the floor next to her bed on November 28, 2015, at 12:15 a.m. Patient 1 sustained head injury which was characterized as "small skin tear and bump to her left eyebrow, and with minimal bleeding." The incident report indicated Patient 1 stated she was lying in bed, tried to roll and reposition to her right side, and accidentally rolled off the bed and fell to the floor. The resident had no complaints of pain, remained alert and oriented, and was able to move all extremities without limitations until 7 a.m. At 7 a.m., Patient 1 was noted having a "mental status change" and "unable to follow commands completely." Patient 1 was transferred to the acute hospital and was found to have a "large subdural hematoma. Patient 1 was intubated (insertion of a tube into the windpipe to open the airway and facilitate breathing), and was not responding."
On December 22, 2015, at 9:18 a.m., the Director of Nursing (DON) was interviewed. The DON stated Patient 1 was transferred to the acute hospital via an ambulance on November 28, 2015, when the patient showed significant changes in her level of awareness. The DON stated later in the afternoon of November 28, 2015, the facility received information from the hospital that Patient 1 had a large subdural hematoma, she was verbally non-responsive, and had to be intubated. The DON stated Patient 1?s family took the patient home on hospice.
The DON was asked how Patient 1 fell and what fall precautions and interventions were in place to prevent falls and injuries. The DON stated Patient 1 had a "Tab" alarm (an electronic device that connects to a resident and alarms when the resident gets up unassisted) while in bed but the alarm did not sound when the patient rolled off the bed. When the DON was asked if a perimeter cushion pad was in place on the floor during the fall, the DON stated, "No, because sometimes the resident (patient) would not like the mat because it's harder for them to walk to the bathroom." The DON further stated Patient 1 had not been assessed for the use of perimeter mat.
Patient 1's comprehensive admission Minimum Data Set (MDS- an assessment tool) dated November 23, 2015, indicated Patient 1's cognitive (memory/judgement) daily decision making was independent. The MDS also indicated Patient 1 required extensive assistance of one person for bed mobility, transfers, ambulation (walking), and toileting.
A review of Patient 1's nursing notes dated November 23 to 28, 2015, indicated the following documentation:
a. On November 23, 2015, at 10:52 a.m., during transfer from wheelchair to bed while working with a Physical Therapist, Patient 1 became unconscious, unresponsive, and slumped forward onto the bed. Patient 1 was sent to the hospital for further evaluation and treatment. The patient returned to the facility on XXXXXXX 2015, with diagnoses of syncope and collapse.
b. On November 28, 2015, at 12:15 a.m., Patient 1 was found by Certified Nursing Assistant 1 (CNA 1) to be "lying prone (face down) position on the floor on the right side of the bed." When Patient 1 was asked what happened, Patient 1 verbalized she fell out of her bed when she was turning on her right side. Patient 1 was assessed and noted skin tear with a bump on her left eyebrow with minimal bleeding. Patient 1 remained alert, oriented, and able to verbalize her needs and follow commands. The physician was notified of the fall and ordered neurological checks, and treatment to the laceration on the forehead.
c. On November 28, 2015, at 7 a.m., Patient 1 was unable to follow command completely, had swelling on the left eyebrow, purplish discoloration and greenish/yellow discoloration on the left knee, and body weakness.
d. On November 28, 2015, at 7:35 a.m., the on-call physician (alternate for the attending physician) for Patient 1 was "made aware of overall status of the patient and suggest to send to ER (Emergency Room) for further evaluation..." The nurse's documentation indicated the physician was notified 35 minutes after Patient 1 was noted having a significant change in her level of awareness including the patient's inability to follow commands completely.
e. On November 28, 2015, at 7:40 a.m., "AMR (American Medical Response- an emergency transport ambulance) was called for transport." Patient 1 remained awake with oxygen at 3 liters per minute continuously.
f XXXXX 2015, at 7:50 a.m., Patient 1 was transported to the hospital.
A review of the AMR personnel report indicated Patient 1 was transported to the ER at 8:08 a.m. with primary and secondary impression of, "Trauma- Head injury; Neurological- Altered mentation."
A review of Patient 1's ER initial assessment and progress notes dated November 28, 2015, at 9:15 a.m., indicated Patient 1 had a swelling and hematoma on the left eye area, had decreased level of consciousness, confused, disoriented to place and time, was not following commands, and her eye pupils were unequal. Patient 1 was intubated due to changed mental awareness. At 11 p.m., Patient 1 was transferred to another acute hospital due to needing a higher level of care. Review of Patient 1's Computed Tomography (CT scan/x-ray) of the head indicated Patient 1 had a "Large left subdural hematoma."
On December 23, 2015, at 10:45 a.m., CNA 1 was interviewed by telephone. CNA 1 stated she was assigned to care for Patient 1 on November 27, 2015, from 10:30 p.m., until November 28, 2015, at 6:30 a.m. CNA 1 was asked to describe how Patient 1 fell. CNA 1 stated she was walking on the hallway at approximately 12 a.m. when she heard a faint voice calling for help repeatedly. CNA 1 found Patient 1 lying on the floor on the left side of the bed by the window. CNA 1 stated Patient 1 was bleeding from her forehead. CNA 1 stated the nurse applied a bandage to Patient 1's forehead to stop the bleeding. CNA 1 stated Patient 1 complained of a headache after the fall but was not sure what time that was.
When CNA 1 was asked about fall preventive measures or devices that were in place for Patient 1, CNA 1 stated Patient 1 had a bed alarm but the alarm did not sound after Patient 1 rolled off the bed. CNA 1 further stated Patient 1's bed was at a low position, and there was no perimeter mat or cushion on the floor.
Registered Nurse 2 (RN 2) who was on duty at the time Patient 1 fell was not able to be interviewed.
A review of Patient 1's care plan to prevent falls and injuries initiated November 19, 2015, included the use of low bed for safety; bed alarm for safety; and a perimeter mat on the floor for safety.
Further review of Patient 1's record did not indicate documentation of a fall risk assessment and post-fall assessment to determine and analyze the cause of the fall. There was no interdisciplinary team (IDT) assessment or investigation why the bed alarm did not sound when Patient 1 rolled off the bed, and why a perimeter floor mat was not in place as listed on the care plan.
In an interview with the DON and the Quality Assurance Registered Nurse (QA-RN) on April 5, 2016, at 3:45 p.m., they were asked if there was an IDT assessment or investigation to analyze and determine the cause of Patient 1's fall. The DON stated no investigation was done to determine the cause of the fall. The DON confirmed there was no perimeter mat on the floor, and could not explain why the bed alarm did not sound at the time of the fall.
In a telephone interview with RN 1 on July 26, 2016, at 4:45 p.m., RN 1 stated he worked on November 28, 2015, from 6:30 a.m. to 2:30 p.m. RN 1 was asked about Patient 1's condition after the fall. RN 1 stated Patient 1 was not stable, was slow to respond, and complained of pain to her head at a five over 10 pain level (5/10 = moderate pain according to the facility pain scale). RN 1 stated he could not remember the exact time Patient 1 complained of pain to her head.
RN 1 was further asked about the time lapse of 35 minutes between RN 1's assessment of Patient 1 at 7 a.m., and when RN 1 notified the physician at 7:35 a.m. regarding Patient 1's changed mental status. RN 1 stated he was gathering information and could not call the physician until he had all the information from the previous shift nurse.
The facility's policy and procedure titled, "Fall Prevention Program," dated November 15, 2015, indicated, "POLICY: Each resident (patient) shall be assessed for propensity for falls, and each resident shall be with adequate supervision and assistance devices to prevent accidents. PROCEDURES: ...11.) Residents assessed to be high risk for fall and appropriate for the use of wheelchair alarms, bed alarms, (a) perimeter mat will be ordered.
The facility's policy titled, "FALLS RESIDENTS," undated, was reviewed and indicated, "...PROCEDURES:...08. Proper actions following a fall include:..Determining what may have caused or contributed to the fall; Addressing the factors for the fall; and Revising the resident's plan of care and or facility practices, as needed, to reduce the likelihood of another fall."
The violation of this regulation had a direct relationship to the health, safety, or security of Patient 1. |
| 250000045 |
Corona Health Care Center |
250012976 |
B |
10-Mar-17 |
92QW11 |
4375 |
California Code of Regulations (CCR), Title 22, Division 5, 72541
Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health office of the Department may require.
On March 5, 2016, at 5:28 p.m., Resident 1 was diagnosed with a legionella infection (LD, according to the Centers for Disease Control, LD is a potentially serious lung disease caused by the bacteria Legionella that lives in water systems and is spread by breathing in contaminated water droplets). Resident 1 was admitted to a general acute care hospital (GACH) where this diagnosis was confirmed. Resident 1 expired on XXXXXXX 2016, while admitted to the GACH.
The GACH notified the facility on March 7, 2016, at 2 p.m., about Resident 1?s diagnosis of legionella infection.
The facility failed to notify the California Department of Public Health (CDPH) until March 28, 2016, 21 days after the facility was notified that the resident was initially diagnosed with a legionella infection. This facility failure increased the potential for ineffective monitoring for other residents to be exposed to Legionella and possible further spread of the Legionnaire?s Disease.
On March 29, 2016, at 8:29 a.m., the Director of Staff Development (DSD), who was also the facility infection control designee, was interviewed. The DSD provided written documentation from the Administrator (ADM) to the Riverside County Public Health, dated March 8, 2016, which stated, ?The Director of Staff Development received a phone call on Monday, March 7, 2016, at about 2 p.m. from (name of Registered Nurse 1 (RN 1)), at (name of GACH). She is the Director of Infection Control. It was reported that our Resident 1 tested positive for legionella disease.?
On March 29, 2016, at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident that the facility had a case with legionella infection, and a possibility of an outbreak at the facility.
On March 29, 2016, a record review was conducted for Resident 1. The resident was admitted to the facility on XXXXXXX 2014, with diagnoses which included ?encounter for attention to gastrostomy (a tube inserted in the stomach wall to administer liquid food, fluids, and medications), and dementia (memory loss).? Resident 1 was admitted to the GACH on XXXXXXX 2016, with complaints of respiratory failure (difficulty breathing).
On March 29, 2016, at 11:15 a.m., an interview was conducted with the ADM, who stated she contacted RN 2 at the Riverside County Public Health on March 8, 2016, at 3:10 p.m., to notify RN 2 that Resident 1 had tested positive for legionella. The ADM further stated she was not instructed by RN 2 to notify CDPH of the diagnosis until after she received a fax from the Riverside County Public Health on March 24, 2016.
On March 29, 2016, at 11:45 a.m., a telephone interview was conducted with RN 2 at Riverside County Public Health, who stated she faxed a ?Surveillance Plan,? to the facility on March 24, 2016, which indicated, ??It is recommended that the facility notify Licensing and Certification (L&C) of the above mentioned legionella case??
During an interview conducted with RN 3, Supervisor at Riverside County Public Health, on March 29, 2016, at 12:58 p.m., she stated the facility had the ultimate responsibility to report even one case of legionella to CDPH as one case is considered an outbreak.
The facility policy and procedure titled, ?Unusual Occurrence Reporting,? revised December 2007, was reviewed. The policy indicated, ??.Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations??
The violation of the regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 250000057 |
CYPRESS GARDENS CARE CENTER |
250013292 |
B |
19-Jun-17 |
UL1311 |
6448 |
HSC 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.
HSC 1418.91 (b) A failure to comply with the requirements of this section shall be a class ?B? violation.
On March 14, 2017, at 11:45 a.m., an unannounced visit to the facility was conducted to investigate a complaint.
Based on interview and record review, it was determined the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an incident of a suspected abuse for one patient (Patient 1). Failure to notify CDPH had the potential to place all the patients in the facility at risk for harm from physical abuse.
Patient 1 was admitted to the facility on XXXXXXX 2015, with diagnoses which included dementia (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), and periprosthetic fracture (broken bone that occurs around the components of implants).
Patient 1's SBAR (situation, background, appearance and request- communication of nursing to physician related to change of condition) dated February 28, 2017, indicated right tibia and fibula (shin/leg bone) fracture. The document indicated Patient 1's right leg was swollen and had purple discoloration. The document indicated Patient 1 was transferred to the acute hospital due to fracture.
On March 14, 2017, at 3:30 p.m., Patient 1 was interviewed. Patient 1 had a cast on her right leg. Patient 1 stated she broke her leg. She stated she felt somebody hit her leg when asked how she broke it. Patient 1 was unable to provide other information on what caused the fracture.
On March 14, 2017, at 5:20 p.m., Licensed Vocational Nurse (LVN) 1 stated Patient 1 was not able to state what happened to her right leg.
On March 16, 2017, at 3:35 p.m., the RN (Registered Nurse) Supervisor stated she did not know what caused the swelling and bump on Patient 1?s right leg. The RN Supervisor stated Patient 1 was unable to provide pertinent information of what caused the swelling. She stated Patient 1's x-ray result indicated a fracture, and Patient A was transferred out to the hospital after obtaining the result.
On March 21, 2017, at 8:45 p.m., Patient 1's family member stated Patient 1 did not have any complaint on February 27, 2017. She stated she did not know of any incident which could have caused the fracture.
The above interviews indicated none of the staff and family member involved with Patient A knew of how and when Patient 1's fracture occurred.
Patient 1's Emergency notes at the acute hospital dated February 28, 2017, indicated,"...Medics state that patient (Patient 1) woke up this morning complaining of right leg pain. Per medics, staff states at this point they noted a deformity to right leg, as well as bruising..."
Patient 1's ED (emergency department) notes at the acute hospital dated February 28, 2017, indicated the following:
a. At 3:15 p.m., "...Daughter reports pt (patient/Patient 1) was seen here yesterday and she took her back to the facility and the patient had no complaints and was acting like normal self...";
b. At 5:25 p.m., the daughter told the RN and stated, "My mom just told me that this am when the nurses came into my room to change me they were rough and pulled on my leg and I felt a pop and I screamed" ;
c. At 5:30 p.m., the case manager at bedside to evaluate and listen to patient?s statement. The patient (Patient 1) stated "this am in my room where I live they came in the room and while changing me and getting up they were rough and I asked them not to be so rough. They squeezed and pulled on my leg and I felt a pop and I screamed".
Patient 1's orthopedic consult at the acute hospital dated February 28, 2017, indicated Patient 1 was assessed with a displaced spiral fracture of the right distal tibia and fibula.
According to the American Academy of Orthopedic Surgeons, the tibia or shin bone is the most common fractured long bone in your body. It takes a major force to break a long bone, and other injuries often occur with these types of fractures. Spiral fracture is a type of fracture caused by a twisting force.
On April 5, 2017, at 2 p.m., the Administrator was interviewed. He stated Patient 1's case was not reported because it did not meet the criteria for an injury of unknown source since it was located in an area vulnerable to trauma which was the shin area.
A review of the facility?s policy and procedure titled, ?Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigation of Injuries of Unknown Origin,? revised November 2016, indicated, ??The Administrator in coordination with Compliance Officer will either verify or report all allegations of abuse or neglect in accordance with state and federal regulations including but not limited to the Elder Justice Act??
According to Code of Federal Regulations 483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
According to Code of Federal Regulations 483.12, Injuries of unknown source was defined as an injury which met the following criteria: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time.
Therefore, it was determined the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an incident of injury of unknown source for one patient (Patient 1).
The failure of the facility to report a suspected abuse related to an injury of unknown source placed all patient?s health, safety, and security in potential danger. |
| 910000065 |
Century Villa, Inc. |
910007645 |
B |
16-May-12 |
JNM011 |
10412 |
483.25(e)(2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. On June 22 to June 28, 2010, an annual standard health survey was conducted to determine if the facility was in compliance with federal participation requirements for nursing homes. Based on observations, interviews, and record reviews, the facility failed to provide restorative nursing treatments to maintain current function and prevent decrease in range of motion (ROM, the distance and direction a joint can move to its full potential) by failing to: 1. Ensure Residents 1 and 2 received ROM exercises and the positioning devices were applied as ordered by the physician.These failures resulted in Residents 1 and 2 having diminished shoulder joint ROM.a. A review of Resident 2's Admission Record indicated the resident was an 82 year old female, admitted to the facility on June 15, 2009, with diagnoses that included muscle weakness, history of cerebrovascular accident (CVA/stroke), dementia (a mental dysfunction), and arthritis (painful, stiff joints). The Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated May 20, 2010, indicated Resident 2 had short and long term memory problems and was moderately impaired in cognitive skills for daily decision-making. The resident required extensive assistance (resident involved in activity, staff provided weight bearing support) in bed mobility, transfer, eating, and was totally dependent on staff in dressing, toilet use, hygiene, and bathing. Resident 2 had functional limitation in ROM to one hand (including right wrist and/or fingers).A review of Resident 2?s physician's orders, dated September 26, 2009, indicated for restorative nursing assistant (RNA) to provide active range of motion (AROM, the resident does the exercise without assistance)) and passive range of motion (PROM, the RNA does the exercise for the resident) exercises to the resident?s upper and lower extremities every day.Another physician's order, dated June 1, 2010, indicated for the RNA to provide active assisted range of motion (AAROM, the resident exerts a small amount of effort) exercise to the resident?s upper extremities, to provide PROM exercise to the right hand as tolerated and to apply a right rolled hand splint every day up to six hours as tolerated, five times a week.A review of the resident?s care plan, dated October 11, 2009, indicated Resident 2 has decreased ROM due to a diagnosis of CVA and arthritis. The goal for the resident was to maintain the current level of ROM and to prevent further contractures to the right hand and left knee. The staff?s approaches included to provide AAROM exercises to both upper extremities, to provide PROM exercises to the resident?s right hand as tolerated, to apply a right rolled hand splint every day up to six hours as tolerated, five times a week, and to provide AROM exercises to lower extremities five days a week. On June 23, 2010, intermittent observations of Resident 2 were conducted. At 8:47 a.m., 9:11 a.m., 9:20 a.m., 9:30 a.m., 10:05 a.m., 10:20 a.m., 10:35 a.m., 10:45 a.m., 11 a.m., 11:07 a.m., 11:15 a.m., 11:38 a.m., 11:58 a.m., 12:08 p.m., 12:30 p.m., 2:10 p.m., 3:30 p.m., 4 p.m., 4:55 p.m., 5:30 p.m., and 5:55 p.m., Resident 2 was observed not wearing a right rolled hand splint or being provided AAROM, PROM and AROM exercises, and/or positioning done by the RNA as prescribed by the physician. On June 23, 2010, at 6 p.m., during an interview, RNA 1 stated his shift began at 9 a.m. and ended at 6 p.m. The RNA stated he took Resident 2 to the Rehabilitation Room at 10 a.m. that morning (June 23, 2010). However, Resident 2 was observed in bed at 10 a.m. and was being provided morning care at 10:20 a.m. RNA 1 then stated, ?because of time factors? he could not tell when he took the resident to the Rehabilitation Room. RNA 1 stated restorative nursing provided ROM exercises to the resident's right shoulder every day, five times a week. RNA 1 could not state when he had provided active range of motion exercises to Resident 2's right shoulder on June 23, 2010. RNA 1 stated the splint was on hold. However, a review of the resident?s record, there was no evidence of any order change for AAROM, PROM exercises, and/or for the application of the right rolled hand splint since prescribed by the physician on June 1, 2010. Further review of Resident 2?s record and interview with RNA 1 on June 23, 2010 at 6 p.m., indicated RNA 1 signed his initials on the restorative record to indicate he provided AAROM exercises to Resident 2's right shoulder including application of the right rolled hand splint on June 23, 2010. The restorative record for June 2010 also indicated Resident 2 was not provided AROM exercises to the lower extremities from June 1, 2010 to June 23, 2010 (23 days). RNA 1 stated the order for AROM to the resident?s lower extremities was not written in the restorative record.On June 24, 2010, the physical therapist (PT) conducted a joint mobility assessment on Resident 2. On June 24, 2010 at 2:45 p.m., during an interview, the PT stated the resident developed a 20 degree limitation or loss of available range on the right shoulder flexion and 30 degree limitation or loss of available range on the right shoulder abduction (moving the limb away from the body). The PT compared the joint mobility assessment done on June 24, 2010, to the joint mobility assessment done on August 17, 2009. She also stated the resident was reassessed on May 21, 2010, and there was no change in ROM to the resident's right shoulder as of May 21, 2010. On May 21, 2010, the resident's right shoulder ROM was within full limit. According to the PT, the decrease in ROM to the resident's right shoulder developed within one month. A review of the Joint Mobility Assessments, dated August 17, 2009, and June 24, 2010, indicated Resident 2's right shoulder flexion range went from normal range to a minimal limitation or loss up to 25% of available range. The resident's right shoulder abduction range went from normal range to moderate limitation with a loss up to 50%.On June 28, 2010, at 9:15 a.m., RNA 1 gave a written declaration indicating he did not provide ROM to Residents 1 and 2 on June 23, 2010. RNA 1 indicated he had 45 residents which he had to provide RNA exercises every day for 15 minutes a day. He indicated in his declaration ?Whatever I cannot do for the day, I carry the rest the next day.?b. On June 23, 2010, a review of Resident 1?s record was conducted. The Admission Record indicated the resident was an 88 year old female, admitted to the facility on March 29, 2010, with diagnoses that included stiffness of the joints, muscle weakness, and CVA.The MDS, dated April 8, 2010, indicated Resident 1 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The resident required extensive assistance in bed mobility and was totally dependent on all other activities of daily living. The resident had functional limitation to the left leg (including hip and knee) and foot (including ankle and toes). A review of the physician?s orders, dated April 30, 2010, indicated Resident 1 was discharged from occupational therapy and for the RNA to provide PROM to Resident 1's left upper and lower extremities every day, five times a week or as tolerated, to apply left knee orthosis (an external orthopedic appliance such as a brace or splint, that prevents or assists movement of the limbs) to prevent further contracture and to facilitate joint positioning every day, and to provide AAROM to the resident's right upper and lower extremities every day as tolerated.The plan of care, dated March 19, 2010, indicated Resident 1 had decreased ROM due to diagnosis of CVA. The approaches plan included to provide AAROM exercises to the right upper and lower extremities five times a week (the order was every day), to provide PROM exercises to the left upper and lower extremities five times a week and to apply a left knee splint for six hours (the order was every day). However, the plan of care did not have a resident?s goal to achieve.On June 23, 2010, intermittent observations of Resident 1 were conducted. At 8:47 a.m., 9:11 a.m., 9:20 a.m., 9:30 a.m., 10:05 a.m., 10:20 a.m., 10:35 a.m., 10:45 a.m., 11 a.m., 11:07 a.m., 11:15 a.m., 11:38 a.m., 11:58 a.m., 12:08 p.m., 12:30 p.m., 2:10 p.m., 3:30 p.m., 4 p.m., 4:55 p.m., 5:30 p.m., and 5:55 p.m., Resident 1 was observed not wearing a leg splint or being provided AAROM and PROM exercises, and/or positioning by the RNA as prescribed by the physician. On June 23, 2010, at 6 p.m., during an interview, RNA 1 stated he did not provide ROM exercises to Resident 1 during his shift because of "too much engagement". However, review of the restorative charting record for June 23, 2010, with RNA 1 indicated RNA 1 signed his initials to reflect he provided ROM exercises to Resident 1 on June 23, 2010. He stated his initials meant he provided the exercises to the resident.Further review of resident?s Restorative Charting Record for June 2010 indicated Resident 1 was not provided AAROM exercises to the right upper and lower extremities and the left knee orthosis was not applied on June 5, 6, 12, 13, 19, and 20, 2010. During an interview on June 23, 2010 at 6 p.m., RNA 1 stated he thought AROM exercises to the right upper and lower extremities and left knee orthotic application were to be provided five times a week. However, the physician?s order indicated every day. On June 24, 2010, the PT conducted a joint mobility assessment on Resident 1. On June 24, 2010 at 2:45 p.m., during an interview, the PT stated the joint mobility reassessment done that day for Resident 1, revealed the left shoulder had lost 10 degrees of left shoulder flexion and abduction. The PT stated the patient was developing spasticity (a constant and unwanted contraction of one or more muscle group).The facility failed to provide restorative nursing treatments to maintain current functional and prevent decrease in range of motion by failing to: 1. Ensure Residents 1 and 2 received ROM exercises and the positioning devices were applied as ordered by the physician.The above violation had a direct relationship to the health and safety of Residents 1 and 2. |
| 910000028 |
COUNTRY VILLA WESTWOOD CONVALESCENT CENTER |
910009207 |
A |
27-Apr-12 |
None |
22215 |
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.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. 72547 (a)(5)(B) Content of Health Record (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses? notes which shall be signed and dated. Nurses? notes shall include: (B) Meaningful and informative nurses? progress notes written by licensed nurses as often as the patient?s condition warrants. However, weekly nurses? progress notes shall be written by licensed nurses on each patient and shall be specific to the patient?s needs, the patient care plan and the patient?s response to care and treatments. On December 19, 2008, the Department received a complaint in which a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was filed.The report alleged a patient (Patient C) arrived at a General Acute Care Hospital (GACH) with a body temperature of 86.9 F (Fahrenheit), hypoxemia (deficient oxygenation of the blood), with an extremely guarded prognosis. On December 19, 2008, a complaint investigation was conducted regarding Patient C, who was transferred to a GACH, from a skilled nursing facility (SNF), with a rectal temperature of 86.9 degrees F (normal rectal temperature is 94-100 degrees F). Approximately 36 hours prior to Patient C?s transfer to the GACH, he sustained an unwitnessed fall (no investigation was conducted and incomplete documentation of the incident, patient condition and neurological assessment was found). Based on interview and record review the facility?s nursing staff failed to: 1. Implement a care plan related to Patient C's diagnosis of pneumonia. Patient C's oxygen Saturation levels (O2 Sats) (how much oxygen is moving through the bloodstream), according to a care plan, were to remain greater than 92% (normal O2 Sat 95%) on room air (RA); however, no documentation could be found to show the patient?s O2 Sats were continuously monitored.2. Investigate when Patient C sustained an unwitnessed fall. Approximately 36 hours later the patient was found unresponsive, and was transferred to a GACH for evaluation, with a rectal temperature of 86.9 degrees F, upon arrival at the GACH.3. To call for emergency response (911), versus an ambulance transfer, when Patient C was found unresponsive (would not wake up) with labored breathing and an O2 Sat of 60%. Patient C was found unresponsive between 8:00 a.m., and 8:30 a.m. He was not transferred to the GACH emergency department until 10:33 a.m., (approximately two hours after he was found with an ALOC [altered level of consciousness]). 4. Document meaningful progress notes (in narrative), to include Patient C?s orientation, skin color, temperature, responsiveness, pulse, respiration, blood pressure, O2 Sats and the circumstances of the discovery of ALOC, when he sustained an unwitnessed fall on December 16, 2008; They failed to document, per the physician?s order and according to facility policy, Patient C's neurological status for 72 hours, after sustaining an unwitnessed fall. Approximately 36 hours after Patient C fell he was transferred to a GACH, for evaluation of an ALOC with a rectal temperature of 86.9 degrees F.These failures resulted in Patient C not being monitored for possible injuries sustained during an unwitnessed fall, delay in evaluation, treatment, and transport to the GACH?s emergency department due to 911 not being called. Patient C was transferred to a GACH approximately two hours after he was found with an ALOC; he required intubation with ventilator assistance (a breathing machine), a warming blanket, and warm intravenous (directly into the vein) fluids due to a subnormal body temperature of 86.9 degrees F.A review of Patient C's Admission Records indicated a 72 year-old male who was admitted to the facility on November 25, 2008, with diagnoses including pneumonia (inflammation of the lungs), chronic obstructive pulmonary disease ([COPD] a progressive disease that makes it hard to breath), dementia (a loss of mental ability), difficulty walking and anemia (a decrease in the number of red blood cells). According to a Minimum Data Set (MDS) Assessment, (a standardized assessment and care screening tool), dated December 5, 2008, Patient C's cognitive skills for daily decision-making were severely impaired.1. A Care Plan, dated December 10, 2008, indicated Patient C had an upper respiratory infection (URI) with a potential for an adverse reaction to antibiotics, and was at risk for respiratory compromise as manifested by (m/b) shortness of breath (SOB) and congestion secondary to COPD. The goal was that the patient?s URI symptoms be resolved after antibiotics were administered. Approaches used included monitoring for effectiveness of medications as m/b decreased SOB, decreased congestion and an O2 Sat greater than 92% RA. However, review of the patient?s medical record indicated one documentation of the patient?s O2 Sat. A Physical Therapy Treatment Record, dated December 10, 2008, indicated Patient C presented with increased upper respiratory congestion, restlessness and an O2 Sat of 93%. On August 27, 2010, at 3:41 p.m., during an interview, the Director of Nursing (DON) stated if the patient?s care plan included interventions to maintain his O2 Sat above 92%, then the nursing staff should have monitored the patient?s O2 Sat, to determine if the goal was being met and recorded their findings on the medication administration record (MAR).2. An Interdisciplinary Resident Safety Investigation and Intervention report, dated December 17, 2008, indicated Patient C fell from his bed on December 16, 2008, at 10:00 p.m. Documentation under ?comments/other? indicated Patient C got out of bed on his own causing him to fall. (There was no written documentation [investigation]) of how this determination was made, i.e., interview of staff, resident, or roommate[s]). The certified nursing assistant (CNA) who was involved was not identified. On September 8, 2010, at 2:45 p.m., an inquiry was made (by the Evaluator) regarding Patient C's fall. The Administrator looked for and could find no written documentation regarding the patient's unwitnessed fall. An investigation report was not available. The Administrator stated she did not know who the CNA was who was mentioned by Staff 2 on the Change in Condition Assessment (no date). The Administrator stated she could not remember the details of the fall. A facility policy on Incident, Accidents, and Injuries of Unknown Origin, dated October 1, 1997, indicated an investigation report form is to be completed, when it has been determined that a serious incident/injury, unusual occurrence, or injury of unknown origin has occurred. All interview records should be attached to the investigation report form.3. On December 18, 2008, between 8:00 a.m., and 8:30 a.m., Patient C was found unresponsive (would not wake up), with labored breathing and an O2 Sat of 60%.A review of the ambulance run sheet, dated December 18, 2008, with an arrival time to the facility of 9:57 a.m., indicated Patient C was non-verbal but responsive to painful stimuli. The nurse reported that at 9:00 a.m., Patient C?s O2 Sat was 60%. Upon reaching the patient (10:00 a.m.) the transportation team found him on 5 liters per minute (lpm) of oxygen, using a simple mask, his O2 Sat was 85%. Further review of the run sheet indicated the patient had an ALOC, cough/congestion with rhonchi (coarse rattling sound), his breathing was labored and he was cold. His vital signs at 10:23 a.m., were blood pressure 96/62 (normal 60/90 diastolic 90-140 systolic), heart rate 56 (normal 60-100), and respiratory rate 24 (normal 12-20). The transportation team left the facility with the patient at 10:33 a.m., and arrived at the GACH emergency department at 10:37 a.m., approximately two hours after he was found unresponsive.On January 8, 2009, at 11:10 a.m., during an interview, Staff 1 stated Staff 3 found Patient C and brought it to Staff 8?s attention that the patient was not behaving normally. She stated the patient was sleeping, when they shook him he moved around but would not wake up and was cold to the touch. She stated the patient's O2 Sat was 60%, they administered oxygen and his O2 Sat increased to 85%. He still did not respond so they called the physician to have him transferred. They called one ambulance service but they were not available and eventually got another one to come. She stated initially they were going to call 911 but called the physician instead. When the transportation company arrived they were hesitant about transporting the patient and wanted to transfer him via 911 because his O2 Sats were below normal.On January 8, 2009, at 11:20 a.m., during an interview, Staff 3 stated on December 18, 2008, between 8:00 a.m., and 8:30 a.m., she went to Patient C's room to get him up for physical therapy, she called him several times but he did not respond, would not open his eyes or speak and was having difficulty breathing.On August 27, 2010, at 3:41 p.m., during an interview and after reviewing Patient C?s medical records, the DON stated she did not know why transportation was called instead of 911, when Patient C?s O2 Sat was 60% and he was unresponsive. A facility policy on Change of Condition Management Guidelines; Effective Change of Condition Management (no date) indicated if the change of condition was reported to or discovered by a license professional staff or other facility personnel then the change of condition should be reported to the charge nurse/RN supervisor. The licensed nurse then collects the assessment data. If the change of condition is life threatening the necessary treatment should be started as indicated by the PIC/DPOA (preferred intensity of care/durable power of attorney) and to notify 911 as indicated.4. A Change in Condition Assessment (not dated) and with the incorrect information (fall, date and time). Indicated Patient C sustained a fall. Documentation under ?Additional Comments? indicated "patient was ushered to bed & when CNA (identity unknown) left pt's (patient) room created a big thumping sound - it was the pt.? Body check was done with no skin tear, no ALOC. A Physician's Order dated December 16, 2008, (no time) indicated to perform a neuro check secondary to the fall incident as per the facility's protocol. A Neurological and Vital Sign Record, dated December 16, 2008 thru December 17, 2008, indicated Patient C was not continuously and completely monitored for his entire neurological status, including his orientation, reaction to light, (vital signs [including temperature]), conscious state, speech, non verbal reaction to pain, pupil reaction and ability to move, prior to being transferred to the GACH on December 18, 2008.A facility policy on Neurological Assessment, dated October 1, 1994, indicated neurological assessments are performed to determine stability, progress or deterioration of the resident's neurological status. Oriented- the progress of disorientation occurs first in time, then place, and then person. Assessment of Vital Signs: Take and document for 72 hours using the neurological and vital sign record. Neurological checks will be done every hour x4; every 4 hours x6; then every shift x6. Documentation: The licensed nurse will document findings on the neurological vital signs record. The licensed nurse will document neurological assessment findings in the licensed nurse's progress notes. On September 9, 2010, at 6:15 a.m., during an interview and after reviewing the neurological and vital sign record, Staff 4, a licensed vocational nurse (LVN), stated she completed Patient C?s neurological assessment on December 16, 2008, but could not recall why she did not document the condition of the patient in the licensed personnel progress notes. On September 9, 2010, at 4:26 p.m., during an interview, Staff 5 (an LVN) stated he did not remember Patient C. After reviewing the neurological assessment form, he stated he did not remember why he did not document the patient's neurological status or chart the patient?s condition in the licensed nursing notes.On September 9, 2010, at 4:35 p.m., during an interview, the Director of Nursing (DON) stated licensed nurses should give a verbal report to the on coming nurses regarding the patient's condition so care of the patient could be maintained. She stated the neurological assessment forms were kept in the same binder as the MAR as a reminder to complete the assessment when the medications were passed. Staff 6 (an LVN) who was assigned to Patient C on December 17, 2008, on the 7:00 a.m., - 7:00 p.m., shift and Staff 7 (an LVN) who was assigned to Patient C on December 17-18, 2008, on the 7:00 p.m., - 7:00 a.m., shift, did not complete the neurological assessment, it was left blank. Both LVNs no longer worked at the facility and were not available for interview.A review of the Licensed Personnel Weekly Progress Notes, for the month of December 2008, indicated there was no written documentation related to Patient C's neurological assessment or condition including the day of his fall (December 16, 2008). A review of the ambulance run sheet, dated December 18, 2008, indicated the transportation team arrived at the facility at 9:57 a.m., departed from the facility at 10:33 a.m., and arrived at the GACH at 10:37 a.m. The run sheet indicated Patient C was found in a semi-Fowler position (A semi-sitting or semi-reclined body position whereby the head is elevated on an angle of approximately 30 degrees), was non-verbal but responsive to painful stimuli. The run sheet indicated the nurse stated at 9:00 a.m., the patient's O2 Sat was 60%. Upon arrival the transportation team reported the patient was on 5 lpm of oxygen, using a simple mask with an increase in his O2 Sat to 85%. The transportation team increased the oxygen to 10 lpm using a non rebreather mask, his O2 Sat increased to 94%. Further review of the run sheet indicated the patient had an ALOC, cough/congestion with rhonchi, with labored breathing and the patient was cold. The patient?s vital signs at 10:23 a.m., were blood pressure 96/62, heart rate 56, and respiratory rate 24. A Nursing Transfer/Discharge Assessment, dated December 18, 2008, at 10:00 a.m., indicated Patient C was transferred to a GACH because of an ALOC. Documentation under ?Skin Assessment? indicated the patient?s temperature as warm. (An interview with Staff 1, on January 8, 2009, at 11:10 a.m., and the ambulance run sheet, dated December 18, 2008, indicated Patient C was cold to touch).On January 8, 2009, at 11:10 a.m., during an interview, Staff 1, a registered nurse (RN) stated Staff 3, a physical therapist (PT) technician, found Patient C and reported to the night shift supervisor (Staff 8) (an RN) that the patient was not behaving normally. Staff 1 stated the patient was sleeping and cold to touch. When they shook him he moved around but would not wake up. She stated the patient's O2 Sat was 60%, they administered oxygen and his O2 Sat increased to 85%. Staff 1 stated the patient still did not respond so they called the physician to have him transferred. Staff 1 stated it was change of shift and she got busy, which was why she forgot to document.On January 8, 2009, at 11:20 a.m., during an interview, Staff 3 stated on December 18, 2008, between 8:00 a.m., and 8:30 a.m., she went to Patient C's room to get him up for physical therapy. Staff 3 stated she called the patient several times but he did not open his eyes, speak or respond. Staff 3 observed the patient having difficulty breathing (labored) and reported the patient's condition to the night shift supervisor (Staff 8) (an RN). A review of Patient C's Medical Records indicated no written documentation of vital signs taken prior to 10:00 a.m., on December 18, 2008, after the patient was found unresponsive between the hours of 8:00 a.m. and 8:30 a.m. On January 8, 2009, at 11:55 a.m., during an interview, Staff 1 stated Patient C was found unresponsive between 8:00 a.m., and 8:30 a.m., she documented the patient's vital signs at 10:00 a.m., however, she actually took them before the transportation company arrived (9:57 a.m.). She stated documentation should have reflected what occurred at the time the patient was found and at least an additional set of vital signs should have been taken before the transportation company arrived, approximately two hours later. On August 27, 2010, at 3:41 p.m., during an interview, the DON stated nursing narratives should be documented in the licensed nursing progress notes as well as on the nursing transfer/discharge assessment, to include how the resident was found, his condition (skin color, temperature, vital signs, breathing, orientation, responsiveness), the course of the resident's treatment, who was notified and when the patient left the facility. A History and Physical Examination, from the GACH, where Patient C was transferred to, for evaluation, after he was found unresponsive with an ALOC, dated December 18, 2008, indicated when he arrived to the emergency room he was responsive only to painful stimuli and his eyes were sluggish to light. His O2 Sat was 93% on 4 lpm of oxygen, which later dropped to the low 80s and the patient had to be intubated. The patient?s rectal temperature was 86.9 degrees F. He was placed on a bear hugger (a heating device), warm blanket and warm intravenous fluids were started.A Discharge Summary, from the GACH, where Patient C was transferred to, for evaluation, after he was found unresponsive with an ALOC, dated December 24, 2008, indicated the neurologist impression was the patient had possible hypoxia (deficiency in the amount of oxygen reaching body tissues) in the setting of hypothermia (when body temperature falls below 95ø) with minimal cortical and brainstem functions. Documentation under final diagnoses indicated severe hypothermia and hypoxic encephalopathy (diminished availability of oxygen to the brain). A facility policy on Change of Condition Management Guidelines (no date) indicated if the change of condition is life threatening the licensed nurse will document assessment, change of....... (There were no further instructions listed). Further guidelines indicated if the change of condition is not life threatening the licensed nurse will document change of condition assessment reporting, and interventions in nursing notes.A facility policy on Incident, Accident, and Injuries of Unknown Origin, dated October 1, 1997, indicated it is the facility?s policy that resident (patient) incidents are properly documented, reported and evaluated to provide a system for documenting and analyzing various types of incidents to develop a plan for continuous quality improvement. When a patient incident occurs, the employee making the discovery initiates an incident report form with the assistance of appropriate supervisory personnel. In the case of a patient incident, pertinent clinical information and observation(s) are documented in the clinical record.On December 16, 2008, at 10:00 p.m., Patient C sustained an unwitnessed fall. There was no written documentation regarding the patient?s fall, no monitoring of the patient?s O2 Sats as care planned and the unwitnessed fall was not investigated by the facility. Approximately 36 hours after Patient C fell, he was found unresponsive, with labored breathing and an O2 Sat of 60%. There was no written documentation to indicate the circumstances surrounding the patient?s ALOC; no written documentation of the assessment of the patient when he was found unresponsive; emergency response (911) was not called, instead the facility?s nursing staff called for ambulance transportation to transfer the patient to the GACH?s emergency department. Patient C was transferred to the GACH for evaluation approximately two hours after being found unresponsive. When he arrived at the GACH he was assessed with a rectal temperature of 86.9 degrees F with diagnoses including severe hypothermia and hypoxic encephalopathy.Therefore the facility failed to: 1. Implement a care plan related to Patient C's diagnosis of pneumonia. Patient C's oxygen Saturation levels (O2 Sats) (how much oxygen is moving through the bloodstream), according to a care plan, were to remain greater than 92% (normal O2 Sat 95%) on room air (RA); however, no documentation could be found to show the patient?s O2 Sats were continuously monitored.2. Investigate when Patient C sustained an unwitnessed fall. Approximately 36 hours later the patient was found unresponsive, and was transferred to a GACH for evaluation, with a rectal temperature of 86.9 degrees F, upon arrival at the GACH.3. To call for emergency response (911), versus an ambulance transfer, when Patient C was found unresponsive (would not wake up) with labored breathing and an O2 Sat of 60%. Patient C was found unresponsive between 8:00 a.m., and 8:30 a.m. He was not transferred to the GACH emergency department until 10:33 a.m., (approximately two hours after he was found with an ALOC [altered level of consciousness]). 4. Document meaningful progress notes (in narrative), to include Patient C?s orientation, skin color, temperature, responsiveness, pulse, respiration, blood pressure, O2 Sats and the circumstances of the discovery of ALOC, when he sustained an unwitnessed fall on December 16, 2008; They failed to document, per the physician?s order and according to facility policy, Patient C's neurological status for 72 hours, after sustaining an unwitnessed fall. Approximately 36 hours after Patient C fell he was transferred to a GACH, for evaluation of an ALOC with a rectal temperature of 86.9 degrees F.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. |
| 910000027 |
COUNTRY VILLA SOUTH CONVALESCENT CENTER |
910009388 |
A |
11-Jul-12 |
DAAS11 |
5954 |
CFR 483.25(h) F323 - Accident Hazards 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 22, 2010, at 8:40 a.m., an unannounced visit was conducted to investigate an entity reported incident (ERI) to the Department. The ERI indicated that Resident A sustained a fracture (break) of the right knee while being transferred by a staff person from the wheelchair to the bed. Based on observation, interview, and record review, the facility?s nursing staff failed to ensure a Hoyer lift ( an assistive device that allows staff to transfer a resident from a bed or a chair using hydraulic power) was used during Resident A?s transfer from her wheelchair to her bed. This resulted in Resident A sustaining a right knee fracture. Resident A was an 89 year old female admitted to the facility on November 13, 2009, with diagnoses that included generalized muscle weakness, debility (weak in health or body), and status post left hip fracture (break in the bone). The Minimum Data Set [(MDS) a standardized uniform comprehensive assessment] dated December 15, 2009, indicated Resident A was alert and independent in cognitive skills for daily decision-making. She was assessed as requiring total assistance with two-plus persons physical assist with transfer, and required physical help with balance while standing. The resident was also assessed as having limitation in range of motion (ROM) in both legs, including the hip or knee with partial loss of voluntary movement. One foot had limitation in ROM with partial loss of voluntary movement. The mode of locomotion was a wheelchair and the mode of transfer was with a ?mechanical lift.?A review of the Physical Therapy Initial Evaluation dated February 15, 2010, indicated for mobility skills, the staff were to transfer Resident A from her wheelchair to her bed using a Hoyer lift. The care plan for Activities of Daily Living (ADL) functioning dated February 23, 2010, indicated Resident A required extensive assistance with bed mobility, was non-ambulatory, and required total assistance with transfers. The approach and plan was to assist with ADLs as needed. A review of the Change in Condition Assessment dated March 2, 2010, at 7 p.m. indicated Resident A had right knee pain with swelling. The physician was notified and a stat (at once) x-ray [an image produced on photographic film, often used as a diagnostic tool] was ordered. The x-ray report dated March 2, 2010, indicated Resident A had an acute right knee fracture. The physician?s response at 7 p.m., was to set up a morning visit on March 3, 2010, with an orthopedic specialist. The physician stated it was not necessary to transfer the resident to the hospital at that time. The Physician?s Progress Record notes dated March 4, 2010, indicated an orthopedic physician?s assessment that reflected the resident had a right tibia plateau fracture [a break in the continuity of the bone occur just below the knee joint and can involve the cartilage surface of the knee]. The plan for the resident was weight bearing as tolerated, physical therapy for range of motion exercises, and repeat the right knee x-ray in one month. A review of the Licensed Personnel Weekly Progress Notes from March 3, 2010, at 8 a.m., through March 7, 2010 at 9:30 p.m., indicated the resident complained of right knee pain that ranged from 4 out of 10, on a scale of 1 to 10 (10 being the worst pain) to 8 out of 10 each day. The treatment was for the resident?s right leg to be was immobilized (with a brace that does not allow the knee to move), and provide Dilaudid (a narcotic pain reliever used to treat moderate to severe pain) 1 milligram (mg) every 4 hours as needed, and Tylenol 650 mg every 6 hours as needed, for pain management. On March 22, 2010 at 8:40 a.m., during an interview with Resident A regarding the March 2, 2010, incident, she stated the nurse (RNA) called for assistance to help transfer her from the wheelchair to the bed, however the RNA did not wait for help to arrive. Instead, she transferred Resident A without assistance, and without using the Hoyer lift. As she was transferred, she felt her right knee pop. There was a sign observed above her bed that stated to use the Hoyer lift. A review of the facility?s Interview Record(s) regarding the March 2, 2010 incident revealed that the RNA transferred Resident A from her wheelchair to her bed without using a Hoyer lift, or without the assistance of another person.Resident A?s daughter, was present at the time of the transfer. She stated that Resident A screamed loudly in pain, and said that she thinks ?her knee was broken.? On March 22, 2010 at 9:15 a.m., during an interview with the Physical Therapist (PT), she stated Resident A required a two person assist with transfers. She stated the instructions that were given to the staff regarding Resident A were to use the Hoyer lift (mechanical lift) during transfers. A review of the Employee Mobility Skills and Safety Techniques Training Workbook indicated that the RNA had been evaluated for one and two person transfers, and for proper use of the Hoyer lift on September 15, 2009. The RNA was terminated after the March 2, 2010, incident, due to an unsafe transfer. On March 22, 2010, at 10:30 a.m., a telephone message was left in an attempt to interview the RNA, with no response. The facility?s nursing staff failed to ensure a Hoyer lift ( an assistive device that allows staff to transfer a resident from a bed or a chair using hydraulic power) was used during Resident A?s transfer from her wheelchair to her bed. This resulted in Resident A sustaining a right knee fracture. 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 to Resident A. |
| 910000028 |
COUNTRY VILLA WESTWOOD CONVALESCENT CENTER |
910009764 |
A |
14-Mar-13 |
None |
11228 |
F 309 483.25 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 March 3, 2009, at 12 p.m., an unannounced visit was made to the facility to conduct a complaint investigation regarding an allegation received by the Department on February 17, 2009, that Resident A, who was insulin dependent, went into a diabetic coma (life-threatening complication from diabetes, causing unconsciousness) and required admission to an intensive care unit (ICU).Based on interview and record review, the facility?s nursing staff failed to:1. Ensure a resident who had a diagnosis of diabetes mellitus [(DM) a condition resulting in too much sugar/glucose in the blood], and a history of unstable blood sugar (amount of glucose in the blood) was monitored and assessed for signs and symptoms of hypoglycemia (low blood sugar ) and hyperglycemia (high blood sugar ) as indicated in the care plan. 2. Ensure the admission physician?s orders for checking the resident?s blood sugar level and/or medication for DM were clarified according to the resident?s health condition and diagnoses. 3. Ensure prompt reporting by the direct care staff to the licensed nurses when there was a change in the resident?s normal status, to prevent delayed notification of the physician and treatment as necessary.On February 1, 2009, at 11:05 p.m., Resident A was non-responsive and was transferred to the general acute care hospital (GACH), and admitted to the ICU, with a blood sugar level of 1333 milligrams per deciLiter (mg/dL) [normal blood sugar levels range between 65 and 100 mg/dL), was intubated and placed on mechanical ventilation (requiring assistance in breathing performed by a machine). He was diagnosed with respiratory failure and diabetic ketoacidosis [a serious complication of diabetes that occurs when the body is unable to produce enough insulin to control the sugar levels in the blood and very high levels of toxic blood acids (ketones) are produced. A review of Resident A?s medical record revealed a 64-year- old male admitted to the facility on January 28, 2009, with diagnoses that included hypertension (elevated blood pressure) and diabetes mellitus. He was admitted to the GACH from home due to a fall that resulted in a fractured hip. A review of the ?Inpatient Transfer Summary? from the GACH to the skilled nursing facility dated January 28, 2009, indicated Resident A had type II diabetes mellitus, end stage renal disease (ESRD), and left hip fracture. The summary indicated that Resident A had been prescribed and was using Lantus Solostar insulin, Novolog insulin, and regular insulin coverage to control his blood sugar while at home. It was documented that during three recent admissions to the GACH (dates not available) his blood sugar had been difficult to control, resulting in hyperglycemic and hypoglycemic episodes. It was indicated that Resident A had very labile (unstable) blood sugar levels while in the GACH, ranging from 85 to 400 mg/dL, depending on the amount of his oral (by mouth) intake. A review of the physician?s orders dated January 28, 2009, which included diagnoses of ESRD with a renal diet, revealed there was no documented evidence that the physician had ordered any diabetic control medications, nor to check Resident A?s blood sugar levels. The Nursing Admission Assessment and Licensed Personnel Progress Notes dated January 28, 2009, did not have any documentation as to why Resident A had no blood sugar level monitoring or medication for his DM, or that the physician was contacted for clarification of the orders in the absence of orders to control DM. The Nursing Admission Assessment dated January 28, 2009, at 4:50 p.m. indicated the resident had diagnosis of diabetes, had ESRD and was on a renal diet. However, there was no documented evidence that the physician was contacted to clarify orders that lacked diabetic control medications or BS level monitoring.There was a care plan dated January 30, 2009, for diabetes mellitus, potential for hypoglycemia/hyperglycemia reaction. The goal was for the blood sugar levels to be within the parameter of 80 to 100. The interventions included blood test as ordered, to observe for signs and symptoms of hyperglycemia [restlessness, appears hot and dry, flushed, thirst, fruity odor and coma (a state of prolonged unconsciousness, including a lack of response to stimuli, from which it is impossible to rouse)], to observe and record for signs and symptoms of hypoglycemia (perfuse sweating, blurred vision, dizziness) and to report poor appetite. The Licensed Personnel Progress Notes dated February 1, 2009, at 10:45 (p.m.- not written), indicated the registered nurse supervisor (RN supervisor) received report from a CNA that Resident A did not eat his dinner that evening. The note indicated that the licensed nurse was unable to give Resident A?s bedtime medication because she was unable to wake Resident A. Resident A?s vital signs were taken and measured as: blood pressure (BP) 60/40 (normal 120/80); pulse rate (PR) 52 (normal 60 ? 80); respiratory rate (RR) 24 (normal 16-20); temperature 97 degrees Fahrenheit (F) and oxygen saturation (amount of oxygen in the blood) 96 ? 97 %. There was no documented evidence the blood sugar level was checked.At 10:50 p.m., the documentation indicated the physician was called, waiting for physician to call back. At 10:55 p.m., the documentation indicated the paramedics were called. At 10:59 p.m., the note indicated the paramedics arrived at the facility and assessed Resident A. The vital signs were taken as follows: BP was 54/44; PR was 44; blood sugar reading was ?hi? indicating the blood sugar reading results were above 550 mg/dL. The note indicated Resident A still could not be aroused from his sleep. Resident A was transferred to the GACH at 11:05 p.m. A review of the facility?s record indicated the scheduled meal time for dinner was 5:15 pm. A review of the Certified Nursing Assistant (CNA) flow sheet dated February 1, 2009, indicated Resident A had refused breakfast and lunch that day. There was no documented evidence that Resident A?s meal refusal for breakfast and lunch was reported to a charge nurse as indicated in the January 30, 2009, care plan, for further actions as necessary. There was also no documented evidence that the resident was assessed and monitored for signs and symptoms of hypoglycemia and/or hyperglycemia as indicated in the care plan. Additionally, the licensed nurse could not wake up Resident A to give his HS (hour of sleep) medication scheduled at 9 p.m. However, there was no nursing assessment of Resident A until February 1, 2009, at 10:45 p.m.The Emergency Transfer Communication form dated February 1, 2009, at 10:45 p.m. indicated the resident was unarrousable from sleep, bedtime meds were not given, resident has DM II but no sliding scale coverage (sliding scale is a program where a fast acting insulin is released at a rate per hour constantly and increased only when carbs are injested), and BS reading said "high". Further review of the CNA flow sheet notes dated January 30, 2009, indicated that Resident A consumed 50 % of his breakfast, was out of the facility for lunch and ate 70 % of his dinner on that particular day. The CNA flow sheet for January 31, 2009, was blank, there was no documentation of how much Resident A ate for breakfast and lunch. The CNA flow sheet indicated at dinner Resident A ate 50 %, and a bedtime snack was not offered. There was no documentation of consistent monitoring of Resident A?s meal intake to be able to provide an accurate report to the physician as indicated in the January 30, 2009, care plan.A review of the emergency department notes obtained from the GACH dated February 1, 2009, indicated that Resident A had a critically high blood sugar level and a heart rate in the forties. While in the emergency room, Resident A was diagnosed with respiratory failure and diabetic ketoacidosis [a serious complication of diabetes that occurs when the body is unable to produce enough insulin to control the sugar levels in the blood and very high levels of toxic blood acids (ketones) are produced. Diabetic ketoacidosis is usually triggered when there is a problem with missed insulin treatment or inadequate therapy with too little insulin in the body].The laboratory result obtained from the GACH dated February 1, 2009, indicated Resident A?s blood sugar level was 1333 mg/dL, which was confirmed by a repeat analysis. A review of the physician?s notes from the GACH dated February 2, 2009, indicated that Resident A had to be intubated and placed on mechanical ventilation. Resident A was administered intravenous insulin for management of his elevated blood sugar,and he remained non-responsive. During an interview with CNA 1 on March 9, 2009, at 2:40 p.m., he stated Resident A was asleep at the beginning of the shift on the date of the incident (3 p.m. to 11 p.m.). He stated that the resident?s roommate informed him that Resident A had been asleep all day. CNA 1 stated that Resident A was very sleepy and didn?t eat his dinner. CNA 1 stated he reported Resident A?s condition to the RN supervisor at approximately 10 p.m. CNA 1 stated he was busy and that?s why he waited so late to report the resident?s condition.During the investigation, several attempts were made to contact the licensed staff (RN, LVN) on duty; however, all attempts were unsuccessful. The Director of Nursing was not available for interview during the investigation. On March 9, 2009, at 3:30 p.m., during an interview, the administrator stated that the history and physical as well as the inter-facility progress notes usually accompany the resident from the GACH. She stated the licensed nurses should have reviewed the attending physician?s orders as well as the transfer notes prior to starting treatment with any resident. And prior to beginning treatment on a newly admitted resident, the licensed nurse should call the assigned physician to discuss and verify any necessary additions or deletions to the physician?s orders. The administrator stated that nursing staff should have followed these procedures, and that they did not follow Resident A?s plan of care. The facility?s nursing staff failed to:1. Ensure a resident, who had a diagnosis of diabetes mellitus and a history of unstable blood sugar, was monitored and assessed for signs and symptoms of hypoglycemia and hyperglycemia as indicated in the care plan. 2. Ensure the admission physician?s orders for checking the resident?s blood sugar level and/or medication for DM were clarified according to the resident?s health condition and diagnoses. 3. Ensure prompt reporting by the direct care staff to the licensed nurses when there was a change in the resident?s normal status, to prevent delayed notification of the physician and treatment as necessary. The above violation presented imminent danger of death or serious harm to Resident A, or a substantial probability of death or serious physical harm to Resident A. |
| 910000065 |
Century Villa, Inc. |
910009971 |
B |
25-Jun-13 |
EDJ611 |
6038 |
Code of Federal RegulationsF323 - 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 nursing staff failed to ensure one of three sampled residents ( Resident 3), who was at risk for falls, was transferred safely without incident.The certified nursing assistant (CNA) staff failed to lock the shower chair brakes to hold the wheels, and did not assist the resident while she attempted to transfer, in accordance with the facility?s policy and procedure and the resident?s assessment requiring one person physical assist. Resident 3 fell, injuring her left foot stump (end of toes amputated) and hitting her right knee and stump [previous above the knee (AKA) amputation], and could not walk due to pain and the inability to wear her prosthesis. On July 19, 2010, at 9 a.m., an unannounced complaint investigation was conducted for an allegation that Resident 3 had a fall which should not have occurred, causing injury and her inability to walk for five months. The clinical record indicated Resident 3 was a 64 year old female, originally admitted to the facility on January 29, 2008, and readmitted on March 10, 2010, with diagnoses that included peripheral vascular disease [(PVD) an occlusion to an artery causing poor circulation and healing] with thrombosis (a blood clot formed inside a blood vessel), right above-the-knee amputation (removal of leg above the knee), surgically removed toes (all five) on the left foot, diabetes mellitus (elevated blood sugar), cerebrovascular accident [(CVA) stroke], and glaucoma (an eye disorder that may cause blindness). The quarterly Minimum Data Set (MDS), an assessment and care screening tool, dated January 14, 2010, indicated Resident 3 had good short and long term memory with no impairment in cognitive skills for daily decision making, was able to understand or be understood, and required extensive assistance (weight bearing support) with one person physical assistance for transfers. The Nurses Notes dated February 23, 2010, at 8 p.m. indicated Resident 3 was heard calling for help and upon arrival, the resident was on her left side on the floor between her wheelchair and her shower chair, and her assigned CNA was there, while waiting for help.The Incident Report dated February 23, 2010, disclosed Resident 3 had a fall on February 23, 2010, at 8 p.m. The report indicated the resident was being transferred and Resident 3 ?missed her mark.?The certified nurse assistant (CNA) was standing right next to the resident and immediately assisted the resident slowly to the floor. The Fall Assessment, dated February 24, 2010, regarding the February 23, 2010 fall indicated the resident stated as she transferred, the shower chair slid and she fell. She hit her right knee and right stump on the floor. The form indicated both the resident and the CNA had poor safety awareness, especially for not locking the wheel chair and shower chair brakes. On July 19, 2010, at 10:45 a.m., during an interview Resident 3 stated that she was getting out of bed to go to the bathroom, her wheelchair was at the foot of her bed, and the ?nurse? (CNA) pushed the shower chair to her and told her to get into it. She stated, ?I stood up and was trying to sit in the shower chair, as I went to sit, the shower chair slid backward (because it was not locked); my left leg slid under the shower chair? I was trapped between the shower chair and the wheelchair?.. I have been in pain ever since that fall. I was doing very well before the fall?.ambulated in the hallway with my prosthesis on but now my stump is too tender?.with no walking since the fall.? She said she has had pain since the fall and has not been able to walk. According to the resident, the CNA did not physically assist her. The documentation on the Fall Assessment Rehabilitation Services (form) dated February 24, 2010, and the Nurses Notes dated February 23, 2010, at 8 p.m., were inconsistent with the resident?s report of how the incident occurred. The form reflected that the resident fell while transferring from her wheelchair to the shower chair. The Nurses Notes indicated the resident was heard calling for help and when nursing arrived, the resident was on her left side on the floor between her wheelchair and her shower chair, with her assigned CNA ?assisting her to lay on the floor? while waiting for help. Review of the CNA's training record indicated she attended a fall prevention class on November 22, 2009, and again on February 5, 2010. The CNA failed to follow the fall prevention training that she received when she did not lock the wheelchair and or the shower chair brakes prior to transferring a resident. On July 19, 2010, at 11 a.m., the director of nursing (DON) stated the shower chair should have been locked during any transfer.Review of the undated facility's document titled, "Long-Term Care Shower Chair Policy and Procedures", indicated under preparation, the most important preparation step before conducting any shower chair procedure is to transfer the resident to the seat safely. Put down the brake to hold the wheels still while you assist the resident into place. The facility's nursing staff failed to ensure one of three sampled residents(Resident 3), who was at risk for falls, was transferred safely without incident. The CNA failed to lock the shower chair brakes to hold the wheels, and did not assist the resident while she attempted to transfer, in accordance with the facility?s policy and procedure and the resident?s assessment requiring one-person physical assist. Resident 3 fell, injuring her left foot stump and hitting her right knee and stump, and could not walk due to pain and the inability to wear her prosthesis. The above violation had a direct relationship to the health, safety or security of Resident 3. |
| 910000058 |
COUNTRY VILLA MAR VISTA NURSING CENTER |
910010093 |
A |
15-Aug-13 |
PNWZ11 |
11471 |
F 323 483.25 (h) Accidents The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On February 5, 2013, at 8:55 a.m., an unannounced visit was conducted for an entity reported incident (ERI) received by the Department on January 23, 2013, indicating Resident 1 was found on the floor on January 12, 2013.Based on observation, interview, and record review, the facility failed to ensure Resident 1, who had a history of falls, and who was assessed as being a high risk for falls, received adequate supervision and assistive devices to prevent accidents by failing to: 1. Develop an initial fall prevention care plan using the information gathered in the Nursing Admission Assessment and Physical Restraint Assessment dated October 28, 2012, that addressed the type of supervision and assistive device to alert the staff when the resident attempted to function beyond her ability and climb out of bed/chair.2. Analyze and address the trends and patterns of the resident having been found on the floor for three of three falls, and review the care plan for appropriateness and effectiveness of the interventions using the information gathered from the previous fall. On January 14, 2013,after a fourth fall incident, Resident 1 was found on the floor, by staff, with a laceration to her forehead, and was transferred to a general acute care hospital (GACH) emergency room (ER). Resident 1 sustained a laceration to the right side of the forehead that required five to six sutures, and ecchymosis (skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels) to both eyes. A computerized tomography [(CT) a cross-sectional images of the body using X-rays and a computer] of the brain showed a small or thin right frontal subdural hematoma (usually result of a head injury, which the bleeding fills the brain area very rapidly, compressing brain tissue), both chronic (persists over an extended period of time) and acute (sudden or severe).According to Resident 1's clinical record (Face Sheet), she was a 63 year-old female originally admitted to the facility on October 28, 2012. Her diagnoses included history of falls, history of an old subdural hemorrhage (the blood vessels supplying the brain are disturbed or interrupted), seizures, and left cerebral infarction (also known as a stroke, which occurs when the blood vessels supplying the left side of the brain are obstructed or interrupted) with right side weakness.The Nursing Admission Assessment dated October 28, 2012, at 6:40 p.m., indicated the resident was a high risk for falls due to psychotropic drug use, disorientation/confusion, had an unsteady gait, required assistance for toileting, and had impaired sitting and standing balance. A review of the Physical Restraint Assessment dated October 28, 2012, at 6:48 p.m., indicated the resident had unsteady poor gait, attempts to function beyond ability, forgetful, had poor safety awareness/judgment, compulsive, climbs out of bed/chair and was a high risk for fall. There was a care plan, titled, "At Risk for Falls", dated October 29, 2012. The goal was for Resident 1 to have no serious injuries related to falls over the next 90 day review. The interventions included to keep the area free of obstructions to reduce the risk of fall or injury; place call light within easy reach, remind resident to call for assistance; respond promptly to calls for assistance to the toilet; and assess for pain or change in level of consciousness. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 23, 2012, indicated the resident was severely impaired in her cognitive skills for daily decision making. The MDS also indicated she required extensive assistance with one person assist with bed mobility, walking, transferring, dressing, personal hygiene and toilet use.A review of Resident 1's Change of Condition Assessment form and Investigations of Incident/Accident/Injury of Unknown Injury form indicated the following:1. On October 29, 2012, at 1 p.m., Resident 1 was found on the floor in front of her wheelchair with no apparent injuries in front of the large dining room. The resident was assisted back to bed and advised to call for help when assistance was needed. The documentation also indicated that the resident stated she slid down slowly. However, after this fall incident, there was no documentation that the facility provided an assistive device for the resident while in the wheelchair to prevent future sliding from the wheelchair.2. On November 13, 2012, at 7:10 a.m., Resident 1 was found on the floor without injury. There was no documentation where the resident was found. On November 13, 2012, a physician's order was obtained for a bed alarm (alerts staff when the resident attempts to get out of bed without assistance) at all times while in bed, to set the bed in the lowest position, and to place a floor mat at all times for safety.3. On December 10, 2012, at 3 a.m., Resident 1 was found on the floor next to her bed with no injury. The documentation indicated the resident's bed was in the lowest position, partial side rails were up and the tab alarm (a pull-string that attaches magnetically to the alarm with garment clip to the resident) was disconnected. The documentation also indicated the resident stated that she wanted to go to the bathroom. The resident was assisted to the bathroom and voided in the toilet. There was no documentation why the tab alarm was disconnected or if the resident disconnected or removed the tab alarm herself. 4. On January 14, 2013, at 11 p.m., Resident 1 was found sitting on the floor with a laceration on the right and left forehead. The documentation indicated the resident stated that she was trying to go to the bathroom. The assessment also indicated 911 (paramedics) were called and the resident was transferred to a GACH - ER.The facility?s investigation dated January 15, 2013, for the fall dated January 14, 2013 at 11:00 p.m., indicated Resident 1 was found on the floor mat by her bed and her call light was in her bed within her reach. The documentation indicated the resident forgot about using her call light and there was no documentation about the bed alarm.Resident 1 had four fall incidents from October 29, 2012, to January 14, 2013, which the fourth fall resulted in a laceration to the forehead and a subdural hematoma. A review of the GACH Physician History and Physical (H&P) Record dated January 15, 2013, indicated Resident 1 had a fall from bed, sustaining a head injury with laceration on her forehead between the eyebrows. The laceration was sutured in the emergency room. A review of the CT scan of the brain showed a small or thin right frontal subdural hematoma, both chronic and acute. The subdural hematoma was measured at 4.1 millimeter (mm) in thickness. The documentation indicated the resident would not need to have any surgical procedure for the subdural hematoma, because of the size of the subdural hematoma being only 4 millimeters in thickness. The resident was readmitted to the skilled nursing facility on January 17, 2013. The readmission physician's order dated January 22, 2013, indicated to apply a bed alarm to prevent falls/detect when the resident was out of bed.However, during an observation on February 7, 2013, at 8:30 a.m., Resident 1 was in her bed with a scab (a crust that forms over a sore or wound during healing) on her mid forehead above her eye brows measuring approximately 1.0 x 1.0 centimeters (cm). It was observed that the resident?s call light and the bed alarm were on the floor. In a concurrent interview with the certified nurse assistant (CNA 1) she stated the resident usually yells out for help, so most of the time, she would not use her call light anyway. CNA 1 also stated the resident was often confused and forgetful. CNA 1 was asked where the call light and bed alarm should be, and she picked up the call light and placed it next to the resident. CNA 1 also stated the bed alarm should be attached/clipped to the resident's gown, so when she attempts to get up unassisted, the alarm would sound and alert the staff.During an interview on March 8, 2013, at 12:09 p.m., the registered nurse (RN 1) stated when a resident is a high risk for falls, the facility has a special needs list on the CNA assignment form, so the staff is aware what interventions are supposed to be implemented for the specific resident. When RN 1 was asked to provide the facility Specific Special Needs List for Resident 1, she stated she could not provide one because it was discarded.On April 22, 2013, at 12:14 p.m., during a telephone interview with RN 1, she stated the staff had witnessed Resident 1 removing her tab alarm. When RN 1 was asked what the facility staff do when Resident 1 removed her tab alarm, she stated they just put it back on.A review of the facility's policy titled "Fall Prevention and Incident Management" dated April 1, 2001, indicated it was the policy of the facility to identify residents at risk for falls and/or accidents which the facility has control over by adequately planning interventions and implementing procedures to prevent falls and/or accidents. The policy included the following: The Special Care Needs/intervention will be communicated by the Licensed Nursing Staff via CNA assignment form and/or facility Specific Special Needs List.According to the facility's undated policy and procedure titled, "Change of Condition Management Guideline", the purpose of the guideline was to ensure that resident's change of health condition is assessed timely, appropriate interventions are implemented, and the effectiveness of the intervention evaluated, to ensure the highest quality of care. The policy also indicated if the change of condition is not life threatening the licensed nurse will document change of condition assessment reporting, and interventions in nursing notes form, and plan of care. An example of a change of condition included falls.The facility failed to ensure Resident 1, who had a history of falls, and who was assessed as being a high risk for falls, received adequate supervision and assistive devices to prevent accidents by failing to: 1. Develop an initial fall prevention care plan using the information gathered in the Nursing Admission Assessment and Physical Restraint Assessment dated October 28, 2012, that addressed the type of supervision and assistive device to alert the staff when the resident attempts to function beyond her ability and climbs out of bed/chair.2. Analyze and address the trends and patterns of the resident having been found on the floor for three of three falls, and review the care plan for appropriateness and effectiveness of the interventions using the information gathered from the previous fall. On January 14, 2013, after a fourth fall incident, Resident 1 was found on the floor, by staff, with a laceration to her forehead, and was transferred to a GACH emergency room. Resident 1 sustained a laceration to the right side of the forehead that required five to six sutures, and ecchymosis to both eyes. A CT of the brain showed a small or thin right frontal subdural hematoma, both chronic and acute.The above violation presented either imminent danger that death or serious harm would result to Resident 1. |
| 970000137 |
COUNTRY VILLA REHABILITATION CENTER |
910010098 |
B |
16-Aug-13 |
8J6U11 |
9899 |
F225CFR 483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.The facility failed to ensure an abuse allegation was thoroughly investigated, and failed to prevent further abuse from occurring as stipulated in the facility's policy. In August 2012, Resident 1 and her family had requested that nursing staff remove a certified nursing assistant (CNA 1) from providing care to Resident 1, after they had complained several times that CNA1 was rough when providing care to the resident. The facility continued to assign CNA 1 to provide care for Resident 1 from August 2012 until she was suspended on October 22, 2012, despite her numerous complaints, which also included Resident 1's allegation that CNA 1 threatened to choke her with the call light cord on October 3, 2012. This resulted in Resident 1 experiencing mental anguish, feeling unsafe, fearful, intimidated, and was observed crying. The Department received an Entity Reported Incident (ERI), dated October 9, 2012, alleging a resident (Resident 1) accused a certified nursing assistant (CNA 1) of threatening to choke her with the call light's cord if she called for assistance again. On October 22, 2012, at 8 a.m., an unannounced complaint investigation was conducted. On October 22, 2012, at 8:10 a.m., the assistant director of nurses (ADON) stated that on October 3, 2012, Resident 1 informed the social services assistant (SSA) that CNA 1 had threatened to choke her with the call light cord if she called for help again. According to the ADON, the SSA reported the allegation to the social service designee (SSD) who reported the incident to the director of nurses (DON) and Administrator 1 (previous administrator during the allegation). On October 22, 2012, a review of Resident 1's clinical records indicated she was a 76 year-old female who was admitted to the facility on April 9, 2012. Her diagnoses included osteomyelitis of the spine (infection in the bones in the back), muscle weakness, diabetes mellitus (elevated blood sugar), and hypertension (elevated blood pressure).A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May 22, 2012, indicated Resident 1 had the ability to understand others and make herself understood at all times.According to the MDS, the resident was able to demonstrate recall (memory) with occasional cueing and had not exhibited any behavioral symptoms. Resident 1 was non-ambulatory, incontinent (inability to control) of both bowel and bladder and required extensive staff assistance with all activities of daily living (ADLs). On October 22, 2012, at 8:30 a.m., during an interview, the SSD stated she had received several grievances from Resident 1 stating the facility's staff were not answering her call light or changing her in a timely manner. The SSD stated Resident 1 appeared to be agitated and very nervous when her family was not able to be at her bedside and she was left alone.At 8:32 a.m., on October 22, 2012, Administrator 1 stated as part of the facility's investigation for the verbal abuse allegation that occurred on October 3, 2012, she and the staff had interviewed other residents CNA 1 had cared for. The administrator stated they had gone into the residents' rooms and pushed the call lights (on day shift, the incident occurred on nightshift) to see how long it was before someone responded. Administrator 1 stated she had questioned Resident 1 if she felt safe while in the presence of the resident's husband. Administrator 1 stated she did not ask Resident 1 any questions regarding the abuse allegation.A review of the facility's investigation, dated October 4, 2012, indicated they interviewed four residents and one staff member (a restorative nursing assistant [RNA]) There was no written evidence of CNA 1 being interviewed by the facility.On October 22, 2012, at 8:38 a.m., the DON stated the resident's allegation of verbal abuse was unsubstantiated because the resident was not able to recall making the statement and the CNA stated she did not do it. When asked if CNA 1 had been suspended during their investigation as stipulated in the facility's policy, the DON stated CNA 1 had not been suspended.According to the facility's Abuse Investigation policy, dated October 1, 2002, if an employee is the suspected perpetrator the employee will be immediately removed from providing care to the resident and may be suspended. The policy also indicated the investigation would be thoroughly investigated.At 9:45 a.m., on October 22, 2012, a telephone call was placed to CNA 1 to interview her regarding the allegation and a voice message was left. The CNA did not return the call. On October 22, 2012 at 10:30 a.m., Resident 1 was observed sitting up in a chair at her bedside with a family member. When an interview was attempted, the resident indicated she could not speak English. After the resident agreed to have an interpreter, the facility's housekeeping staff was asked to interpret. The interpreter stated the resident stated she had told the social worker a CNA (CNA 1) had threatened to choke her with the call light cord. The resident stated her family members had told her CNA 1 was not supposed to take care of her anymore, but CNA 1 continued to care for her when the other CNAs went to lunch. Resident 1 requested the surveyor to call her family members, through the interpreter, and provided the telephone number. During the interview, Resident 1 started crying and stated, "I don't like ---- (CNA 1's name) and I'm scared of ------ (CNA 1's name). A review of CNA 1's employee file with the director of staff development (DSD) indicated on September 10, 2012, CNA 1 was disciplined for refusing to care for Resident 1. The entry indicated CNA 1 stated she could not care for the resident because the resident's family had filed a complaint against her for being too rough. The file indicated CNA 1 was written up in 2008, 2009, and 2010, related to providing poor resident care, residents' complaints, and walking off the job while being counseled by her supervisor. At 11:10 a.m., on October 22, 2012, the DON confirmed that CNA 1 had been disciplined on September 10, 2012, for refusing to care for Resident 1. The DON stated there was no documentation the family had requested CNA 1 not to care for Resident 1, and she had not believed CNA 1, but the DON did not call the family to verify. When asked if the CNA's employee file had been reviewed prior to the allegation of verbal abuse being unsubstantiated the DON stated, "No." On October 22, 2012, at 11:15 a.m., the DSD stated if a family member requested for a specific CNA to not care for a resident, the request should be documented, and the CNA should not be assigned to that resident. The DSD stated he did not know why the family's request to not have CNA 1 care for Resident 1 had not been honored or documented. At 5:45 p.m., on October 22, 2012, during a telephone interview, Resident 1's family member stated in August 2012 she and another family member had reported to one of the charge nurses of Resident 1's complaint of CNA 1 being too rough when cleaning her and that the CNA would not answer the call light when she called for help, and that Resident 1 did not trust CNA 1. The family member stated a charge nurse (name unknown) had told her CNA 1 would not be assigned to take care of Resident 1 anymore. The family stated the facility had not called and informed them of the verbal threat allegation on October 3, 2012, as stipulated in the facility's policy for abuse investigation.A review of CNA 1's assignment sheets for September 2012 through October 2012, indicated CNA 1 was assigned to care for Resident 1 on September 23 and 24, 2012, over a month after the family requested CNA 1 not be assigned to Resident 1. In addition, CNA 1 was assigned to care for the resident on September 7, 9, 12 and 30, 2012. CNA 1 also provided care to the resident on October 6 and 7, 2012, after the resident reported that CNA 1 had threatened to choke her with the call light cord on October 3, 2012. A review of a Licensed Nursing Note, dated September 10, 2012, and timed at 1:37 a.m. (the same day CNA 1 refused to care for Resident 1), Licensed Nurse 1 documented the resident's head was bumped against the head board when two CNAs (names not documented) were pulling the resident up in bed. Another licensed nurse's note, dated September 10, 2012, and timed at 8:09 a.m., indicated the physician was called regarding the resident's head being bumped and ordered neurological checks (assessments made after a head injury to check for changes in level of consciousness).On October 22, 2012, at 11:30 a.m., the DSD stated CNA 1 was one of the CNAs pulling the resident up in bed when the resident's head was bumped against the headboard. At 3:45 p.m., the same day, the DON stated she had heard about the head bumping incident with CNA 1, but she did not feel it was "related." The DON further stated she did not know if the resident's family had been informed who the CNAs were when the incident occurred. On June 24, 2013, at 2 p.m., during a telephone interview, Administrator 2 stated CNA 1 was suspended on October 22, 2012, after the Department's investigation, which was 19 days after the alleged verbal threat. Administrator 2 stated CNA 1 did not return to work.The facility failed to ensure an abuse allegation was thoroughly investigated, and failed to prevent further abuse from occurring by continuously assigning CNA 1 from August 2012 until October 22, 2012, to provide care to Resident 1, after Resident 1 complained and family member requested not to assign CNA 1 to the resident. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 910000318 |
COUNTRY VILLA PAVILION NURSING CENTER |
910010101 |
B |
16-Aug-13 |
FOEO11 |
4211 |
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 facilities objectives are achieved. On July 1, 2009 at 2:45 p.m., an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate an entity reported incident (ERI) that Patient 1 fell out of a Hoyer lift (a manual patient lift) and sustained a laceration to the back of the head. Based on interview and record review, the nursing staff failed to follow the facility's policy and manufacture?s warning that slings and lifts of different manufactures are not to be intermixed to ensure safe patient transfers. By not using the correct sling with the Hoyer lift (medcare sling with the medcare lift), Patient 1 fell out of the Hoyer lift and sustained a laceration to the back of her head. During a review of the clinical record for Patient 1, the Resident Identification form indicated Patient 1 was a 90 year- old female who was admitted to the facility on June 13, 2008, with diagnoses that included seizure (wild thrashing body movement), dementia (a loss of brain function) and muscle weakness.According to the Minimum Data Set (MDS) Resident Assessment and Care Screening Tool, dated April 8, 2009, the patient was moderately impaired in her cognitive skills for daily decision making, and was totally dependent on staff with transfer and locomotion on and of the unit.On October 13, 2009, at 11:20 a.m. during an interview and record review with the Rehabilitation Director, he stated based on the patient's initial assessment dated September 13, 2008, and the discharge summary dated October 13, 2008, the patient would benefit from the use of a Hoyer lift for transfer. A review of the Change in Condition Assessment dated June 18, 2009, at 1:30 p.m. revealed the licensed nurse documented the patient fell from the Hoyer lift. At 1:30 p.m., the physician was notified of the fall and ordered to transfer Patient 1 to a general acute care hospital (GACH).The patient was transferred to the emergency room by ambulance on June 18, 2009, (no specific time). A review of the Emergency Record Report obtained from the GACH dated June 18, 2009, at 4:50 p.m. indicated the chief complaint was a laceration to the back of her head. However, there was no documented description of the laceration.On July 1, 2009, at 3:30 p.m., during an interview with Certified Nursing Assistants (CNA) A and B, both stated they had received in-service on theHoyer lifts (Invacare and Medcare lifts) and the sling that was to be used with each Hoyer lift.The in-service record dated February 24, 2009, revealed that CNA C was in-serviced on the use of the two types of Hoyer lifts and their slings.On October 14, 2009, at 4 p.m., during an interview with Director of Nurses (DON), she said she was called to the room after the patient fell and found the patient on the floor face up and the sling was still attached to the lift. The DON stated the patient fell due to CNA C using the Invacare sling with the Medcare lift. The Medcare sling was the correct sling that was to be used with the Medcare lift. On July 1, 2009, at 4:20 p.m., during an interview with the Administrator she stated CNA C was terminated as this was not the first incident of the employee?s incorrect use of equipment.A review of the facility's policy, ?Hoyer Lift? dated October 1, 1994, indicated the purpose is to lift and move a patient safely from one location to another.A review of the manufacture?s recommendation for operation of the Invacare lift, under warning indicated the Invacare slings are made specifically for use with the Invacare lift. The warning also indicated slings and lifts of different manufactures' are not to be intermixed.The nursing staff failed to follow the facility's policy and manufacture?s warning, (slings and lifts of different manufactures are not to be intermixed) to ensure safe patient transfer. By not using the Medcare sling with the Medcare lift, Patient 1 fell out of the lift and sustained a laceration to the back of her head. This violation had a direct relationship to the health, safety, or security of Patient 1. |
| 970000137 |
COUNTRY VILLA REHABILITATION CENTER |
910010192 |
A |
13-Nov-13 |
RZ7513 |
9830 |
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. An entity reported incident (ERI) CA00359517, received on June 20, 2013, was investigated during the 2nd revisit survey on July 1. 2013. The ERI report was regarding a fall incident that occurred when a certified nursing assistant (CNA) transferred Resident 1 without assistance of another staff while using a mechanical lift. The resident fell from the mechanical lift and sustained a gash (a long, deep wound or cut) to the left side of the forehead. Based on interview and record review, the facility failed to ensure Resident 1 received adequate supervision to prevent accidents in accordance with the facility?s policy and procedure titled, "Residents Who Require Electronic/Mechanical Lifts for Transfer." The policy indicated that the electric/mechanical lift (lift) is required for any residents who require total assist with transfers, two people for transfers, or have the inability to bear weight on both lower extremities. The policy also indicated the number of staff required will be based on the manufacturer's guideline, resident's assessment, and care plan.Resident 1, who had multiple contractures (a permanent shortening of a muscle or joint), could not bear weight on her lower extremities (legs) and required two (+) persons physical assist with transfers, was transferred using a mechanical lift (Invacare) by only one certified nursing assistant (CNA 6). This resulted in the resident falling to the floor, along with the mechanical lift and CNA 6. Resident 1 sustained a gash on the left side of the forehead, had pinpoint pupils (indication of head injury) and vomited, required cardiac pulmonary resuscitation (CPR), and was transferred by paramedics to the general acute care hospital (GACH) where she subsequently expired due to arteriosclerotic cardiovascular disease (heart disease). During an interview and review of the undated Investigative Summary report with the administrator on July 1, 2013, at 2:30 p.m., he stated the facility's risk management and legal team completed the report. He stated CNA 6, the CNA involved in the incident, had been terminated. A review of the clinical record for Resident 1 indicated she was an 89 year-old resident who was admitted to the facility on April 9, 2010, with diagnoses of dementia (a loss of brain function) and multiple joint contractures. The Minimum Data Set (MDS) a standardized assessment and care screening tool, dated April 3, 2013, identified the resident as being severely impaired in cognition, with unclear speech rarely/never understood and rarely/never understands.The MDS assessment Section G dated April 3, 2013, for functional ?limitation that interfered with daily functions or placed resident at risk of injury? indicated Resident 1 had functional limitations with impairment in both upper and lower extremities on both sides, required total assistance from staff with transfers and bed mobility requiring a two-person physical assist, and was totally dependent in all activities of daily living (dressing, eating, toilet use, and personal hygiene). The balance assessment indicated the resident was not steady, and was "only able to stabilize with staff assistance" for surface-to-surface transfers. There was a plan of care dated April 2013, with a goal date of July 16, 2013, for the problem of potential for (further) injury related to fall risk factors of: disorientation/confusion, poor safety judgment, impaired sitting balance, and predisposing disease or injury. The goal was the resident will have no major injuries from falls. One of the interventions was to assist with transfers and mobility as needed. The care plan did not include the mode of transfer required (mechanical lift) or the number of persons required to transfer [two (+) persons physical assist] as indicated in the nursing assessment. A review of the Change of Condition Assessment dated June 20, 2013, at 8 a.m., indicated licensed vocational nurse 9 (LVN 9) documented an assessment for neurological ([neuro] nervous system) changes. Resident 1 was transferred to the GACH for altered level of consciousness. The assessment indicated the resident was not alert, was incoherent, with no speech, pupils equal and reactive to light, and upper/lower extremities were rigid (appearing stiff and unyielding), and had vomited a moderate amount of clear/water liquid. Resident 1 was experiencing pain rated at 2 out of 10 (pain scale of 1 to 10, 1 being the least pain, 10 being the most severe pain), had guarded movement and grimacing (facial expression).The Clinical Notes Report dated June 20, 2013, 4:40 p.m., documented by LVN 9, indicated at 7:45 a.m., a CNA asked for immediate assistance with Resident 1. Upon assessment LVN 9 noted a gash on the left side of the resident's forehead. A neuro check indicated the resident's eyes were open and blinking, both pupils were reactive to light, the resident's oxygen saturation level (oxygen in the blood normal 95 to100 percent [%]) was 91%, blood pressure was 106/63 (normal 120/80), and pulse 115 beats per minute (normal range is 60 to 100).A review of the GACH Emergency Department notes dated June 20, 2013, indicated Resident 1 arrived at 9:17 a.m., with CPR in progress, via ETT ([endotracheal tube] tube that is inserted through the mouth for the primary purpose of establishing and maintaining an open airway and to ensure the adequate exchange of oxygen and carbon dioxide). According to the notes, the emergency medical services staff stated the resident had gone into cardiac arrest when loading in the ambulance. Resident 1 was unresponsive, and there was no cardiac activity despite all resuscitative efforts, and she was pronounced dead at 9:34 a.m.According to the facility's June 25, 2013, investigation report of the June 20, 2013, incident, CNA 6 was using the lift to transfer the resident from the bed to the shower chair when the resident tumbled out of the chair, causing the lift and CNA 6 to fall with her. At 7:50 a.m., registered nurse 3 (RN 3) provided first aid to the left side of the resident's forehead. At about 8:05 a.m., the resident vomited, and at that time 911 was called. The resident's oxygen saturation was 80%, her pulse was fluctuating "greatly", her eyes were pin-point, and her blood pressure had dropped to 40/20. CPR was started, and Resident 1 was transferred to the GACH where she subsequently expired. A review of the resident?s Death Certificate dated July 31, 2013, indicated the immediate cause of death was arteriosclerotic cardiovascular disease (a specific form of arteriosclerosis in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol [fat-like substance in the body] and triglyceride [major form of fat stored by the body]). During an interview with LVN 9, on July 2, 2013, at 7:45 a.m., regarding the June 20, 2013, incident, she said CNA 6 asked her to come to Resident 1's room, and when she entered the room the resident was in bed. LVN 9 observed a gash on the left side of the resident's forehead and RN 3 was at the bedside. The physician was notified and ordered to transfer the resident to the GACH. Transportation was called, but after the resident vomited a clear color material, 911 was called immediately by LVN 9.During a phone interview with CNA 6 on July 5, 2013, at 1:45 p.m., he stated that Resident 1 was on his regular assignment on June 20, 2013. He was transferring the resident with the lift, and after placing the resident on the shower chair and was unhooking one side of the sling, the chair tilted over to the left and the resident fell and hit her head on the floor. He stated he called for help, and another CNA came and helped him put the resident back to bed. Resident 1 had blood coming from her head, and vomited before going to the hospital. He stated that he had used the lift by himself "many times" and had no problems. During an interview with the director of staff development 2 (DSD 2), on July 1, 2013, at 9:30 a.m., while reviewing CNA 6's employee records, she said CNA 6 was in-serviced via video on the use of the Invacare mechanical lift on April 4, 2012. DSD 2 was unable to provide the annual skilled proficiency check list for CNA 6, but stated there should have been one. The facility's manual titled "Mechanical Lift Transfer Program" dated August 2004, for transferring of residents, indicated the manufacturer (Invacare) recommends that two (2) assistants be used for all lifting preparation, transferring from and transferring to procedures. The facility failed to ensure Resident 1 received adequate supervision to prevent accidents in accordance with the facility?s policy and procedure titled, "Residents Who Require Electronic/Mechanical Lifts for Transfer." Resident 1, who had multiple contractures (a permanent shortening of a muscle or joint), could not bear weight on her lower extremities (legs) and required two(+)persons physical assist with transfers, was transferred using a mechanical lift (Invacare) by only one certified nursing assistant (CNA 6). This resulted in the resident falling to the floor, along with the mechanical lift and CNA 6. Resident 1 sustained a gash on the left side of the forehead, had pinpoint pupils (indication of head injury) and vomited, required cardiac pulmonary resuscitation (CPR), and was transferred by paramedics to the general acute care hospital (GACH) where she subsequently expired. This 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. |
| 910000027 |
COUNTRY VILLA SOUTH CONVALESCENT CENTER |
910010440 |
B |
06-Feb-14 |
QMZ511 |
6605 |
483.25(j) Sufficient fluid to maintain hydration The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. An unannounced complaint visit was concluded on February 3, 2014, regarding the allegation that Resident 1 was transferred to a general acute care hospital (GACH) with a diagnosis of dehydration. Based on interview and record review, the facility failed to ensure a resident who had a history of dehydration (a dangerous lack of water in the body resulting from inadequate intake of fluids), and had an order not to receive anything by mouth, was monitored for signs and symptoms of dehydration as indicated in the care plan (outlines the nursing care to be provided to a resident). The facility also failed to provide other means of hydration when the nasogastric tube [(NGT) a tube inserted through the nose and into the stomach to feed and/or provide hydration] was changed and awaiting X-ray confirmation of the NGT placement for one of one sampled residents (1). These deficient practices resulted in Resident 1's admission to a general acute care hospital (GACH) with a diagnosis of dehydration.Resident 1's Admission Record indicated she was admitted to the facility on January 19, 2013, with diagnoses that included dehydration (inadequate hydration), dementia (cognitive and intellectual deterioration), acute kidney failure (sudden and often temporary loss of kidney function), and had an NGT inserted.The Minimum Data Set (MDS), an assessment and care screening tool, dated January 28, 2013, indicated Resident 1's cognitive skills for daily decision-making were impaired. The resident required extensive assistance to totally dependent on staff with her activities of daily living, including fluids and nutrition. The resident had the following physician's orders dated January 20, 2013: 1. Isosource (feeding formula) 1.5 at 60 cubic centimeters (cc) an hour for 18 hours by NGT (for nutrition). 2. Flush (administer water) NGT with 120 cc of water every six hours (for hydration). 3. Give nothing by mouth (NPO). A Care Plan dated May 15, 2013, indicated Resident 1 was at risk for dehydration related to failure to thrive. The interventions included to monitor (to watch/check) the resident for signs and symptoms of dehydration such as poor skin turgor, dry oral mucosa, sunken eyeballs, foul odor urine, thick consistency, decreasing output of urine, low blood pressure, faster than usual heart rate, sudden onset of confusion, and change in level of consciousness, and to notify the physician if necessary. The Clinical (nurses) Notes dated January 21, 2013, at 3:02 p.m., indicated Resident 1's NGT was changed and an x-ray was ordered to check the placement of the NGT in the resident's stomach. The Clinical Notes dated January 22, 2013, at 4:16 a.m., indicated the x-ray result was pending. At 1:38 p.m., the Clinical Notes indicated the X-ray result was obtained and the result indicated no pneumonia.The Clinical Notes dated January 22, 2013, at 3:33 p.m., (24 hours after the NGT was changed) indicated the X-ray result for NGT placement was confirmed in the right place, and the NGT feeding was started. There was no documented evidence that Resident 1 was monitored for signs and symptoms of dehydration. Also, there was no documentation that the resident's physician was notified that the resident was not receiving feeding formula while waiting for the NGT X-ray result, for further instructions for alternative interventions. There was no documented evidence that Resident 1 received any fluids from January 21, 2013, at 3:03 p.m., to January 22, 2013, at 3:33 p.m., (24 hours) to prevent dehydration. The Clinical Notes dated February 5, 2013, at 1:50 p.m., indicated at 1 p.m., Resident 1's NGT was out and the afternoon medications were held. The note indicated the NGT was changed and a Kidney Ureter Bladder (KUB) X-ray was called to check the NGT placement. The Clinical Notes dated February 5, 2013, at 8:14 p.m., indicated at 6:02 p.m., the KUB results was received; the notes further indicated the NGT was in the proximal (next to) stomach. The X-ray reader (radiologist) was called to determine the exact location of the NGT and stated they were unable to determine the exact location of the NGT, and to advance the NGT. The documentation indicated the feeding was resumed. The resident went over 6 hours without any fluids on February 5, 2013, at 1:50 p.m. to 8:14 p.m. The Clinical Notes dated February 6, 2013, at 3:30 a.m., indicated Resident 1's blood pressure was 90/57 (normal systolic range 120 to 129 millimeter mercury (mmHg), diastolic normal range 80 to 84 mmHg), heart rate 121 per minute (normal range 60 to 80 per minute), and respiratory rate 36 to 39 per minute (normal range 16 to 20 per minute). The physician was notified and the resident was transferred to a GACH at 7:28 a.m. The History and Physical (H&P) obtained from the GACH dated February 6, 2013, indicated the resident was tachycardic (fast heart rate) and was dehydrated. The resident was given intravenous (administered into a vein) fluids and antibiotics for pneumonia.On April 8, 2013, at 11 a.m., during an interview and record review with the director of nurses (DON), she confirmed Resident 1 did not receive any type of hydration while waiting for the NGT X-ray confirmation result. She was also unable to provide documentation that Resident 1 was monitored for signs and symptoms of dehydration. The DON stated the licensed nurses should have notified the physician that the resident was not receiving fluids/formula while waiting for NGT placement to be confirmed, and to get an order for alternative measures for the resident to receive fluids.According to the facility's policy and procedure titled, "Tube Placement and Patency, Check, Dislodging/Pulling Out?, if correct tube placement is not completely assured, feeding or medication should not be administered. Staff should not attempt to reinsert the tube, and contact the physician for further instruction. The facility failed to ensure a resident who had a history of dehydration, and had an order not to receive anything by mouth, was monitored for signs and symptoms of dehydration as indicated in the care plan. The facility also failed to provide other means of hydration when the nasogastric tube was changed awaiting X-ray confirmation of the NGT placement. These deficient practices resulted in Resident 1's admission to a GACH with a diagnosis of dehydration.These violations had a direct relationship to the health, safety or security of Resident 1. |
| 910000032 |
CULVER WEST HEALTH CENTER |
910010487 |
B |
20-Feb-14 |
3GGY11 |
6897 |
483.13(c) F224 Each resident had the right to be free form mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. ?Misappropriation of resident property? means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent.On July 3, 2012, at 1 p.m., an entity reported incident (ERI), #CA00315862 and Complaint CA00317194 were investigated regarding financial/fiduciary abuse to a former resident (Resident 13). It was alleged that unauthorized money was withdrawn from Resident 13?s bank account, during his stay at the facility, from April 27, 2012, through May 30, 2012.Several of the checks were made payable to the facility's social service designee (SSD).The facility failed to ensure Resident 13 was free from misappropriation of his property (money), by not safeguarding the resident?s checks, which were in the possession of the facility's SSD and not placed in a secured/locked location. Investigation of the allegation and review of Resident 13's financial records revealed five checks, in the amount of $4,100.00, were made payable to and cashed by the facility's SSD.A review of Resident 13's Admission Records indicated he was admitted to the facility on April 18, 2012, and discharged on June 4, 2012. A review of Social Work Progress Notes, dated May 2, 2012, indicated the SSD went to Resident 13's former residence (a guest home) to pick up some of his belongings, which included personal checks. A review of an Inventory List, dated May 3, 2012, indicated the SSD added a box of checks to the inventory list. On July 3, 2012, at 1 p.m., during an interview, the Administrator (A1) stated Resident 13 was transferred from the skilled nursing facility (SNF) on June 4, 2012, to a general acute care hospital (GACH). He stated he later received a call from the Administrator (A2) of the guest home, where the resident had resided in the past and was currently residing. A2 informed him that Resident 13 had been readmitted to the guest home and she was looking for his identification. A2 asked if A1 could deliver the resident's property to them.When he arrived at the guest home he was informed by A2 that there had been some fraudulent (unauthorized) activity in the resident's bank account. A2 presented copies of the resident's returned checks, which revealed several were made payable to one of A1's employees, the SSD. A1 stated he returned to the guest home on another day to interview Resident 13, who did not remember being at the SNF, and when told the name of and shown a picture of the SSD, did not remember her. The resident told him he had not authorized money to be taken from his account, made any checks payable to cash or any other individual, including the SSD.During the interview, A1 stated he asked the SSD, who was on medical leave at the time, to come to the facility for follow up on the situation. He showed her the checks that were made payable to her and asked if she knew anything about them. She stated it was not her. During the interview with A1, a review of Resident 13's canceled checks was conducted, which revealed the signatures appeared to be different, and not that of the resident. On July 5, 2012, at 7:52 p.m., during a telephone interview, the SSD stated when it was determined that Resident 13 would remain at the SNF, she contacted A2 at the guest home and made arrangements to pick up the resident's personal items. She stated she took the resident with her and A2 was present when she picked up the resident's property, which included some of the resident's clothing, checks and paperwork. The SSD stated when she returned to the SNF she took the checks to A1 who told her to take them to the business office staff. She stated the business office staff refused to take the checks because of previous incidents of missing money. The SSD stated she then took the resident's checks and his other personal items, which were in a plastic trash bag, and put them under her desk. The checks were still under her desk when she became unexpectedly ill and did not return to work. She stated anyone could have taken them. When asked, she could not explain why the person who may have taken the checks would have made them payable to her and cashed them using her name.On July 9, 2012, at 11:50 a.m., during an interview, A1 stated he never told the SSD to take Resident 13's checks to the business office. He stated the SSD knew the procedures for residents' valuables and would not have had to ask him what to do with the checks, because she knew. A1 stated it was a practice of the facility to lock up residents' valuables in a safe they have located in the business office. On July 9, 2012, at 11:50 a.m., during an interview, the Business Office staff person stated she never had a conversation with the SSD regarding Resident 13's property and she was never asked to lock up the resident's checks.On August 1, 2012, at 12:30 p.m., during an interview, Resident 13 stated he had no memory of his stay at the SNF or going to the GACH, because he was very ill at the time. When told the name of the person who the checks were made payable to, the SSD, he stated he did not know anyone by that name. He asked what reason he would have had to pay anyone that much money, and what did he get for that kind of money? Resident 13, after reviewing copies of the canceled checks, stated the signatures on the checks were not his. He stated he had absolutely no memory of the events from the time he left the guest home until he returned there and that it was really scary to know you could get sick, lose your mind and someone would take advantage of you while you were in that condition. He stated he never felt vulnerable and mistrustful before, but now he doesn't trust anyone and stated, "I don't know what the hell is going on, I feel absolutely vulnerable." Therefore, the facility failed to ensure Resident 13 was free from misappropriation of his property (money), by not safeguarding the resident?s checks, which were in the possession of the facility's SSD and not placed in a secured/locked location. Resident 13, after his discharge from the facility, reported money was taken from his checking account, without his knowledge or authorization. Investigation of the allegation and review of Resident 13's financial records revealed five checks, in the amount of $4,100.00, were made payable to and cashed by the facility's SSD.This violation presented a direct relationship to the health, safety, security, or welfare of Resident 13. |
| 910000065 |
Century Villa, Inc. |
910011180 |
A |
23-Dec-14 |
GY1811 |
10975 |
72311 Nursing Services ? General (a) Nursing services 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 Department received an entity reported incident (ERI) on February 8, 2012. The ERI indicated on February 5, 2012, a patient (Patient A) was found on the floor in her room between two beds. The patient was sent to a general acute care hospital (GACH 1) where she was treated for a fracture left shoulder. Patient A was later sent to (GACH2) for treatment of the fractured left cheek bone that was also sustained during the same fall. Patient A expired while admitted to GACH 2 on February 7, 2012. Based on interviews and record reviews, the facility failed to develop a plan of care to address Patient A?s: 1. Fall risk while in a wheelchair. 2. Wandering behaviors while in a wheelchair. 3. Attempts to stand unassisted while in a wheelchair. These failures resulted in Patient A falling sustaining a fracture left shoulder and multiple facial fractures, being transferred to separate hospitals, and secondary to a respiratory arrest expired two days later. On October 7, 2014, at approximately 10 a.m., an unannounced investigation was conducted to investigate the ERI. A review of Patient A?s medical record (face sheet) indicated the patient was a 95 year-old female admitted to the facility on January 25, 2012. Her diagnoses included hypertension (high blood pressure), osteoarthritis (cartilage in the joints breaks down over time causing pain) of the knees, and neurogenic bladder (dysfunction of the urinary bladder due to disease of the central nervous system). A review of a form titled, ?Supplemental Statement to Incident Report,? dated February 5, 2012, and timed at 4:30 p.m., indicated Patient A was heard calling out for help. The report indicated Patient A was found lying on her left side with her right shoulder slightly forward to the floor and the left side of her face touching the floor with both legs flexed. The patient?s left arm was slightly twisted to her back and a moderate amount of blood was noted coming from Patient A?s nose. Patient A was sent out to the GACH and was diagnosed with a fracture shoulder and a broken cheek. According to the ?Nurse?s Note? dated February 5, 2012, and timed 5:05 p.m., Patient A?s physician determined the patient should be sent to the GACH. According to the physician?s orders, Patient A?s medications for the month of February 2012 included Ambien ( sedative, also called a hypnotic that causes sleep) 5mg every hour of sleep at 9pm (also indicated may give another 5 mg at am if patient not sleep), Seroquel (antipsychotic medication) 25mg one tablet twice a day for psychosis manifested by compulsive behavior and repeatedly yelling, Remeron (antidepressant medication used to treat major depressive disorder) 15 mg one tablet at the hour of sleep for depression manifested by poor appetite and sleeplessness and Zoloft (used to treat depression, obsessive-compulsive) 25 mg one tablet by mouth every day for depression manifested by seeking attention by yelling.On October 7, 2014, during an interview at 10:15 a.m., the director of nursing (DON) was asked how she believed Patient A got on the floor. The DON stated she did not know, but indicated it was determined that Patient A wheeled herself into her room and attempted to get out of her chair without help and fell. When the DON was asked if Patient A was capable of realizing the safety aspect of calling for help, she did not answer. A review of Patient A?s risk for falls, dated January 25, 2012, eleven days prior to the fall, indicated a score of 12 (a score above 10 represents a high risk for falls) secondary to balance problems while standing and walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns, requiring use of an assistive device (wheelchair) and receiving three or four psychotropic and sedative medications. Patient A was receiving Ambien, Seroquel, Remeron and Zoloft. A review of Patient A?s care plan, dated January 25, 2012, indicated she was at risk for falls or injury due to her unsteady gait, use of psychotropic medication, use of antidepressant medication, use of medications that could affect her balance and generalized weakness. The goal for Patient A was to be free from fall or injury daily until the next review April 2012. The staff?s approach plan was to keep the call light in reach and answer promptly, announce self when entering, explain all procedures, keep environment free of hazards, side rails up while in bed, use a one-two person assist during transfers, and notify physician and responsible party promptly for all fall incidents. There was no plan of care to address Patient A?s risk for falls from the wheelchair. A review of a Resident Care Conference Note, dated January 30, 2012, indicated the patient required extensive assistance from staff with activity of daily living and was usually up in the wheelchair self-propelling around the facility. A review of a form titled, ?Initial Wandering Assessment? dated January 25, 2012, indicated the patient had a history of wandering and was currently taking medications that could cause confusion and disorientation. A review of a physical therapy note, certified period from January 26, 2012 to February 24, 2012, indicated Patient A was at risk for falls secondary to the patient?s documented physical impairments and associated functional deficits. The physical therapist also documented the patient had a decline in function and an increased dependency upon caregivers with a decreased ability to return to prior level of assistance. A review of Patient A?s Minimum Data Set (MDS)(an assessment and care screening tool), dated February 5, 2012, indicated the patient required extensive assistance with locomotion on the unit (how the patient moved between the room and corridor in her wheelchair) and required a one-person physical assist. The MDS also indicated the patient had impaired vision and was hard of hearing.On October 7, 2014, at approximately 11 a.m., during a subsequent interview, the DON was asked why the facility did not address Patient A?s risk for falls from her wheelchair since the patient was up in her wheelchair daily. Patient A was also identified as taking medications that affects balance, while attempting to stand up from wheelchair without assistance. The DON was also asked why there were no preventative measures in place such as an alarm or wheelchair pillow after the patient was identified to have such behaviors. The DON stated she did not know to both questions. A review of Patient A?s GACH 1?s medical records indicated the patient arrived at the hospital on February 5, 2012, secondary to a mechanical fall while trying to get into her bed at the skilled nursing facility. A computed tomography scan (C-T scan diagnostic test that produces multiple images or pictures) of the brain and head indicated Patient A sustained a comminuted fracture (bone is splintered or crushed) of the anterior wall left maxillary sinus medley buckled, fracture left maxillary sinus lateral wall, slightly displaced, fracture floor of the left orbit without significant displacement and hemorrhagic products left maxillary sinus (facial bone fractures). According to the records, due to the patient?s multiple facial fractures she required an evaluation by an ear nose and throat (ENT) (a physician who specialized in the care and treatment of the ear, nose and throat). Patient A was transferred to GACH2 on February 6, 2012 at 6:13 a.m. for an ENT evaluation A review of Patient A?s GACH2 medical summary indicated the patient was seen in the emergency room on February 6, 2012 and was admitted later that day. The patient was found to have a left proximal humeral fracture (injury to the shoulder), in addition to her periorbital fracture (facial and eye bones). The record indicated a recommendation for a non-surgical treatment for both the humeral and periorbial fractures. According to the summary on February 7, 2012 at 9:15 a.m., Patient A expired secondary to a respiratory arrest (unable to breathe on own). The summary indicated Patient A had a pulse (heart rate) as low as 35 (normal 60-100), her oxygen saturation (measure of the amount of oxygen in the body) kept decreasing , she continued to have bradycardia (heart beats very slow) and received Narcan (used for complete or partial reversal of opioid depression, including respiratory depression, induced by natural and synthetic opioids) . On October 14, 2014, at approximately 10:20 a.m., in the presence of the DON, a telephone conference interview was conducted with the certified nurse assistant (CNA) 1 who was assigned to the patient on February 5, 2014, the day of the patient?s fall. CNA 1 stated at 3 p.m., the day of the incident she observed the patient in her room and at 3:30 p.m., the patient was observed outside her room.According to CNA 1 when she observed the patient outside of her room (did not know who put the patient there) the patient appeared agitated and was trying to get out of the wheelchair. When CNA 1 was asked what she did when she saw the patient getting up from the wheelchair, she stated she did what she was told to do, talk to the patient and try to calm her down. On October 29, 2014, at 2:30 p.m., another interview was conducted with CNA 1. During the interview CNA 1 stated the patient was always leaning forward and trying to get up from her wheelchair. When CNA 1 was again asked what she did when she observed Patient A attempting to get up from the wheel chair, CNA 1 again stated she tried talking to the patient to calm her down.According to a psychiatric evaluation, dated January 30, 2012, Patient A was orientated to name only, her concentration was impaired, was hard of hearing and had a fragmented thought process. According to Medicine.Net (www.medicine.net.com) patients with a fragmented through process may be unable to connect thoughts into logical sequences, with thoughts becoming disorganized and fragmented. The psychiatric evaluation also indicated the patient had poor judgment. The facility failed to develop a plan of care to address Patient A?s: 1. Fall risk while in a wheelchair. 2. Wandering behaviors while in a wheelchair. 3. Attempts to stand unassisted while in a wheelchair. The above violations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 910000027 |
COUNTRY VILLA SOUTH CONVALESCENT CENTER |
910011207 |
A |
31-Dec-14 |
CEZQ11 |
6132 |
F323 CFR 42 483.25(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. Based on interview and record review, the facility failed to ensure Resident 1 who was assessed to be non-compliant in following the facility?s smoking policy and required supervision during smoking did not have cigarettes, matches and/or a lighter in her possession. Resident 1 had these items and was able to light a cigarette in her room that caused a fire.On January 24, 2014 at 2 p.m., an unannounced visit was conducted regarding an Entity Reported Incident (ERI). According to the ERI report on January 10, 2014 at approximately 4 a.m., Resident 1 was assisted from her bed to the wheelchair. Shortly thereafter a staff member smelled smoke and saw smoke coming from Resident 1?s room. The staff member immediately went into the room and saw the small smoldering fire. Staff members removed Resident 1 from the room and a staff member was able to immediately extinguish the small fire in the bed linen. Resident 1?s roommate was removed from the room in her bed and relocated to another room. According to the admission record, Resident 1 was admitted to the facility on May 31, 2013, with diagnoses that included osteoarthritis of the knee (joint disorder causing pain and stiffness), osteoporosis (fragile bones with an increased susceptibility to fracture), history of right hip fracture, dementia without behavior disturbance (loss of mental functions such as thinking, memory, and reasoning). According to the Smoking Assessment, dated May 31, 2013, the resident should be monitored by staff when smoking. Resident 1 was assessed as non-compliant with following the smoking policy schedules, and kept cigarettes and lighter in her possession.The Minimum Data Set (MDS ? a standardized assessment care and screening tool) dated, June 6, 2013, indicated the resident spoke clearly and the resident was able to make herself understood and could understand others. The resident?s cognitive skill for daily decision-making was moderately impaired and she required extensive assistance from the nursing staff with bed mobility, transferring, dressing, personal hygiene and bathing. The resident?s mobility device was a wheelchair used to move around the facility.The smoking plan of care with goal date of March 1, 2014, indicated the resident required supervision and was non-compliant with the designated smoking areas and schedules. The care plan indicated the resident smoked in the employee/visitor parking lot or outside Station B nurses station by the door. The resident was non-compliant in wearing the smoking apron and hid cigarettes and lighters in her room. The nursing interventions included to monitor the resident every hour, to monitor any smoking materials the resident may have on hand, and to keep matches/lighters at the nursing station. During an interview and record review on January 30, 3014 at 11:30 a.m., with the Director of Nursing (DON), she stated the residents who are assessed for the smoking program are not to keep their cigarettes, matches or lighters on hand. The residents? cigarettes, matches or lighters are kept inside the medication cart. The DON stated the facility has scheduled smoking hours and the residents? cigarettes are lit by the employee scheduled to observe/supervise the residents. When the DON was asked how the resident is being monitored by the nursing staff members to ensure the resident did not have smoking materials in her possession, the DON stated the resident should have been assigned to a one to one monitoring and room check, where the nursing staff would ask the resident what smoking materials were in her possession, every two hours or more frequently and document the findings. The DON stated there was no documentation in Resident 1?s clinical records that one to one monitoring or room checks every two hours or more frequently were done.During an interview with Resident 1 on January 31, 2014 at 1 p.m., Resident 1 stated the staff did not ask her to keep her cigarettes in a medication cart. Resident 1 stated she could smoke anytime she wished to smoke, before the fire incident happened. Resident 1 stated on the date of the incident she had her cigarettes and lighter and was sitting in her wheelchair and took it upon herself to light her cigarettes with her lighter. The resident stated when she lit the lighter a huge flame flared out of the lighter, the flame ignited so fast, and she dropped the lighter on her bed sheet and mattress. Then a nurse came into the room and put the flame out. Resident 1 stated she was wheeled out the room and her roommate was pushed out of the room in her bed. The resident was asked where she got her cigarettes. The resident stated, she went out on a pass to buy cigarettes and a lighter and kept them in her room, but the staff did not know anything about the cigarettes and the lighter. According to the facility?s policy and procedure titled, ?Smoking,? dated August 12, 2012, it is the policy of this facility to accommodate residents who desire to smoke by providing a safe environment for the resident and to protect the non-smoking residents.Smoking is prohibited inside the facility and is allowed outside in designated, marked smoking areas with ashtrays of noncombustible material and safe design.The facility failed to ensure Resident 1 who was assessed to be non-compliant in following the facility?s smoking policy and required supervision during smoking did not have cigarettes, matches and/or a lighter in her possession. Resident 1 had these items and was able to light a cigarette in her room that caused a fire.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 for Resident 1 and all of the residents residing in addition to the facility and staff and visitors. |
| 910000027 |
COUNTRY VILLA SOUTH CONVALESCENT CENTER |
910011225 |
A |
26-Feb-15 |
7U9311 |
8502 |
CCR Title 22 72311 Nursing Service ? General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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 assessment shall commence at the time of admission of the patient and be completed within seven days after admission. Based on interview and record review, the facility failed to ensure Patient 1 who verbalized he was depressed upon initial admission assessment, was continuously monitored for signs and symptoms of depression, and referred to behavioral specialist to identify Patient 1?s level of depression. Patient 1 was found hanging from a closet rod in his room, and then was pronounced dead by the paramedic. On January 30, 2012 at 12:20 p.m., an unannounced visit was conducted regarding an Entity Reported Incident (ERI). According to the ERI report on January 29, 2012 at approximately 7:30 a.m., Patient 1 was found hanging in his room, in the closet, secured by pillow cases tied around his neck. Emergency telephone number 911 was immediately called.The emergency response services instructed the charge nurse to release Patient 1 from the hanging position, and perform cardiopulmonary resuscitation (CPR [an emergency lifesaving technique]) until the paramedics arrived. At 7:45 a.m. Patient 1 was pronounced dead by the paramedics. According to the admission record, Patient 1 was a 75 year old male admitted from a general acute care hospital (GACH) on January 20, 2012, with diagnoses that included alcohol withdrawal (symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol).The Nursing Admission Assessment, dated January 20, 2012 at 4:40 p.m., completed by the licensed vocational nurse 1(LVN 1), signed as completed by registered nurse 15 (RN 15) indicated Patient 1 was alert, confused, oriented to person, place, and time. The patient?s behavioral moods were anxious, and sad. The diagnosis or history indicated the patient had no anxiety disorder, psychosis or depression. The Nursing Admission Assessment indicated under the narrative notes the patient was in bed, awake, alert, verbally responsive and able to make his needs known. The narrative notes indicated the patient stated he was depressed and he needed someone to talk to. The note indicated Patient 1 was interviewed for a little while and by the end of the interview the patient stated he felt better, but there was no documentation of any other information gathered during the interview.Review of the physician?s orders dated January 20, 2012, indicated Librium (Chordiapoxide [antianxiety]) 25 mg two tablets three times a day for alcohol withdrawal, and Ativan (Lorazepam [antianxiety]) 1 mg every four hours orally as needed for anxiety manifested by agitation. The Psychotropic Risk and Benefits, dated January 20, 2012, signed by Patient 1, indicated the benefits of the Ativan medication was to decrease anxiety, to increase socialization, to increase comfort and to decrease injury to self and/or others. The risks indicated adverse effects associated with Benzodiazepine (Ativan ? a benzodiazepine) therapy are usually dose-dependent; Central Nervous System (CNS) related risks include headache, drowsiness, ataxia (unstable gait and loss of balance), dizziness, confusion, depression, slurred speech, syncope (passing out), lightheadedness, fatigue, tremors and vertigo. Review of Medication Administration Record (MAR [serves as a legal record of medications administered to patients in a facility by a health care professional]), from January 20, 2012 to January 29, 2012, indicated Patient 1 received Librium 25 mg (2 tablets) three times a day, for alcohol withdrawals. Ativan 1 mg per tablet was given on January 20, 2012 at 8 p.m. for agitation.There was no documentation to indicate what type of agitation was manifested by the patient. According to a review of the Clinical Notes Report from January 21, 2012 at 6:25 a.m., to January 28, 2012 at 9:07 p.m., there was no specific documentation to indicate the patient was being monitored and assessed for the adverse effect of the benzodiazepine (Librium and Ativan) which included depression as indicated in the facility?s Psychotropic Risk and Benefits. There was no follow up after Patient 1 verbalized that he was depressed on January 20, 2012, upon his initial admission assessment.The Transdisciplinary Information Rehabilitation Evaluation, dated January 22, 2012, under past medical history indicated Patient 1 fell two weeks ago after drinking heavily due to reported depression. No plan of care was developed to address depression and the use of benzodiazepine for alcohol withdrawal and anxiety. The Clinical Notes Report, dated January 29, 2012 at 3:58 a.m., indicated the patient was alert, oriented, able to make needs known, and in no apparent distress. The documentation indicated the patient was re-oriented to time and place times two due to the patient being restless. There was no documentation of what type of restlessness Patient 1 manifested, or if this was a new behavior. On January 29, 2012 at 9:22 a.m., (three hours, 27 minutes after the Patient 1 was identified being restless) the Clinical Notes Report indicated late entry for January 29, 2012, at 7:25 a.m. The documentation indicated during 7 a.m. to 3 p.m. shift rounds, Patient 1 was not in his room. The assigned certified nursing assistant was also looking for the patient to prepare him for breakfast. At 7:35 a.m., Patient 1 was found inside his closet, kneeling with white cloth around his neck which was attached to the closet bar.Emergency telephone number 911 was called. The emergency response services instructed the charge nurse to cut the white cloth on the patient?s neck. The patient was eased down to the floor by three staff.The documentation stated staff were unable to obtain the patient?s vital signs (signs of life). At 7:40 a.m., the facility staff initiated the CPR, and when the paramedics arrived, the paramedics took over the CPR. At 7:45 a.m., Patient 1 was pronounced dead by the paramedics. The County of Los Angeles, Department of Coroner Investigator?s Narrative report, dated January 30, 2012, indicated the patient was recently transferred from the GACH after staying there for approximately one week due to a back injury from a recent fall. Then the patient was transferred to the Skilled Nursing Facility. The narrative report indicated the patient?s history included possible prior suicide attempt, mental problems, and hypertension. No suicide note was found.The Death Certificate signed February 17, 2012, indicated the immediate cause of death was hanging. During an interview on March 13, 2012 at 3:30 p.m. LVN 1, stated he did not notify the physician about the patient?s verbalization of depression upon his initial admission assessment.The facility policy and procedure titled, ?Behavioral Management,? dated January 18, 2011, indicated it is the policy of the facility to ensure that when a patient displays mental or psychosocial adjustment difficulties, he/she receives appropriate treatment and services to correct the identified problems in order to obtain or maintain the highest practicable physical, mental, and psychosocial well-being.According to DailyMed, the official provider of Food and Drug Administration (FDA) label information (package inserts), indicated, ?The usual precautions are indicated when chlordiazepoxide HCI (Librium) capsules are used in the treatment of anxiety states where there is any evidence of impending depression; it should be borne in mind that suicidal tendencies may be present and protective measures may be necessary.? The facility failed to ensure Patient 1, who verbalized he was depressed upon initial admission assessment, was continuously monitored for signs and symptoms of depression, and referred to a behavioral specialist to identify his level of depression. Patient 1 hanged himself from a closet rod in his room, and died from the hanging. This 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. |
| 910000316 |
COUNTRY VILLA TERRACE NURSING CENTER |
910011245 |
AA |
26-Feb-15 |
VYC711 |
11703 |
42 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 comprehensive assessment and plan of care. 42 CFR 483.25(g)(2) Based on the comprehensive assessment of a resident, the facility must ensure that 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. 42 CFR 483.25(k)(2) The facility must ensure that residents receive proper treatment and care for the following special services: Parenteral and enteral fluids.On February 2, 2012 at 12 p.m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI), and two complaints from different sources regarding Resident 1?s jejunostomy tube (J-tube, a special feeding tube surgically inserted through an incision in the upper abdomen, that permits enteral feeding and insertion of medications and nutrients for the Resident). Resident 1?s J- tube, according to the complaints, was replaced with an incorrect type of tube which after being placed in the intestine and inflated, caused an intestinal obstruction (blockage of contents of the intestine). Based on interview and record review, the licensed nursing staff failed to ensure that Resident 1 who was admitted with a jejunostomy feeding tube received appropriate treatment and services, including but not limited to: 1. Failure to ensure the entry site and correct type of Resident 1?s feeding tube was accurately identified upon admission. 2. Reinsertion of Resident 1?s feeding tube without a physician?s order, in violation of the facility?s policy and procedure. According to the admission record, Resident 1 was admitted to the facility on December 21, 2011, with diagnoses that included dysphagia (difficulty swallowing) and status post (after) gastrostomy (a surgical procedure for inserting a tube through the abdominal wall, into the stomach). A review of the Nursing Admission Assessment narrative notes, dated December 21, 2011, indicated the resident?s diagnoses included status post gastric resection (surgical removal of part or all of the stomach) due to ischemia (insufficient supply of blood to an organ) with esophagogastrectomy (partial removal of the lower esophagus [lower esophagus carries food, liquids and saliva from your mouth to the stomach]), aspiration pneumonia (infection of the lungs caused by food, saliva, liquids or vomit breathed into the lung), and had a gastrostomy tube (GT) feeding intact and patent (unobstructed). A review of the GACH Discharge Medication List dated December 21, 2011, obtained from Resident 1?s Skilled Nursing Facility (SNF) clinical record indicated Resident 1?s medications were being administered through the J-tube. A review of the Minimum Data Set (MDS ? a standardized assessment care and screening tool), dated December 29, 2011, indicated the resident sometimes made self-understood and had the ability to understand others. The resident?s cognitive skills for daily decision-making were moderately impaired and the resident had a feeding tube.The resident had a physician?s order, dated December 21, 2011, for Peptamen nutritional formula 1.5 at 65 cubic centimeters (cc) per hour for 18 hours to provide 1170 cc/1755 calories per 24 hours. The Clinical Notes Report, dated January 16, 2012 at 1:33 p.m., indicated Resident 1 was noted with copious of green drainage from GT stoma (opening). The physician was called. At 1:54 p.m., the physician called back and gave an order for a wound culture and to call the resident?s surgeon. At 2:04 p.m., the physician gave an order to transfer the resident to general acute care hospital (GACH) for a GT evaluation follow up.The Nurses Notes from the GACH, dated January 16, 2012 at 4:10 p.m., indicated the resident was admitted from SNF with a complaint of leaking from the GT with green output for one day. At 5:42 p.m. the documentation indicated the resident?s GT had thick yellow drainage from stoma, and the surrounding skin was red. At 6:43 p.m., the documentation indicated the resident was actively vomiting with green bile colored vomitus. The resident?s oxygen saturation level was less than 80 percent (normal range 95 to 100 %). The resident was tachycardic (had an excessively rapid heartbeat) to 120 beats per minute (bpm) (normal heart rate ranges from 60 to 100 bpm). The documentation indicated the resident was placed on a non-rebreather mask (device primarily used to deliver oxygen to treat hypoxia, wherein the arterial blood oxygen saturation is less than 90 percent) at 15 liters per minute of oxygen.The Emergency Treatment Record from GACH, dated January 16, 2012, indicated the surgeon was consulted regarding the GT, and the resident was admitted to Intensive Care Unit (ICU -the department of a hospital that is designed and equipped for the monitoring, care, and treatment of the seriously ill patients).The Consultation Report, dated January 17, 2012, no specific time indicated the computed tomography (CT - detailed images of internal organs, obtained by sophisticated X-ray device) scan was significant for small bowel obstruction and bilateral pleural effusion (excess fluid filled space that surrounds the lungs). The complaint intake report, dated January 19, 2012, indicated the GACH?s surgeon and the ICU attending physician reported finding an indwelling catheter (Foley catheter) tube with a balloon in the J-tube site that caused an obstruction. (A Foley catheter is a type of urinary drainage catheter, commonly inserted in the urinary bladder for urine drainage; this type of indwelling catheter tube has an inflatable balloon used to maintain position of the catheter in the urinary bladder.) The GACH?s surgeon stated he did not place this catheter tube upon the resident?s last recent discharge from the GACH and the catheter is the wrong tube. The GACH suspected the catheter tube was replaced at the skilled nursing facility incorrectly.During an interview on February 10, 2012 at 12 p.m., with the 7 a.m., to 3 p.m., shift registered nurse (RN 1) supervisor, stated on January 15, 2012, upon leaving the facility, he observed certified nursing assistant (CNA 2) approach the 3 p.m., to 11 p.m., registered nurse (RN 2) supervisor. RN 1 stated RN 2 stopped him and informed him Resident 1?s feeding tube was pulled out. RN 1 and RN 2 went to Resident 1?s room and the 3 p.m., to 11 p.m., shift licensed vocational nurse (LVN 3) arrived into the room to assist. RN 1 stated RN 2 replaced the feeding tube with the indwelling urinary catheter French 18 (Foley type of catheter commonly used for urinary drainage). RN 1 stated he checked the feeding tube for placement by instilling 90 milliliter (ml) of air and listening to his stethoscope. RN 1 stated the feeding tube was in place and he observed gastric juice in the tubing. LVN 3 inflated the indwelling catheter?s balloon with 20 ml of normal saline (salty water). RN 1 stated he checked the GT placement one more time by instilling 20 ml of air with a 60 ml syringe and auscultated to check for tube placement. RN 1 stated he did not ask RN 2, if she called the physician, RN 1 stated the facility?s policy is to notify the physician when a tube is replaced. During an interview on February 29, 2012 at 2 p.m., RN 2 supervisor stated on January 15, 2012, CNA 2 reported Resident 1?s feeding tube was pulled out. RN 2 stated she and RN 1 went to assess Resident 1 and found the feeding tube hanging on the pole. RN 2 stated RN 1 asked her to re-confirm the placement of the feeding tube. RN 2 stated she checked the feeding tube placement by instilling 10 to 20 ml of air, and listened with her stethoscope for gurgling sound. RN 2 stated at 5 p.m. she checked the feeding tube again for placement, instilled 60 ml of air and listened to gurgling sound. RN 2 stated she administered the resident?s medications and the resident received the formula feeding for five to six hours. RN 2 stated the physician was not notified and no abdominal x-ray was done. RN 2 stated the facility has a GT policy for re-inserting the GT. RN 2 stated she was not made aware the resident?s feeding tube was a jejunostomy tube.During an interview with Director of Nurses (DON) on March 5, 2012 at 3 p.m., the DON stated RN 2, who took the telephone report from GACH, would identify whether Resident 1 had J-tube or GT. During the interview, the GACH Operative Report was provided by the DON. The GACH Operation Report dated November 29, 2011, provided by the DON, indicated the operation performed included feeding jejunostomy (J-tube).The facility?s policy and procedure titled, Gastrointestinal Tube Change and Reinsertion, dated December 2000, indicated the gastrointestinal tubes will be changed/reinserted, per physician?s order. During an interview on April 6, 2012 at 11:50 a.m. at the GACH, Physician 1 (the surgeon who inserted the initial J-tube) stated as to his recollection the resident was readmitted from the nursing home with what looked like pneumonia and possible bile obstruction. Physician 1 stated his recollection was that the resident was very sick from this process. The resident underwent a CT scan of the abdomen which was read by a radiologist, who detected that the feeding tube had a balloon on the end of it and that the balloon was inflated to such a degree it was obstructing the bile. Physician 1 stated the radiologist thought it was probably related to the degree that the tube?s balloon was inflated too great for the size of the intestine. Physician 1 stated whenever someone has a bile obstruction it can make them vomit, and it is possible the vomiting led to an aspiration, which led to pneumonia. So, tie all these events together and typically the tube was the source of the problem. Physician 1 stated when the tube was put in initially; the tube did not have a balloon on it, because it was not that type of tube. Physician 1 stated they knew the tube had been replaced. Physician 1 stated the resident had a feeding tube that went right into the jejunum and the jejunum is small compared to the feeding tube that goes into the stomach called a gastrostomy tube. So with the GT it does not matter how much balloon is blown up because the stomach is big, but the jejunum is small. The problem was the balloon was inflated a little bit too much for the caliber of the (jejunum). The Los Angeles County Medical Report from the Department of the Coroner, dated January 24, 2012, indicated the immediate cause of death as intestinal obstruction due to leakage from the feeding tube. The Death Certificate indicated immediate cause of death as intestinal obstruction.The facility failed to ensure that Resident 1 received appropriate treatment and services, including but not limited to: 1. Failure to ensure the entry site and correct type of Resident 1?s feeding tube was accurately identified upon admission. 2. Reinsertion of Resident 1?s feeding tube without a physician?s order, in violation of the facility?s policy and procedure. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of death of the patient. |
| 970000131 |
CALIFORNIA CONVALESCENT CENTER 1 |
910011310 |
A |
18-Mar-15 |
I17611 |
6258 |
42 CFR 483.25(h) F323 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.Based on observation, interview and record review, the facility failed to ensure Resident 16, who had episodes of trying to get out of the facility, was maintained on close supervision as indicated in the plan of care. Resident 16 eloped from the facility on March 25, 2014, and was found by paramedics on March 28, 2014, (three days later). When Resident 16 was found, he required immediate medical care for his life threatening condition of altered level of consciousness, dehydration (lack of body fluid), and hypoglycemia (low blood sugar). Resident 16 was brought to the general acute care hospital (GACH) for treatment. During the recertification survey on August 16, 2014 at 12:30 p.m., one resident was observed walking out of the facility. A certified nurse assistant (CNA) was seen leaving out of the facility to return the resident to the facility. On August 17, 2014 at 2:10 p.m., five residents were seen sitting in the facility entrance hallway without staff supervision. One resident got up and stated, "I need to leave,? and attempted to leave the facility. The evaluator informed the facility staff regarding resident?s statement and brought the resident back inside. During observations from August 15, 2014, from 5 p.m. to 9 p.m. and on August 16, 2014, from 7 a.m. to 5 p.m. and again on August 17, 2014, from 7:30 a.m. to 4 p.m., there was no facility staff assigned to supervise the front entrance of the skilled nursing facility. During an interview on August 17, 2014 at 11:45 a.m., when the administrator was asked about the lack of staff supervising the front entrance door she stated, there are video cameras constantly being used to monitor the front entrance door. During an interview with the assistant administrator on August 17, 2014, at 1:10 p.m., when asked if any residents eloped, he stated Resident 16 was missing from the facility on March 25, 2014, but was found on March 28, 2014, at the GACH. A closed record review of Resident?s 16?s History and Physical (H&P) dated August 25, 2012, indicated the resident was admitted to the facility on August 24, 2012, with diagnoses that included schizophrenia (mental disorder), 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), and syncope (fainting or passing out).The Minimum Data Set assessment, dated December 2, 2013, indicated the resident?s cognitive skills for daily decision-making were severely impaired. The resident was assessed as independent with bed mobility, transfer, and required supervision in walking in his room/corridor, and locomotion on and off the unit. The care plan, dated September 2013, for behavioral problem related to hitting himself, pacing, agitation and trying to get out of the facility with aggressive behavior had interventions that included to maintain close supervision and vigilance at all possible times. The Social Work Progress Notes, dated October 10, 2013, indicated an interdisciplinary care conference was held with the resident?s public guardian. The documentation indicated the resident likes to be at the parking lot and once in a month the resident tried to escape. The documentation further indicated the facility will continue with the plan of care. There was no documented evidence the resident was assessed for elopement risk. Additionally, the care plan intervention was not updated and/or revised to address resident?s behavior.There was a physician?s order, dated November 25, 2013, for Seroquel (antipsychotic medication - used to treat psychosis and other mental and emotional conditions) 200 milligrams (mg) one tablet twice a day, and 300 mg at bedtime for psychotic behavior manifested by (m/b) pacing, agitation, hitting himself and trying to get out of the facility. The Psychotherapeutic Drug Summary Sheet for Seroquel m/b hitting himself, pacing, agitation and trying to get out of the facility indicated from January 1 to 31, 2014, the resident had 28 episodes of this behavior, and from February 1 to 28, 2014, indicated 42 episodes.According to the Licensed Nursing Notes, on March 25, 2014 at 3:10 p.m., Resident 16 was seen standing at the entrance of the dining room. At 4:20 p.m., certified nursing assistant (CNA) was unable to locate the resident. Attempted to locate the resident by checking all rooms, bathrooms, shower rooms and outside premises, but unable to locate the resident. At 7 p.m., after the unsuccessful search for the resident, the police department (missing persons division) was notified.A review of the GACH H&P, dated March 28, 2014, (three days after the resident was missing from the skilled nursing facility [SNF]) indicated Resident 16 was found on the street with altered level of consciousness, blood sugar of 42 milligram per deciliters (mg/dL) (normal range 100 to 125 mg/dL), and dehydration. The resident was given intravenous hydration and was admitted to the hospital. Resident 16 was transferred back to the SNF on January 31, 2014, and was discharged to another facility on July 21, 2014. The facility had no policy and procedure on how to identify who was at risk for elopement, and to develop effective interventions that would be taken to protect residents from leaving the facility unsupervised. The facility failed to ensure Resident 16 who had episodes of trying to get out of the facility was maintained on close supervision as indicated in the plan of care. Resident 16 eloped from the facility on March 25, 2014, and was found by paramedics on March 28, 2014, (three days later). Resident 16 was brought to general acute care hospital (GACH) with an altered level of consciousness, dehydration (lack of body fluid), and hypoglycemia (low blood sugar).This presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 16. |
| 970000137 |
COUNTRY VILLA REHABILITATION CENTER |
910011627 |
B |
22-Jul-15 |
3ZRC11 |
6549 |
483.259(h) AccidentsThe 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 facility nursing staff failed to ensure a resident was transferred safely by ensuring that two staff provided physical assistance when transferring Resident 1 who was totally dependent on the staff from the wheelchair to the bed, and that the footrests on the wheelchair were removed and not swung back, to prevent the injury to Resident 1?s right leg. According to the general acute care hospital (GACH) record, dated June 17, 2011, Resident 1 sustained an 8.5 centimeter (cm) x 2 cm laceration to the right lower extremity shin (the front part of the leg from the knee to the ankle). The resident states she was being transferred into the bed with assistance and possibly cut her leg on the side of the bed. The GACH record indicated the resident?s medical history diagnoses included glaucoma (damage to the optic nerve that leads to progressive irreversible vision loss), cataracts (clouding of the lens in the eye leading to a decrease in vision) and bilateral hearing aid.On June 21, 2011 at 8:38 a.m., the Department received an Entity Self-Reported letter from the facility. The letter indicated Resident 1 sustained a laceration to her lower leg during transfer from her wheelchair to the bed. The resident was transferred to the GACH and returned within hours that same day on June 17, 2011. According to the admission record, Resident 1 was admitted to the facility on June 13, 2011, with diagnoses that included paralysis agitans (disease distinguished by muscular weakness and trembling of parts of the body at rest), Alzheimer?s disease (a progressive, degenerative disorder resulting in loss of memory, thinking and language skills, and behavioral changes) and Parkinson?s disease (neurodegenerative disorder which leads to progressive deterioration of motor function due to loss of dopamine-producing brain cells).The Minimum Data Set (MDS, an assessment and care screening tool), dated June 24, 2011, indicated the registered nurse assessment coordinator signed the assessment as completed. The resident speech was unclear and she was sometimes able to make herself understood and sometimes understood others. The resident?s cognitive skills (process of thought) for daily decision making were moderately impaired. The resident requires extensive assistance with two person physical assists and resident?s mobility device, the wheelchair or walker.A review of the plan of care for physical therapy, dated June 15, 2011, indicated problems with range of motion limitations and decreased ability to transfer, impaired balance and decreased safety awareness.A review of the Resident?s Post Change of Condition, dated June 18, 2011, indicated the resident was sent out by the 7 a.m., to 3 p.m., shift charge nurse due to a right leg laceration. The resident returned from the GACH emergency room the same day at 9 p.m., treated for the right lower leg laceration with 19 staples.On August 23, 2011, at 11:45 a.m., during an interview, certified nursing assistant 2 (CNA 2) stated the day of the accident (June 17, 2011), Resident 1 was sitting in her wheelchair and CNA 2 placed a gait belt around the resident?s waist. CNA 2 stated she then lowered the bed to an appropriate level to place the resident back into bed and pushed the resident?s wheelchair close to the bed. CNA 2 stated she swung back the footrests on the wheelchair before transferring the resident but did not remove the footrests. CNA 2 stated she lifted the resident from the wheelchair and pivoted the resident and placed the resident onto the bed. CNA 2 stated she did not look to see if the footrests were in the way of transferring the resident. CNA 2 stated the right footrest got caught between the edges of the bedframe and when she put the resident into bed she saw the blood caused by the accident. CNA 2 stated she applied pressure to the right leg and asked the activity staff to get a licensed nurse to help. CNA 2 stated she did not have help transferring the resident. On August 23, 2011, at 2:30 p.m., during an interview with the resident she stated she was clumsy and hit her leg on the side of the wheelchair. On August 24, 2011, at 12:35 p.m., during an interview, the director of physical therapy stated the resident?s mode of locomotion is a wheelchair or a walker. The director of physical therapy stated when transferring the resident from the wheelchair to the bed; the wheelchair should be locked, the footrests removed, the gait belt should be applied, the resident stood up and pivoted and then returned to the bed. The physical therapy director stated the wheelchair?s footrests should be removed, not swung back. When the footrests are not removed; the wheelchair footrests will create a gap between the wheelchair and bed, increasing the turning radius to pivot to return the resident into the bed during the pivot. The footrest would be in the way when the resident stood up. According to the facility Interview Record dated June 17, 2011, CNA 2 stated while transferring the resident stated, you hurt my leg, then CNA 2 saw the bleeding, but did not know what happened until the resident was in the bed and noticed blood coming from the resident?s right leg. CNA 2 saw the opening of the resident?s leg then CNA 2 called the treatment nurse and charge nurse.A review of the facility?s Tracer EX 2 - Owner?s Operator and Maintenance Manual Safety/Handling of Wheelchairs, not dated, indicated before attempting to transfer a resident in or out of the wheelchair, every precaution should be taken to reduce the gap distance.According to a review of the Interdisciplinary Resident Safety Investigation and Intervention, dated June 17, 2011, a wheelchair safety device, in-service training was provided regarding safe resident transfers and two-person assists during transfer. The facility nursing staff failed to ensure that a resident was transferred safely by ensuring that two staff provided physical assistance when transferring Resident 1 who was totally dependent on the staff from the wheelchair to the bed, and that the wheelchairs footrests were removed and not swung back, to prevent the injury to Resident 1?s right leg. The above violation had a direct relationship to the health, safety, or security of Resident 1?s. |
| 910000005 |
Centinela Skilled Nursing & Wellness Centre |
910012281 |
B |
31-May-16 |
24RM11 |
5234 |
72527 Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right:
(23) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in section 72018, except in an emergency which threatens to bring some immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specific period of time.
The Department of Public Health received an Entity Reported Incident on July 12, 2011, the allegation indicated Patient 1 was found tied with a bed sheet around her waist to her wheelchair on the 7 a.m. - 3 p.m. shift by certified nursing assistant (CNA 2).
Based on interview, and record review, the facility staff failed to ensure CNA 1 did not restrain Patient 1 with a bed sheet, by tying the bed sheet around Patient 1?s waist while she sat in a wheelchair.
A review of Patient 1's admission records indicated she was admitted to the facility on XXXXXXX2011, with diagnoses that included diabetes mellitus (high blood sugar), hypertension (high blood pressure), dyspnea (difficulty breathing), and had difficulty walking,
A Minimum Data Set (MDS, resident assessment and care screening tool), dated June 2, 2011, indicated Patient 1 had clear speech and had the ability to usually understand others and was usually understood by others. The assessment further indicated Patient 1 required extensive assistance with one person physical assistance with bed mobility, transfers, dressing, toilet use, and required limited assistance with personal hygiene, bathing, locomotion, and supervision with set up help for eating. The MDS indicated the patient was continent of bowel and bladder.
During an interview with Patient 1 on September 20, 2011 at 9:45 a.m., she stated she did not remember who it was that tied her up. The patient stated ?I think it may have been a woman late in the afternoon. I am sure I made some kind of noise. I think I was in the wheelchair in the room.? Patient 1 stated her memory was really bad back then and she felt really bad that a person, someone who was to take care of her, would tie her up, and who could have been that low to do something like that. Patient 1 stated she was not really sure who untied her.
During an interview on September 20, 2011 at 9 a.m., with the director of nurses (DON), she stated on July 12, 2011, around 9 a.m., CNA 2 reported to the charge nurse that Patient 1 was tied with a white sheet. The DON stated CNA 1 who was assigned to Patient 1 on the previous shift (11 p.m. to 7 a.m. shift) was interviewed and stated he did not tie Patient 1 with the bed sheet.
During an interview with the assistant director of staff development (DSD), on September 20, 2011 at 11:45 a.m., she stated after CNA 2 notified her about Patient 1, she went to the patient room and saw Patient 1 was tied with a bed sheet around her waist inside of her gown.
A review of a CNA Report of Misconduct, dated July 20, 2011, indicated on July 12, 2011, Patient 1 was found in a wheelchair restrained with a bed sheet. The notes indicated after interviews and video review, CNA 1 admitted to restraining Patient 1 in the wheelchair. CNA 1 stated he thought it was okay to do so because he was trying to ensure patient safety.
According to the facility's policy and procedure dated May 2010, titled, Nursing Administration Care and Treatment Restraints, Physical, the resident has the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The noted purpose of the policy was to attain and maintain the resident's highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the patient has medical symptoms that warrant the use of restraint.
Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body that the individual cannot move or have normal access to one's body. Physical restraints include tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that the patient's movement is restricted.
The facility failed to ensure CNA1 did not restrain Patient 1 with a bed sheet by tying a sheet around Patient 1?s waist while she sat in a wheelchair.
This violations had a direct relationship to the health, safety and security of Patient 1. |
| 920000084 |
CHATSWORTH PARK CARE CENTER |
920009123 |
A |
03-Apr-12 |
D6R911 |
10266 |
Title 22 Section 72311 (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. (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 identify patient care needs to prevent accidents or reduce the incidence of falls and implement its policies for transferring a patient from her bed to a shower chair which resulted in a fracture to the patient's spinal column (Patient 1) by failing to: 1. Ensure that a patient, who was assessed as requiring two-plus persons and a Hoyer Lift (an assistive hydraulic lift/hoist device used to lift a patient) for transfers, was provided the same when transferred from her bed to a shower chair. 2. Develop a plan of care based on the comprehensive assessment information with useful interventions to prevent injuries from falls during transfers. The Department received an Entity Reported Incident (ERI) regarding a patient who was injured during a transfer from the bed to the shower chair. During an ERI investigation on July 22, 2011, at 12:05 p.m., a review of the admission record indicated Patient 1 was re-admitted to the facility on March 29, 2011, with the diagnoses that included postural abnormality, and muscle weakness.According to the full Minimum Data Set (MDS) assessment dated August 30, 2010, and the June 5, 2011, quarterly MDS, Patient 1 was independent with skills for daily decision-making, required extensive assistance for bed mobility, dressing, and personal hygiene. Patient 1 was totally dependent on staff for transfers (how patient moves between surfaces), and required a two-plus person physical assist with transfers. She also had a diagnosis of paraplegia (loss of voluntary control of the lower extremities). She was 59 inches in height, and weighed 205 pounds. The Occupational Therapy Initial Evaluation/Discharge Summary form dated March 30, 2011, indicated Patient 1 was dependent on staff for functional transfers and required a Hoyer lift (an assistive hydraulic lift/hoist device used to lift a patient).The Fall Risk Assessment forms dated March 29, 2011, and May 12, 2011, indicated Patient 1 was a high risk for falls. According to the assessment tool, a score that represents a high risk for falls requires that a prevention protocol be ?initiated immediately and documented on the care plan.?On April 28, 2011, a Restorative therapy program was established by the OT and reviewed with the Restorative Nursing Assistant (RNA). This program indicated that transfers were to be done with a Hoyer Lift.The plan of care initiated on March 29, 2011, the day she was re-admitted, and updated June 2011, indicated Patient 1 was at risk for falls or injury due to muscle weakness, abnormal posture, spastic paraplegia, and anxiety. The goal in the care plan was that Patient 1 would be free from falls or injury daily through the next review. The interventions on the plan of care included to assist the patient with all transfers. The care plan did not include interventions related to the use of a two-plus-person assist during transfers, or the use of the Hoyer lift, as required in the comprehensive assessment. Although the Fall Risk Assessment, the MDS assessment, and the Occupational Therapist?s (OT) evaluation indicated the patient was a high risk for falls, and the MDS assessment indicated the patient required a two-plus person physical assist and a Hoyer lift for transfers, the plan of care did not include interventions to direct the nursing staff on how to transfer Patient 1 safely.A review of the Nurses Progress Notes form dated July 1, 2011, at 2:01 p.m., indicated that at 11:25 a.m. the charge nurse was called into Patient 1's room and found the patient on the floor "with the shower chair." Patient 1 was assisted back onto the bed, a body check was done and redness was noted on the patient's back. The patient did not complain of pain at that time, but did verbalize decreased sensation to both lower extremities. Patient 1 did not respond to painful stimuli to both lower extremities or her lower back. At 11:40 a.m., the nurse was unable to contact the physician and left a message at his office. At 12:20 p.m. the Nursing Supervisor called the physician and received an order to transfer Patient 1 to a general acute care hospital (GACH). At 1 p.m., Patient 1 complained of back pain which she rated 5 out of 10, on a one to ten pain scale, ten being the worst pain. Patient 1 was administered Vicodin ES (a narcotic drug used as a pain reliever for moderate to severe pain) for her pain. At 1:15 p.m. Patient 1 was transferred to the General Acute Care Hospital (GACH) emergency room via ambulance for evaluation.According to the facility's Incident/Accident (IA) Report dated July 1, 2011, Patient 1 was in the process of being transferred from her bed to the bathroom with the assistance of one CNA (CNA 1). The shower chair got stuck on the foot of the (Hoyer) lift machine. When CNA 1 pulled the patient back, and the shower chair rolled forward, CNA 1 tried to hold the sling (a sling is part of the Hoyer lift) but because of "my weight" the CNA had to drop the patient on the floor on her back with the shower chair.The IA Report reflecting CNA 1's description of the July 1, 2011 incident, written in Spanish, indicated she transferred Patient 1 from the bed to the shower chair to take the patient to the bathroom. The (shower) chair rolled backwards while Patient 1 was still in the sling. CNA 1 held her until she put her on the floor so she would not get hurt, and called for help. A nurse and another staff member arrived and assisted CNA 1 place Patient 1 on her bed. The facility terminated CNA 1 following this incident; therefore she was not available for an interview. On July 1, 2011, Patient 1 was admitted to the GACH for magnetic resonance imaging [(MRI) uses large magnet and radio waves to look at organs and structures inside the body] tests. The patient had extensive imaging studies which indicated a compression fracture (when the normal vertebral body of the spine is compressed to a smaller height of the spinal column) through the spinal disc at the thoracic 8 and thoracic 9 levels. The GACH Physician's Progress Notes (notes) dated July 7, 2011, indicated the patient was a poor surgical candidate, and also indicated a Telso brace (a brace designed to limit the motion of the spine in cases of fractures) had been ordered for the patient. The notes dated July 10, 2011, indicated that surgery would not be pursued.On July 26, 2011, at 1:30 p.m. an interview with Patient 1 was attempted at the GACH, however, she was sedated and was not able to respond. On July 29, 2011, at 2:30 p.m., during an interview regarding the July 1, 2011 incident, Licensed Vocational Nurse 1 (LVN 1) stated that CNA 1 called her on the ?walkie-talkie? to come assist her. LVN 1 went to Patient 1?s room and found her on the floor, and the shower chair was tipped backwards. LVN 1 stated that she called RNA 1, Staff 1, and Staff 2, but could not remember who it was, to assist in putting the patient back to bed.During a review of CNA 1?s personnel file and an interview with the Assistant Director of Staff Development (DSD) on July 29, 2011, at 3:10 p.m., it was revealed that CNA 1 had been trained using transfer equipment on the facility?s ?No Lift? and ?Safety? policies on October 13, 2009. She had also received training on Injury Prevention on April 17, 2010. On July 29, 2011, at 3:30 p.m., during the exit conference interviews with the Director of Nursing (DON) and the Administrator, it was stated that CNA 1 should have asked for help when transferring Patient 1. The Administrator added that staff training should be conducted on ?trouble shooting? if staff encounters a problem when transferring a patient. It was stated the individual (CNA1) made the decision to transfer Patient 1 by herself, and all staff know they should ask for help. There is always someone available to help. The comprehensive assessment and care plans were reviewed with them, and when asked, they could not provide any other documented information during the exit conference.A review of the facility's policy titled ?Fall Prevention Policy? indicated that nursing staff, together with the rehabilitation staff will assess a patient for fall risks and document on the patient's plan of care and licensed staff progress notes. The policy on ?Lifting Machine, Using a Portable? indicated that if a resident cannot participate in the lifting procedures, two (2) nursing assistants will be required to perform the procedure. The policy and procedure on ?Safe Work Environment for Residents during Transfer? indicated that there must be another CNA/RNA present especially if using a full lift.The facility failed to identify patient care needs to prevent accidents or reduce the incidence of falls and implement its policies for transferring a patient from her bed to a shower chair which resulted in a fracture to the patient's spinal column (Patient 1) by failing to: 1. Ensure that a patient, who was assessed as requiring two-plus persons and a Hoyer Lift (an assistive hydraulic lift/hoist device used to lift a patient) for transfers, was provided the same when transferred from her bed to a shower chair. 2. Develop a plan of care based on the comprehensive assessment information with useful interventions to prevent injuries from falls during transfers. The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 920000084 |
CHATSWORTH PARK CARE CENTER |
920009694 |
A |
11-Mar-13 |
54O711 |
13592 |
CCR T-22 72315(f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. On August 19, 2011, the Department received a complaint allegation that Patient 1 developed multiple infected Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) pressure ulcers, was severely dehydrated and suffered from repeated urinary tract infections. The patient was transferred to a general acute care hospital (GACH) for wound debridement, (the surgical removal of dead tissue).On September 1, 2011 at 12:40 p.m., an investigation of the above allegations was initiated. Based on interview and record review, the facility failed to prevent the development of pressure ulcers(decubiti), of a patient who was assessed at risk for the development of pressure ulcers by failing to: 1. Provide the proper nutrition that included adequate protein, calories, fluids and food supplements as directed by the physician. 2. Monitor the patient?s food and fluid consumption and notify the physician when the patient?s food and fluid consumption were below the desired amounts as assessed by the dietician. 3. Identify the reason(s) why the patient?s food and fluid consumption was below the desired amount, and develop a plan of care with appropriate interventions useful to increase the patient?s fluid and food consumption. 4. Ensure that the interdisciplinary team that included the wound care specialist, the dietician and the physician were involved in the treatment of the pressure ulcers and in the evaluation of the effectiveness of the treatment when the healing of the pressure ulcers was delayed and the pressure ulcers deteriorated and were infected. 5. Ensure that the patient was placed on a special assisted feeding program since the patient had diagnoses that included Parkinson's disease (A degenerative disorder of the central nervous system that often impairs the sufferer's motor skills, speech, and other functions that affects movement. It develops gradually, often starting with a barely noticeable tremor in just one hand) and dysphagia (difficulty in swallowing), and when the laboratory test results indicated the patient had poor nutritional status. 6. Ensure the feeding program was guided by a plan of care with diagnoses specific interventions appropriate for a resident with Parkinson's disease and dysphagia. A review of the admission record indicated Patient 1 was originally admitted to the facility on October 16, 2010, with diagnoses that included Parkinson's disease, dysphagia, and status post-acute renal failure. The patient expired in the facility on February 4, 2011. The Minimum Data Set (MDS ? a standardized comprehensive assessment of the patient?s problems and conditions) assessment dated October 22, 2010, indicated the patient cognitive level was severely impaired and the patient required extensive assistance from the staff for eating, bed mobility, transfers, dressing and personal hygiene. The MDS indicated the patient had no pressure ulcers upon admission and had a history of dehydration.The Admission Body Assessment diagram, dated October 16, 2010, indicated the patient's skin was clear with no skin breakdown. According to the Braden Scale for predicting Pressure Sore Risk, dated October 16, 23, 30 and November 6, 2010; the patient was identified to be at mild to moderate risk for skin breakdown.A review of the Dehydration Risk Assessment, dated October 16, 2010, indicated the patient was moderately at risk for dehydration (a condition in which the total body fluids inside and outside the vascular system are depleted due to several causes including insufficient fluid consumption. 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/the premature death of cells and living tissue AJN May 1999-Vol.99-Issue 5 Pages 66 to 69). A review of the Nutritional Assessment, dated October 21, 2010, indicated the patient admission weight and height at 182 pounds (lbs.) [83 kilograms (kg)] and 65 inches respectively. The patient?s usual body weight was unknown. The patient's adjusted body weight was 162 lbs. (74 kg). The estimated daily nutritional requirement, calculated based on the patient?s adjusted weight was 1825 to 2190 cubic centimeters (cc) of fluids per day, 1825 to 2555 calories and 73 to 87 grams of protein. There was no documented evidence why the usual body weight of the patient was not obtained in order to calculate the patient?s daily fluid needs to prevent dehydration since the patient had a history of dehydration and acute renal failure.On December 22, 2011 at 10:20 a.m., during an interview, the patient's family member stated the patient?s usual body weight was between 200 to 210 lbs. (91 to 95 kg) for his entire adult life. However, this information was not obtained from the family member and used to calculate the patient?s calories, protein and fluid needs.A care plan was initiated on October 16, 2010, for the risk of dehydration related to status post dehydration. The approaches included monitoring the patient for signs and symptoms of dehydration, to monitor the intake and output as ordered, to encourage increased oral fluid intake and provide extra fluids with meal trays.Although the patient was assessed to be at a risk for dehydration and for developing pressure ulcers, and had diagnoses related to challenges (Parkinson's disease and dysphagia) to self-feeding due to a disorder of the nervous system that affects hand movements and swallowing difficulties, the plan of care did not include the appropriate interventions for a patient with Parkinson's disease and dysphagia. For example, the patient was not placed in a special assisted feeding program in order to ensure he consumed the meals provided that would meet the assessed needs for adequate protein, calories, fluids useful in the prevention of the development of pressure ulcers.The Change of Condition sheet, dated December 21, 2010 at 9 a.m., indicated the patient had redness to his coccyx. Another Change of Condition sheet dated December 22, 2010 at 10 a.m. indicated the patient had Stage II (partial thickness skin loss) pressure ulcers to his coccyx and right inner buttock. A review of the Interdisciplinary Progress Notes, dated December 22, 2010 at 9 a.m. indicated the pressure ulcer to patient's coccyx was superficially open, measuring 3 centimeters (cm) by 2 cm with discoloration on the surrounding area. There was no description of the right buttock pressure ulcer.On December 22, 2011 at 10 a.m., during an interview, the Director of Nurses was unable to provide documented evidence that indicated the patient was provided and consumed the Novasource Renal (protein supplement) ordered by the physician to promote the healing of the patient's pressure ulcers. A review of the licensed nurse's note, dated December 22, 2010 at 10:45 a.m., indicated the patient was unresponsive and lethargic (a condition of drowsiness or indifference). The physician was notified and an order was obtained to transfer the patient to the GACH. The patient was transferred to the GACH on December 22, 2010 at 12:15 p.m. The GACH Admission Skin Assessment, dated December 22, 2010 at 3:29 p.m., indicated the patient had Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia), Stage IV and unstageable pressure ulcers.The Critical Care Evaluation from the GACH dated December 22, 2010 at 7:08 p.m. indicated that the patient hypotension (low blood pressure) was more likely due to sepsis and dehydration. The patient?s diagnoses included sepsis, dehydration, acute renal failure and hyperkalemia, deep vein thrombosis (DVT) and multiple pressure ulcers. The laboratory result from the GACH dated December 23, 2010 at 10:30 p.m. indicated the patient?s Total Protein was 6.3 gram/deciliter (g/dL) (normal range 6.4 to 8.3 gram/deciliter), Albumin 2.6 g/dL (normal range 3.5 to 5.2 g/dL).The patient was hospitalized until he was discharged and readmitted to the facility on December 30, 2010 at 9:50 p.m. On December 30, 2010, the patient was readmitted to the facility and a Re-Admission Skin Assessment diagram completed that same day, indicated the patient had pressure ulcers on the coccyx Stage IV, right and left inner buttock Stage II and right and left heel Stage I. The patient was also assessed with three plus (3+) edema (Fluid/water retention in cells or tissues due to disease or injury, quantified as 1+, 2+, 3+), to upper and lower extremities. A review of the Weekly Skin Integrity Sheets indicated the following assessment: 1. Coccyx pressure ulcer was assessed on December 30, 2010, January 3 and 10, 2011, as Stage IV, measuring 4 centimeters (cm) by 3 cm, depth 0.1 cm, with 20 percent (%) yellow black necrotic tissue. 2. Right inner buttock pressure ulcer was assessed on December 30, 2010, January 3 and 10, 2011, as Stage II, measuring 2 cm by 2 cm, red in color and the wound depth was superficial. 3. Left inner buttock pressure ulcer was assessed on December 30, 2010, January 3 and 10, 2011, as Stage II, measuring 2 cm by 2 cm, red in color and the wound depth was superficial.A care plan was initiated on December 30, 2010, for the patient?s pressure ulcers to coccyx, inner buttocks and heels. The approaches included to turn and reposition the patient at least every two hours, to encourage fluid intake if not contraindicated, monitor food intake and nutritional decubitus protocol. The plan of care did not address the low albumin and edema to identify if the patient's edema was protein deficient.The patient had the following nutritional physician's orders: 1. Pureed Diet and Novasource Renal 240 cc twice a day at 10:30 a.m. and 3:30 p.m. ordered on December 30, 2010. 2. The Pureed Renal Diet was discontinued and changed to Pureed Renal Diet with Nectar thick liquids on January 8, 2011. A review of the Medication Administration Record (MAR) and Certified Nursing Assistant (CNA) charting from December 30 to January 17, 2011, did not include documented evidence that indicated the volume of Novasource Renal protein supplement ordered by the physician was provided and consumed by the patient in order to promote healing of the multiple pressure ulcers. In addition, a review of intake and output (I&O) records indicated the patient was not receiving the estimated daily fluid needs as indicated in the plan of care. On January 13, 2011, there was a physician's order for laboratory tests and the results obtained on January 14, 2011, indicated a very low Pre Albumin level of 5.2 mg/dL (normal reference range 18 to 38 mg/dL).A review of the Wound Care Assessment, dated January 14, 2011, done by the wound consultant indicated the following assessment of the patient?s wounds: 1. Coccyx pressure ulcer was unstageable, measuring 4 cm by 4 cm; the depth was unstageable, black in color, with minimal drainage and had 100 percent necrotic tissue. 2. Right inner buttock pressure ulcer measuring 5.6 cm by 3.3 cm, the depth was unstageable, black in color, with minimal drainage and had 100 percent necrotic tissues. 3. Left inner buttock pressure ulcer measuring 2.5 cm by 1.4 cm, red in color and the wound depth was superficial. The above assessment of the patient?s wounds indicated that the patient's pressure ulcers deteriorated within 15 days of the patient?s December 30, 2010, re-admission to the facility. On January 17, 2011, the patient was again transferred to the GACH for evaluation of pressure ulcers and possible debridement of the wounds. The physician?s progress note obtained from the GACH, dated January 18, 2011, indicated the patient was diagnosed as having protein-calorie malnutrition. The facility failed to prevent the development of pressure ulcers of a patient who was assessed at risk for the development of pressure ulcers by failing to: 1. Provide the proper nutrition that included adequate protein, calories, fluids and food supplements as directed by the physician. 2. Monitor the patient?s food and fluid consumption and notify the physician when the patient?s food and fluid consumption was below the desired amount as assessed by the dietician. 3. Identify the reason(s) the patient?s food and fluid consumption was below the desired amount, and develop a plan of care with appropriate interventions useful to increase the patient?s fluid and food consumption. 4. Ensure that the interdisciplinary team that included the wound care specialist, the dietician and the physician were involved in the treatment of the pressure ulcers and in the evaluation of the effectiveness of the treatment when the healing of the pressure ulcers was delayed and the pressure ulcers deteriorated and were infected. 5. Ensure that the patient was placed on a special assisted feeding program since the patient had diagnoses that included Parkinson's disease and dysphagia, and when the laboratory test results indicated the patient had poor nutritional status.6. Ensure that the feeding program was guided by a plan of care with diagnoses specific interventions appropriate for a patient with Parkinson's disease and dysphagia. The above violation presented either imminent danger that death or serious harm would result to Patient 1. |
| 920000084 |
CHATSWORTH PARK CARE CENTER |
920010415 |
B |
29-Jan-14 |
5JLN11 |
14739 |
Title 22 Section 72311 (a)(2) (a) Nursing services 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. Based on interview and record review, the facility failed to communicate a patient?s request to be on a life-sustaining treatment status to paramedics which resulted in the patient?s intubation (insertion of a tube into the respiratory tract through the mouth for airway maintenance), mechanical ventilation and extubation.1. Patient 1, who had ?do not attempt resuscitation? (DNR) status and a request for transfer to the acute care hospital only, was found to have labored breathing which required the patient?s admission to the acute care hospital. Patient 1 was intubated (insertion of a tube into the respiratory tract through the mouth to maintain the airway) by paramedics and transferred to the hospital where he was mechanically ventilated and extubated. 2. The facility failed to implement Patient 1?s plan of care for DNR by not honoring Patient 1?s request for limited interventions which included comfort measures only and excluded intubation and mechanical ventilation.On December 6, 2012 at 3 p.m., an unannounced visit was made to the facility to investigate a complaint alleging Patient 1 was administered full resuscitation measures unnecessarily when he was transferred to the acute care hospital. Patient 1 was a very ill man and had very fragile skin, so when the paramedics and the hospital proceeded with the full resuscitation Patient 1?s arms, mouth and throat were very bruised and bloodied.According to the admission record, Patient 1 was initially admitted to the facility on November 1, 2011, and re-admitted on November 11, 2011, with diagnoses that included diabetes mellitus with blood sugar being over 700, cirrhosis, severe cardiomegaly (a heart condition that causes the heart to become larger than normal as a result of heart disease) and acute congestive heart failure (CHF) exacerbation.According to the Nursing History and Admission Assessment, dated November 1 and 11, 2011, the patient was alert but forgetful, was in poor general physical condition, was bedfast, had very limited mobility, and was dependent on staff for activities of daily living. There was a Physician Orders For Life-Sustaining Treatment (POLST) form, dated November 7, 2011, indicating if the patient did not have a pulse and was not breathing, the medical personnel should not attempt to resuscitate the patient (DNR) and if the patient was not in cardiopulmonary arrest, to follow orders in section B of the POLST.Under Section B of a POLST, the patient would require limited medical interventions in addition to comfort measures only such as use of medical treatment, antibiotics and intravenous fluids if indicated. Section B directives were ?Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care?. There was a plan of care, dated November 7, 2011, for the patient?s DNR status including limited medical interventions and transfer to the hospital only if comfort needs could not be met in the facility. The goal was to honor the patient?s wishes. The intervention was to adhere to the patient?s request for DNR and transfer to the hospital only.According to the licensed nurse?s progress note, dated November 12, 2011 at 6:15 p.m., the patient had a change in condition. It was documented that at 5:30 p.m., the patient?s blood sugar was 450 and insulin (insulin is a hormone that lowers the level of blood sugar) was given as ordered.A review of Change of Condition Documentation, dated November 12, 2011 at 6 p.m., indicated the resident had hyperglycemia (abnormally elevated blood sugar) and his code status was DNR. The form also indicated the patient?s plan of care was current and updated. There was a physician order, dated November 12, 2011, for blood sugar check by finger stick before each meal and at hours of sleep with insulin coverage on a sliding scale as follows: 1. For a blood sugar range from 150 to 200 give two units of insulin. 2. For a blood sugar range from 201 to 250 give three units of insulin. 3. For a blood sugar range from 251 to 300 give five units of insulin. 4. For a blood sugar range from 301 to 350 give six units of insulin. 5. For a blood sugar range from 351 to 400 give eight units of insulin. 6. For a blood sugar more than 400 give 10 units of insulin and call the physician.The patient?s blood sugar was re-checked in 20 minutes and it was 410. The patient?s physician was contacted and informed of the patient?s status and an order for additional eight units of insulin ?now? and re-check blood sugar in one hour was obtained. It was documented that the physician?s order was carried out. At 7:15 p.m., it was documented that the patient?s blood sugar was re-checked and it was 318. The physician was contacted and informed again on the patient?s condition. The order was to continue to monitor the patient and to report to the doctor if the patient?s blood sugar still would be high before a bed time. According to the licensed nurse?s note, dated November 12, 2011 at 9 p.m., the patient?s blood sugar was re-checked at 8:30 p.m., and it was 587. The physician was informed of results and gave an order to administer ten units of insulin ?now and re-check blood sugar in one hour and to notify the doctor if blood sugar would be more than 400? was given and carried out. At 10 p.m., it was documented that the patient?s blood sugar was 393, the patient?s doctor was aware of it and the licensed nurses were continuing to monitor the patient. The licensed nurse note, dated November 13, 2011 at 1:18 a.m., indicated the patient was asleep, was not in distress and his vital signs were stable. According to the licensed nurses note dated November 13, 2011 at 8:57 a.m., the patient was found to have labored breathing, was lethargic but arousable. The patient?s respiratory rate was 21 to 24 breaths per minute (average respiratory rate in a healthy adult at rest is usually 12?18 breaths per minute); his oxygen saturation rate was 87 to 88 percent on a room air (normal oxygen saturation range in a healthy individual is 95 to 100 percent on a room air) with apnea (transient cessation of breathing) for 15 to 25 seconds every two minutes.It was documented that the licensed nurses administered oxygen through non-rebreather facial mask (is a device used in medical emergencies that quires oxygen therapy and allows the delivery of higher concentrations of oxygen) ten liters per minute and called paramedics. Also, it was documented that the licensed nurses contacted the patient?s physician and responsible party to notify of transfer to the hospital due to shortness of breath.A review of Prehospital Care Report Summary from Los Angeles County Fire Department dated November 13, 2011, indicated the paramedics arrived to the facility at 8:22 a.m.According to the Prehospital Care Report Narrative Summary, the patient was found in respiratory distress with respiration rate of four breaths per minute and was a full code (full cardiopulmonary resuscitation). According to the Clinical Documentation of paramedics report at 8:22 a.m., the patient had an oxygen saturation rate of 89 percent on bag-valve-mask with oxygen flow at 15 liter per minute and at 8:23 a.m., while at the facility, the paramedic performed orotracheal (when the tube passed through the mouth into the trachea) intubation on the patient. At 8:39 a.m., the paramedics left the facility transferring the patient to the acute care hospital. A review of the acute care physician?s clinical report dated November 13, 2011 at 8:50 a.m., indicated the patient arrived to the emergency room intubated. At 8:52 a.m., per paramedics report the patient was a full code. At 10:33 a.m., the Family member 1 (patient?s medical care decisions maker) communicated to the hospital physician that the patient had a DNR wish. It was documented that this information was told to the physician after the patient had been intubated. Also, it was documented that the Family member 1 stated that she wanted to follow the patient?s wishes and she wanted the patient extubated (removal of the tube used in intubation) as this was what the patient actually told her in the past. The patient?s Family member 1 insisted that she did not want any heroic measures or even temporary intubation and she wanted the patient to have a comfort measures only. On November 13, 2011 at 10:59 a.m., the patient was extubated. During an interview with Family member 2 on December 6, 2011 at 11:35 a.m., she said the patient undergone intubation which was unnecessary and against his wishes. The patient had fragile skin and was very ill man so when the paramedics proceeded with the full resuscitation the patient was ?beat up pretty good?. His arms, mouth and throat were very bruised and bloodied. Family member 2 said that the patient suffered a great physical abuse during resuscitation.During an interview with the RN 1 on December 6, 2011 at 3:30 p.m., she said that upon patient?s re-admission to the facility on November 11, 2011, there was no updated POLST and the one dated November 7, 2011, was locked in the medical records office. RN 1 confirmed that according to the POLST dated November 7, 2011, the patient had DNR status. RN 1 said that every time when the patient comes back from the hospital the facility should update the POLST form.RN 1 said if the original POLST was available in the patient?s record the licensed nurses would honor it and act accordingly. RN 1 confirmed that the Change of Condition Documentation form dated November 12, 2011 at 6 p.m., indicated the patient was DNR.RN 1 said on November 13, 2011, when the patient was in respiratory distress, she called the patient?s Family member 1 and explained that there was a need to call 911 because there was no updated POLST and that the patient would be going to the hospital. Family member 1 agreed on the patient?s transfer to the hospital.A review of the licensed nurses note dated November 13, 2011 at 8:57 a.m., indicated RN 1 made the Family member 1 aware of the patient?s transfer to the hospital after the paramedics left the facility with the intubated patient to the acute care hospital. There was no documented evidence that RN 1 explained the Family member 1 about the need for the resident?s transfer to the hospital because the facility could not meet his comfort measures only. During an interview with RN 1 on December 6, 2011 at 3:30 p.m., she verbalized an agreement she did not discuss intensity of a life-sustaining treatment with the Family member 1 on November 13, 2011, when the need to call paramedics arised. During an interview with the Family member 2, on December 6, 2011 at 11:35 a.m., she said that Family member 1?s understanding was that if she documented the patient?s wishes by electing DNR on the POLST the facility would honor the patient?s wishes. Family member 1 was not aware of possibility that the facility might treat the patient as a full code and he would be intubated when RN 1 called her on November 13, 2011.During an interview with the Director of Nursing (DON) on December 6, 2011 at 4 p.m., she said that the facility would honor the most recent and updated POLST and if there is no updated POLST then it have to be updated otherwise the facility would care for a patient as if a patient is a full code. DON also said that from the patient?s arrival time to the facility there are 72 hours to update the POLST.During an interview with DON on February 13, 2012, at 1:30 p.m., she said that paramedics were not informed of the patient?s DNR status because there was no updated POLST during patient?s re-admission on November 13, 2011, and according to the facility?s policy only original POLST could be honored.DON also said there was no updated POLST upon the patient?s re-admission on November 11, 2011, because the patient?s medical decision maker did not accompany the patient upon re-admission.DON said that on November 13, 2011 at 8:57 a.m., Registered Nurse 1 (RN 1) called Family member 1 and informed her of the patient?s transfer to the hospital and she agreed on the patient?s transfer.DON confirmed the patient was admitted on November 11, 2011, (Friday) at 5:30 p.m., when the medical record office was closed until November 14, 2011, (Monday) and the patient?s clinical record for November 1 to November 7, 2011, was not available, however the licensed nurses had access to the patient?s medical record for re-admission on November 11, 2011.The DON also said that POLST dated November 7, 2011, was not accessible and it would not be legally in effect because it was not updated upon patient?s re-admission on November 11, 2011. The DON confirmed that it would be the licensed nurse?s responsibility to ensure the POLST was updated.A review of the patient?s clinical record revealed that there was no documented evidence the licensed nurses attempted to update the patient?s POLST during communication with the Family member 1 on November 12, 2011, at 6:15 p.m. and 9 p.m., or at any other time from the patient?s re-admission time until his transfer to the hospital.Also, the patient?s record indicated that upon re-admission on November 11, 2011, the patient came with the hospital record which included transfer form dated November 11, 2011, with an attached hospital physician?s order, dated November 8, 2011. According to this order the patient had DNR status and DNI (do not intubate) status. There was no documented evidence the licensed nurses acknowledged and confirmed this order with the patient?s primary physician.The facility failed to communicate to paramedics Patient 1?s request on a life-sustaining treatment status which resulted in patient?s intubation mechanical ventilation and extubation. Patient 1, who had DNR status and a request for a transfer to the acute care hospital only, was found to have a labored breathing which required the patient?s admission to the acute care hospital. Patient 1 was intubated by paramedics and transferred to the hospital where he was mechanically ventilated and extubated. The facility failed to implement Patient 1?s plan of care for DNR by not honoring Patient 1?s request for limited interventions which included comfort measures only and excluded intubation and mechanical ventilation. The above violation had a direct relationship to the health, safety or security of Patient 1. |
| 920000083 |
Canyon Oaks Nursing and Rehabilitation Center |
920010441 |
A |
11-Feb-14 |
V0PF11 |
11383 |
42 CFR ?483.25(h) Free of Accidents F 323 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 December 17, 2012, the Department received a complaint allegation regarding a resident (Resident 1) who had a fall on November 20, 2012, and sustained a broken neck and back. On December 18, 2012, at 9:55 a.m., an unannounced visit was made to the facility to investigate the allegation.Based on interview and record review, the facility failed to maintain a hazard-free environment for Resident 1 who was a hemiplegic (paralysis of one side of the body), totally dependent on staff for all care, and had a history of falls with injury. The Facility failed to: 1. Supervise the resident during morning care. 2. Maintain side-rails in the up-right position when away from the resident?s bedside. 3. Maintain the floor mats and bed in lowest position as stipulated in the resident?s plan of care. These failures resulted in Resident 1 falling and sustaining neck and back fractures, transferring to a general acute care hospital (GACH) on November 20, 2012, receiving intravenous morphine (strong pain medication) for pain management, wearing a neck collar to stabilize her neck fracture, being high risk for aspiration due to the neck fracture requiring a placement of a feeding tube. While at the GACH, Resident 1 succumbed to her injuries 11 days later on December 1, 2012.A review of Resident 1?s face sheet indicated the resident was a 91 year-old female that was originally admitted to the facility on July 25, 2006 and last readmitted on August 4, 2012. The resident?s diagnoses included cerebral vascular accident (blood flow stops to part of brain), dementia (decline of mental abilities such as thinking, reasoning, and memory), right-sided hemiplegia (weakness on one side of the body), osteoarthritis (pain in the bones and joints) and status-post pinning right femur (surgical placement of screws to repair the long bone of thigh fracture). A review of the facility?s Fall Risk Assessment tool for Resident 1, initially assessed on August 4, 2012, indicated the resident had a score of 12 (a total score of 10 or above represents high risk). The next fall assessment, on September 15, 2012, after a fall the same day, the resident had a score of 16. However, on November 13, 2012, the resident fall assessment score had increased to 20. On November 20, 2012, after a fall that day with fractures, the resident was reassessed to have a score of 22. The resident had a decline in activity of daily living and her fall risk had increased over a period of 70 days.According to the Minimum Data Set (MDS), a standardized assessment tool, dated August 16, 2013, the resident was assessed as having memory recall problems, difficulty with communication. The MDS indicated the resident was dependent on staff and required a two-person physical assist for bed mobility and transfer between surfaces. The resident was incontinent (inability to retain or hold body secretions) of bowel and bladder functions, was non-ambulatory and required a wheelchair for mobility. The MDS, under Section G0400 Functional Limitation in Range of Motion, indicated the resident?s upper extremity (shoulder, elbow, wrist, and hand) was coded ?0? indicating free of impairment. However, the resident?s lower extremities was coded a ?2? which indicated as being impaired.A review of the Care Area Assessment (CAA) Summary indicated falls were triggered as a problem area that required further assessment. It was dated August 4, 2012, and signed by a registered nurse on August 17, 2012, under Care Plan Considerations, indicated the IDT (inter-disciplinary team) agreed to proceed with care planning with focus on minimizing risk for falls and injuries to the resident and provide a safe environment and observe fall precautions.A review of a Resident Transfer and Referral Record, dated September 15, 2012, indicated the resident was transferred to the GACH for further evaluation after an un-witnessed fall.A review of the GACH?s emergency room (ER) report, dated September 15, 2012, and timed at 11:53 p.m., indicated the resident was transported by EMS to the ER on September 15, 2012 after a fall out of bed. The resident had ecchymosis (escape of blood into the tissues from ruptured blood vessels marked by a livid black-and-blue or purple spot) over her right leg and right leg x-rays were taken and were negative for any fractures. The clinical impression was a contusion of the right lower leg with instructions to apply ice, elevate, and give Tylenol. Resident 1 was transferred back to the facility on September 16, 2012. A care plan, dated September 15, 2012, titled, ?Actual Fall? indicated the resident was found on the floor next to her bed. The goal was to minimize the incidence of falls every shift. The staff interventions included to assist with activities of daily living, keep the bed at the lowest position, perform environmental assessment, and place landing pads on the floor. A review of a Fall Evaluation Conference form, dated September 17, 2012, after the resident was found sitting on the floor after a fall, at 9:10 p.m., on September 15, 2012, indicated recommendations by the IDT which included a landing pad on the floor and continuing the resident on a low bed.A review of another Resident Transfer and Referral Record, dated November 20, 2012, indicated the resident was transferred to the GACH for further evaluation after a fall from the bed with complaint of neck, left shoulder, head, and pelvic pain.According to the GACH?s ER records, dated November 20, 2012, the resident arrived to the ER via ambulance at 12:25 p.m. with the chief complaint being a fall out of bed. The ER records indicated the resident sustained a blow to the head with soft tissue swelling to the right parietal lobe (section of the brain that sits between the front and back lobes), lacerations to the right shoulder, and multiple fractures.A review of the GACH?s discharge summary, dated December 5, 2012, indicated the resident sustained many C2 (cervical vertebrae closest to the base of the skull) compression fractures (a collapse of several spinal bones, usually caused by trauma) T5 (thoracic vertebrae compose the middle segment of the vertebral column [spine]), L1, and L2 (lumbar region of the back is the lower area just above the sacrum [a bone found at the base of the spinal column]) status-post fall. On December 18, 2012 at 11:50 a.m., during an interview, a certified nursing assistant (CNA1), indicated on November 20, 2012 between the hours of 7 a.m. and 8 a.m., she told Resident 1 she wanted to clean her and get her up, because it was her scheduled shower day. CNA 1 stated she gets the resident up from bed every day, although the MDS indicated the resident required a two-person assist. CNA 1 stated she had asked CNA 2 for help with the resident, but CNA 2 was busy and continued with her own assignment.A review of the Resident Care Plan Conference Minutes, dated November 28, 2012, indicated CNA 1 was on the resident?s right side and was preparing to get the residentdressed. The CNA was not facing the resident and pulled the many blankets from the resident?s chest area. CNA 1 stated she then heard the resident land on the floor with the wheelchair near the resident?s head. The IDT explained the fall prevention program to the family that the facility had in place before the fall, which included the bed being at the lowest position, floor mats on the side of bed, and use of a two-person assist during morning care. However, CNA 1 was the only staff present during the initiation of the resident?s morning care.On December 14, 2012 at 11:25 a.m., during an interview, the director of nursing (DON) stated the staff attempted to provide morning care and the resident fell to the floor during the bath. The DON stated the CNA informed her when she moved the resident?s blankets down to the resident?s feet the resident suddenly rolled out of the bed.On December 18, 2012 at 12 p.m., during an interview, a licensed vocational nurse 1 (LVN 1 /charge nurse), stated, ?I was called to the resident?s room by the CNA who was yelling, I need help, I need help, I ran there and saw the resident lying on her left side on the floor close to the bed next to a wheelchair.? LVN 1 stated, ?I saw slight bleeding from the resident?s back.?On September 25, 2013 at 11 a.m., during an interview, CNA 1 stated she was getting the resident ready for a shower. CNA 1 stated she drew back the resident?s blankets, ?I felt the resident?s legs on top of my feet because she had already hit the floor. I called out for a LVN for help. The charge nurse (LVN 1) came to check on the resident and to help transfer the resident back to bed. The resident had bruises on her head and lower shoulders.? When asked about the low bed position, CNA 1 stated, ?I do not remember how high the bed was and I had removed the landing mattress when I started.?During an interview, on September 25, 2013, at 11:25 a.m., the director of staff developer (DSD) stated, ?From what I remember, the CNA raised the bed to waist level, placed the bath towels on the bottom foot of the bed, and then she pulled down the resident?s linen and that?s when the accident occurred.? The DSD stated, ?The CNA should not have turned away from the resident to pull her blankets down. I had a one on one in-service with her right after the resident?s fall.?On January 16, 2014 at 3:05 p.m., during a telephone interview, Resident 1?s family member stated while tearful, ?She suffered while in the hospital during her last days because of this serious injury that could have been avoided.? The family member also stated the resident?s side rail was down during the fall when the CNA was providing care and the facility investigated and indicated the CNA walked away during the care. Resident 1?s family member stated that during one of the resident?s care conference the family was informed that the facility fall prevention program included a two-person assist during the resident?s morning care and that CNA 1 was not facing the resident when she heard the fall that occurred after she pulled the blankets from the resident?s chest area to her feet to get her dressed. The family member further stated, ?The facility?s program that was in place failed not only the resident, but our family too.?According to the GACH?s records, Resident 1 expired on December 1, 2012, due to acute cardiopulmonary arrest (stoppage of the heart-lung function) and other diagnoses which included status-post fall with a C2, T5, L1, and L2 compression fractures.The facility failed to maintain a hazard-free environment by failing to: 1. Supervise the resident during morning care. 2. Maintain side-rails in the up-right position when away from the resident?s bedside 3. Maintain the floor mats and bed in lowest position as stipulated in the resident?s plan of care. 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 to Resident 1. |
| 970000083 |
COUNTRY VILLA LOS FELIZ NURSING CENTER |
920011797 |
AA |
2-Aug-16 |
WU6I11 |
12660 |
42 CFR? 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. 42 CFR? 483.20 (k)(1) Comprehensive Care Plans 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 following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ? 483.25. 42 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 October 3, 2014, the Department received a complaint (CA00415541) that alleged Resident 1 had a fall on October 2, 2014, between 6:30 p.m. and 7 p.m., while she was getting her snack from the nourishment cart. The resident fell and sustained an injury to her head, and was transferred to the general acute care hospital (GACH), where she died the same day. The facility failed to ensure Resident 1's environment was free of accident hazards during the distribution of snacks, and failed to provide adequate supervision and assistance to Resident 1 in receiving her snacks from the nourishment cart. The facility also failed to monitor Resident 1's orthostatic hypotension blood pressure on the date she had the fall. Resident 1, who had a history of falls and was assessed as being a high risk for falls, was using her front-wheeled walker [(FWW) an assistive device to use for additional support to maintain balance or stability while walking] when she came to the nourishment cart to get her own snacks. When she let go of her FWW to grab snacks and put them in a plastic bag hanging from her FWW, she lost her balance and fell backwards hitting her head on the floor. As a result, Resident 1 sustained a fatal blunt head injury from the fall. She was sent to the GACH where she died on October 2, 2014, the same date of her fall. On March 19, 2015, at 11:32 p.m., during a telephone interview, Family Member 1 (FM 1) stated Resident 1 fell and hit her head. According to FM 1, Resident 1 had a previous fall without injury and she was under close supervision to prevent an injury from a fall. FM 1 stated this time she fell while she was getting snacks from the nourishment cart. On March 19, 2015, at 1:40 p.m., during the onsite investigation, a review of Resident 1's admission record indicated she was admitted to the facility on November 3, 2008, with diagnoses that included rib fracture, syncope and collapse [also known as fainting, passing out and swooning, a short loss of consciousness and muscle strength, characterized by a fast onset] and osteoporosis (a progressive bone disease that weakens bones and makes them susceptible to bone fractures). A review of the current Minimum Data Set [MDS-a comprehensive assessment and care screening tool] dated February 12, 2014, indicated Resident 1 had moderately impaired cognitive skills for daily decision-making, had poor vision (able to read large print only), required supervision (oversight, encouragement or cueing) and set up help only while walking with a FWW. Resident 1 required limited assistance in dressing, toilet use and personal hygiene, and required physical help in part of bathing activity. The MDS indicated Resident 1 was not steady when walking or turning around, even with her assistive device (FWW), and had a history of falls. The Care Area Assessment (CAA) was triggered for falls as a problem area of concern requiring further assessment and a plan of care. A review of the Fall Risk Assessments dated August 12, 2014, indicated Resident 1 was a high risk for falls. Resident 1 was also assessed as having poor safety awareness and judgment, unsteady gait, and received multiple medications, including Vasotec, Clonidine (medications to treat high blood pressure), and Ultram (pain medication that may cause drowsiness, and dizziness, with increased risk for falls). A review of the physician's orders indicated the following: 1. Clonidine 0.2 milligram (mg) one tablet by mouth two times a day for high blood pressure, dated November 27, 2011. The adverse side effects included drowsiness, dizziness, dry mouth, nausea and vomiting. 2. Vasotec 10 mg at 9 a.m. every day, dated on November 11, 2011. The adverse side effects of these blood pressure medications included orthostatic hypotension (a condition in which your blood pressure falls when you stand up quickly, leaving you feeling dizzy or lightheaded). 3. Ultram 50 mg one cap by mouth one time a day for pain, dated November 21, 2013. The adverse side effects of Ultram included drowsiness and dizziness. 4. Monitor orthostatic hypotension (blood pressure while lying, sitting and standing). A review of the medication administration record (MAR) indicated Resident 1 had received the above medications as ordered. There was no documented evidence that indicated the adverse effects of the above three medications were monitored on the date Resident 1 fell and sustained a head injury. The resident's orthostatic hypotension blood pressure was not monitored on the date she had the fall. There was a care plan developed with a goal date of November 30, 2014, for the potential for recurrent falls/injury related to the presence of fall risk factors: history of falls, visually impaired, poor safety awareness, problems of impaired decision making, impaired judgment, predisposing disease or injury, heart medications, advanced age, osteoporosis and unsteady balance. The interventions to prevent falls and injury included to escort Resident 1 to activity programs for safety; keep the resident in frequently monitored areas; remind Resident 1 to use her ambulation device (FWW), and to keep her environment safe from hazards/clutter. On March 19, 2015, at 3:35 p.m., an interview was conducted with Certified Nursing Assistant 1 (CNA 1), who was assigned on the 3 p.m. to 11 p.m. shift, to pass nourishments on the day of Resident 1's fall incident. CNA 1 stated at approximately 6:45 p.m., while she was passing nourishments, Resident 1 was ambulating in the hallway with her FWW. Resident 1 started to pick multiple nourishments directly from the cart, and put them inside a plastic bag that was hanging on her walker, as she always did. While doing so, Resident 1 had to take her hands off of her FWW to place the items into her bag. Resident 1 then lost her balance and fell backwards, hitting the back of her head on the floor. CNA 1 stated she attempted to grab Resident 1 before she landed on the floor but she did not succeed. CNA 1 stated she summoned for help, and staff members rushed to the location. Vital signs were done, but Resident 1 was unresponsive, and the paramedics were called via 911. On March 19, 2015, at 4: 05 p.m., during an interview CNA 2 stated the charge nurse would announce when the nourishments were to be passed to the residents. CNA 2 stated ambulatory residents came all at once to the nourishment cart. Resident 1 walked with her FWW to the nourishment cart, took multiple items to place inside a plastic bag hanging on her walker. In doing so, when she took her hands off the walker, she lost her balance and fell backwards, hitting the back of her head on the floor. On March 19, 2015, at 4:45 p.m., during an interview Licensed Vocational Nurse 1 (LVN 1) stated that in the past, he observed Resident 1 take snacks directly from the cart because she did not have the patience to wait until the staff members served her snack. LVN 1 stated that in the past, he attempted to stop Resident 1 from taking snacks from the cart, but Resident 1 became upset and angry. On March 19, 2015, at 5:15 p.m., during an interview, the director of Nurses (DON) stated CNA 1 had witnessed Resident 1's fall at the nourishment cart. The DON stated Resident 1 always picked up food from the cart by herself, so this behavior was not an isolated incident. If the staff handed her the food, Resident 1 became angry and upset. There was no documented evidence provided to indicate the facility had addressed this potential safety problem in Resident 1's plan of care. A review of the facility's policies entitled "Snack Cart - H.S." and "Nourishment", both dated October 1, 1994, indicated the snacks are displayed on a cart and circulated to the residents' rooms by the nursing staff. The nurses aide asks each resident which snack they would care for, after checking the resident's diet order and/or allergies. It is the responsibility of the charge nurse to ensure nourishments are distributed to the residents. Assist the resident as necessary. If the resident is in the activity room, the staff are to take their nourishment to them, and assist them if needed. A review of the facility's Investigation Record dated October 3, 2014, at 9 a.m., indicated CNA 1 saw Resident 1 walking with her walker to the nourishment cart in the hallway. Resident 1 began picking up multiple food items from the cart and placed them into a plastic bag. CNA 1 was standing on the opposite side of the nourishment cart facing Resident 1, when the resident suddenly fell backwards hitting the back of her head. The Charge Nurse Narrative Notes regarding the incident dated October 2, 2014, indicated at 6:30 p.m., Resident 1 was seen ambulating with her walker heading towards the nourishment cart near Room 123. Resident 1 approached the cart on the opposite side, started picking up multiple items from the cart to place into a plastic bag hanging on her FWW. Resident 1 let go of the walker in order to place the items into her bag. While doing so she lost her balance and fell backwards hitting the back of her head on the floor. CNA 1 ran to the other side of the cart, and the resident was unresponsive for approximately two minutes. Nursing staff were notified and responded immediately. Vital signs were checked and 911 called. At 6: 35 p.m., the paramedics arrived, assessed the resident who remained unmoved, awake but altered in mental status. Resident was not able to answer any questions, and had an episode of vomiting. The paramedics transferred Resident 1 to the GACH. A review of the GACH Emergency Room Report dated October 2, 2014, indicated Resident 1 arrived at the emergency room at 7:11 p.m. Resident 1 was assessed in emergency with an altered level of consciousness with an acute brain injury. Resident 1 was intubated (the process of inserting a tube through the mouth and into the airway to enable the use of a breathing machine to assist with breathing when unable to breath independently). Resident 1 had an elevated systolic blood pressure of 260 (reference range 120), with no movement to all extremities. A brain scan revealed a large left subdural hematoma (a collection of blood outside the brain usually caused by severe head bleeding and increased pressure on the brain and can be life-threatening) with midline shift, mass effect and evidence of herniation (a potentially deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across the brain structures). The ER report indicated Resident 1 had an extremely poor prognosis (outcome) consistent with brain death at 8:27 p.m., and there were no further interventions needed to preserve the neurological functions. Resident 1 died the same date she was admitted to the GACH, October 2, 2014, at 10:27 p.m. A review of the Certificate of Death dated October 2, 2014, indicated the following: 1. Immediate Cause of Death: (a) Subdural Hematoma [is a collection of blood is a collection of blood between the covering of the brain (dura) and the surface of the brain, usually caused by severe head injuries] (b) Blunt Force Head Injury. 2. Other Significant conditions contributing to death but not resulting in the underlying cause: Hypertension, Cerebral Vascular Accident. The above violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of death of Resident 1. |
| 920000014 |
CHANDLER CONVALESCENT HOSPITAL |
920012672 |
A |
27-Oct-16 |
SRLQ11 |
7902 |
F-223 CFR 483.13 (b) ? Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. F-226 CFR 483.13 (c) Staff Treatment of Residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On 7/7/16, at 2:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1 been subject of abuse from certified nursing assistant 1 (CNA 1). Based on interview and record review, the facility failed to ensure Resident 1, who was cognitively impaired and dependent on staff for care, had the right to be free from abuse and failed to ensure written policies and procedures that prohibit abuse of residents were implemented including: 1. Failure to ensure Resident 1 was not physically, verbally, and mentally abused by CNA 1. 2. Failure to ensure CNA 2 and 3, and Housekeeping 1 immediately reported the abuse when they witnessed CNA 1 abusing Resident 1, as indicated in the facility?s policy and procedure on abuse prohibition. As a result, Resident 1 was subjected to repeated physical and verbal abuse by CNA 1. Staff observed CNA 1 slapping Resident 1?s face and verbally referring to the resident as Bald. The repeated abuse resulted in a reasonable person experiencing pain, mental anguish, and emotional distress. A review of the admission record indicated Resident 1 was admitted to the facility, on 5/23/14, with diagnoses including brain cancer, dementia (a decline in mental ability severe enough to interfere with daily life), and muscle weakness. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/3/16, indicated Resident 1 was usually able to make herself understood and usually understood others, was severely impaired in cognitive skills for daily decision-making, and was totally dependent on staff for all her activities of daily living (ADLs). A review of the SOC 341 (Report of Suspected Dependent Adult/Elder Financial Abuse) form dated 6/22/16, indicated two staff members (CNA 2 and CNA 3) had knowledge of abuse which occurred at the facility. An interview with Resident 1 was attempted, on 7/7/16, at 2:15 p.m.; however, the resident was unable to answer questions due to confusion. During an interview on 7/12/16, at 12:15 p.m., CNA 3 stated some time in April 2016, CNA 1 called him to help her transfer Resident 1 from the shower chair to the wheelchair. After the transfer was completed, CNA 3 stated he observed CNA 1 slap Resident 1's face several times and he told her (CNA 1) to stop. He stated CNA 1 struck the resident on both sides of her face with both hands and the resident put her hands up to cover her face. CNA 3 indicated Resident 1 looked scared and frightened. CNA 3 stated when he cares for Resident 1, she sometimes seems scared. CNA 3 stated he did not report the incident at that time because he was very busy and on 6/20/16, he talked to a co-worker (CNA 2) and reported the incident the following day, 6/21/16. On 7/12/16, at 3:15 p.m., during an interview, CNA 2 stated she observed CNA 1 slap Resident 1 in the face "...around a year ago." CNA 2 stated she could not remember exactly when the incident occurred. She stated CNA 1 had asked for her assistance in providing bedside care for Resident 1, and while doing so, CNA 2 observed CNA 1 slap the resident's face with an open hand. CNA 2 stated she was shocked and told CNA 1 not to hit the resident. She stated CNA 1 ignored her comment and continued fixing the resident's bed. CNA 2 stated she failed to report the incident at the time because she was scared. On 7/7/16, at 3:45 p.m., during an interview, the Director of Nursing (DON) stated CNA 3 told her he had witnessed an incident when CNA 1 slapped Resident 1 in the face several times and called her ?Bald? in Tagalog. A review of a care plan, initiated 3/10/16, indicated Resident 1 was at risk for body image disturbance due to alopecia (hair loss) related to history of cancer. The care plan interventions included to refer for counseling if needed, allow resident to verbalize feelings regarding change in body image, and observe for changes in mental status. According to the facility investigation, there was a third staff member (Housekeeping 1) who also witnessed CNA 1 abusing Resident 1. A review of the social service progress notes dated 6/21/16 indicated Resident 1 was interviewed regarding the abuse incident and stated she had been hurt several times by CNA 1. A review of the facility's policy and procedure titled, "Patient Abuse," updated 4/30/13, indicated the facility administrator and/or designee shall ensure the prevention, monitoring, and identification of unusual occurrences and events that may constitute abuse. Any incidences or occurrences that may constitute abuse shall be recorded on the Incident Report form and reported to the Director of Nurses, facility Administrator/Abuse Coordinator immediately after and/or no later than 24 hours after the identification of the unusual occurrence or events constituting abuse or probable abuse. The policy indicated CNAs were most likely to notice something was wrong. Professionally and legally nursing home staff was required to report. Possible abuse must be reported immediately to the nursing home administrator. The time period for reporting events that cause reasonable suspicion of abuse, but do not result in serious bodily injury to a resident was immediately, not later than 24 hours after forming the suspicion. The facility failed to ensure Resident 1, who was cognitively impaired and dependent on staff for care, had the right to be free from abuse and failed to ensure written policies and procedures that prohibit abuse of residents were implemented including: 1. Failure to ensure Resident 1 was not physically, verbally, and mentally abused by CNA 1. 2. Failure to ensure CNA 2 and 3, and Housekeeping 1 immediately reported the abuse when they witnessed CNA 1 abusing Resident 1, as indicated in the facility?s policy and procedure on abuse prohibition. As a result, Resident 1 was subjected to repeated physical and verbal abuse by CNA 1. Staff observed CNA 1 slapping Resident 1?s face and verbally referring to the resident as Bald. The repeated abuse resulted in a reasonable person experiencing pain, mental anguish, and emotional distress. The facility failed to ensure Resident 1, who was cognitively impaired and dependent on staff for care, had the right to be free from abuse and failed to ensure written policies and procedures that prohibit abuse of residents were implemented including: 1. Failure to ensure Resident 1 was not physically, verbally, and mentally abused by CNA 1. 2. Failure to ensure CNA 2 and 3, and Housekeeping 1 immediately reported the abuse when they witnessed CNA 1 abusing Resident 1, as indicated in the facility?s policy and procedure on abuse prohibition. As a result, Resident 1 was subjected to repeated physical and verbal abuse by CNA 1. Staff observed CNA 1 slapping Resident 1?s face and verbally referring to the resident as Bald. The repeated abuse resulted in a reasonable person experiencing pain, mental anguish, and emotional distress. 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. . |
| 920000084 |
CHATSWORTH PARK CARE CENTER |
920012834 |
B |
23-Dec-16 |
RGV311 |
10403 |
F205 - ?483.12(b)(1) (d) Notice of bed-hold policy and return- (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under ? 447.40 of this chapter, if any; (iii) The nursing facility?s policies regarding bed-hold periods, which must be consistent with paragraph (c)(5) of this section, permitting a resident to return; and (iv) The information specified in paragraph (c)(3) of this section. (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 the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section. F206 - ?483.12(b)(2) (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. 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 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. 3) Failure to permit Resident 1 to return and resume residence in the facility to the next available bed after 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. The Department received a complaint on December 9, 2016, alleging the facility failed to provide Resident 1 with a written bed hold notice; failed to afford Resident 1 the right to a bed hold; failed to readmit Resident 1 during the bed hold period; and failed to readmit Resident 1 to the first available bed following the bed hold period. On December 9, 2016 at 5 p.m., an unannounced complaint investigation was initiated to investigate the facility's refusal to readmit Resident 1 from the general acute care hospital (GACH 1). A review of Resident 1's Admission Face Sheet indicated Resident 1 was an 84 year old female Medi-Cal beneficiary, admitted to the facility on xxxxxxx, from GACH 2. Family 1 was listed as Resident 1's responsible party. A review of Resident 1's Client Diagnosis Report indicated Resident 1's diagnoses included pressure ulcer of sacral region (an injury to skin and underlying tissue resulting from prolonged pressure on the skin at the base of the spine) ; recurrent urinary tract infection (UTI ? an infection in any part of the urinary system, the kidneys, bladder, or urethra); Parkinson's Disease (a progressive disorder of the nervous system that affects movement); dysphagia (difficulty in swallowing); muscle wasting and atrophy; history transient ischemic attack (a temporary episode of neurologic dysfunction caused by loss of blood flow to the brain); protein-calorie malnutrition; and dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning). A review of Resident 1?s Minimum Data Set (MDS ? a comprehensive standardized assessment and screening tool) dated October 10, 2016, indicated Resident 1?s cognitive skills for daily decision making were moderately impaired, and needed total assistance from two staff members for dressing, toilet use, personal hygiene, and bathing. Resident 1 had impairment on both sides of upper extremities for functional limitation in range of motion. The resident was always incontinent of bowel and bladder. A review of the facility's Release of Responsibility/Temporary Absence log indicated on October 30, 2016, at 1 p.m., Family 1 took Resident 1 out of the facility on pass. A review of Resident 1's nurse's note dated October 30, 2016, at 1:25 p.m. indicated Resident 1 went out on pass with Family 1. A nurse's note written at 11:33 p.m., by Registered Nurse 1 (RN 1) indicated she spoke with Family 1 who advised RN 1 that she had brought Resident 1 to a hospital; RN 1 contacted the primary physician (MD 1). There was no indication in the note that RN 1 spoke to Family 1 regarding whether Resident 1 would like to have a 7 day bed hold. A review of Resident 1's physician order dated October 30, 2016 indicated Resident 1 transferred to GACH 1. A review of Resident 1's clinical record indicated that Family 1 had signed a Bed Hold Notification on Admission on October 3, 2016. A blank Second Notice of Bed Hold (to be completed upon transfer to a GACH) was in the chart. During an interview with the administrator of the facility (ADM) on December 13, 2016, at 2:00 p.m., he stated the facility did not provide a written notice of bed hold to Family 1 even after Family 1 notified the facility that Resident 1 had been admitted to the hospital. A review of the Refusal to Readmit Appeal No. 16-1132 Decision and Order from the Office of Administrative Hearings and Appeals (OAHA) indicated that during a hearing on November 16, 2016 at 10:45 a.m., GACH 1 staff stated Resident 1 was admitted on October 30, 2016, via ambulance. GACH 1 staff stated Resident 1 was ready for discharge to a skilled nursing facility on November 2, 2016, three days after her transfer to GACH 1 from the facility. During an interview with the facility's admission coordinator (AC) on December 14, 2016, at 11:00 a.m., she stated she was informed of Resident 1's readiness for readmission on November 2, 2016, through a computerized referral system. She stated she received another referral for Resident 1 on November 15, 2016, 16 days after her transfer to GACH 1. She stated Resident 1 was not accepted for readmission by the facility on both occasions. During an interview with ADM on December 14, 2016 at 11:16 a.m., he stated he received a phone call from GACH 1 on November 1, 2016, indicating Resident 1 was ready for readmission back to the facility. He also stated that he refused transfer as Resident 1 did not have Medi-Cal benefits; and on November 4, 2016, GACH 1 called him again for readmission of Resident 1, and advised him they were working on reinstating coverage. A review of the Refusal to Readmit Appeal No. 16-1132 Decision and Order from OAHA indicated that during a hearing on November 16, 2016 at 10:45 a.m., the facility acknowledged Resident 1's Medi-Cal was reinstated on or around November 4, 2016 (five days after Resident 1's transfer to GACH 1). A review of the facility's census for the month of November indicated there were available beds at the facility from November 1, 2016, to November 30, 2016. A review of the facility's census dated November 1, 2016, two days after Resident 1's transfer to GACH 1, indicated Resident 1 was "Off Bed Hold" or no longer on a bed hold. The facility's policy and procedures titled, "Bed Hold" dated September 20, 2009, indicated: a. The facility will provide a bed hold of up to seven (7) days when a resident is transferred for hospitalization or therapeutic leave. b. If a hospitalization or therapeutic leave exceeds bed hold period, the resident has the right to be re-admitted to the facility immediately upon the first of a bed in a semi-private room if the resident requires services the facility provides and is eligible for Medi-Cal (Medicaid) services. c. The facility will inform residents of the bed hold option upon admission and upon transfer. During a telephone interview with CM 1 on December 14, 2016, at 11:35 a.m., she stated she had received acceptance of Resident 1 for readmission to the facility. 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. 3) Failure to readmit Resident 1 to the first available bed following the bed hold period. The above violation had a direct relationship to the health, safety, or security of residents. |
| 970000083 |
COUNTRY VILLA LOS FELIZ NURSING CENTER |
920012916 |
B |
31-Jan-17 |
44WY11 |
7570 |
CFR 483.15 (d) Notice of Bed-Hold Policy and Return- (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under ? 447.40 of this chapter, if any; (iii) The nursing facility?s policies regarding bed-hold periods, which must be consistent with paragraph (c) (5) of this section, permitting a resident to return; and (iv) The information specified in paragraph (c) (3) of this section. (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 the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section. CFR 483.15 (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. On December 7, 2016, at 12:20 p.m., an unannounced visit was made to the skilled nursing facility (SNF) to investigate a complaint related to the facility?s refusal to readmit Resident 1. Based on interview and record review, the facility failed to implements its Bed Hold policy by: 1. Failing to provide Resident 1, at the time of transfer to a general acute hospital (GACH), a written notice specifying the duration of the bed-hold policy during which the resident was permitted to return. 2. Failing to allow Resident 1 to return to the facility after the hospitalization leave exceeded the seven day bed-hold. Upon transferring Resident 1 to a GACH on November 14, 2016, the facility did not provide the resident or the resident?s representative with a written notice specifying the duration of the bed-hold policy. On November 28, 2016, when the GACH called the facility for the resident?s return, the facility refused to readmit Resident 1. As a result, Resident 1 was not able to return to the facility of preference and had a longer stay in the GACH while a placement in another SNF was found. A review of the admission record indicated Resident 1 was readmitted to the facility, on XXXXXXX, with diagnoses including unspecified dementia (deterioration of memory, changes in behavior, and various other physical and mental problems) with behavioral disturbances and history of falls. The admission Face Sheet form indicated Family Member 1 was the resident?s responsible party. The Minimum Data Sheet (MDS ? a standardized assessment and care planning tool) dated September 9, 2016, indicated Resident 1 was able to communicate, was unable to walk, and required limited to extensive assistance with activities of daily living (ADLs). A physician's order dated November 14, 2016, indicated to transfer Resident 1 to a GACH due to hitting staff and having verbal outbursts. There was no physician?s order to hold the bed for seven days. Resident 1 was transported to the GACH on the same day XXXXXXX at 4:30 p.m. A social services clinical note dated November 17, 2016; timed at 12:43 p.m., indicated Social Services Designee (SSD) contacted Family Member 1 notifying her, the facility was not able to meet the resident?s needs and Family Member 1 needed to find placement for Resident 1 in another facility. Further record review disclosed a written Notice of Proposed Discharge/Transfer dated November 14, 2016 and signed by a facility representative but the notice was not signed by Family Member 1. There was no evidence the written Notice of Proposed Discharge/Transfer was mailed to the Family Member 1. According to a Discharge Chart Monitor form, dated November 21, 2016, the Bed-hold Notice/Bed-hold Order section was documented as not applicable (N/A). A late entry case management clinical note dated December 2, 2016, indicated that on November 28, 2016, the social worker from the GACH called the facility regarding Resident 1's return but the facility reiterated its intention/decision not to accept Resident 1 back. The facility policy and procedure titled, "Bed Hold," dated January 1, 2012, indicated the facility notifies the resident and/or representative, in writing, of the bed hold policy, any time the resident was transferred to a general acute care hospital. The Licensed nurse would communicate with the acute care hospital staff to monitor the resident's medical progress and expected date of return to the facility. In the event that the resident is in the hospital more than seven days, meets the standards for skilled nursing care, and is Medi-Cal eligible, the facility will readmit the resident to the first available bed in a semi-private room. During an interview, on December 7, 2016, at 2:15 p.m., the Director of Nursing (DON) stated a seven day bed-hold was not provided to Resident 1. During an interview, on December 7, 2016, at 3:40 p.m., the administrator confirmed the facility refused to let the resident return. The facility failed to implement its Bed-Hold policy by: 1. Failing to provide Resident 1, at the time of transfer to a GACH, a written notice specifying the duration of the bed-hold policy during which the resident was permitted to return. 2. Failing to allow Resident 1 to return to the facility after the hospitalization leave exceeded the seven day bed-hold. Upon transferring Resident 1 to a GACH on November 14, 2016, the facility did not provide the resident or the resident?s representative with a written notice specifying the duration of the bed-hold policy. On November 28, 2016, when the GACH called the facility for the resident?s return, the facility refused to readmit Resident 1. As a result, Resident 1 was not able to return to the facility of preference and had a longer stay in the GACH while a placement in another SNF was found. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000014 |
CHANDLER CONVALESCENT HOSPITAL |
920012970 |
B |
14-Feb-17 |
KBMB11 |
8751 |
?483.13(c)
The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences.
?CFR 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.
?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 5/9/16, at 11:50 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of resident to resident abuse.
Based on observation, interview, and record review, the facility failed to ensure its abuse policies and procedures were implemented; failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being; and failed to ensure a safe environment to its residents and that each resident receives adequate supervision to prevent accidents; including:
1. Failure to develop and implement behavioral management interventions addressing Resident 1?s known behavior to get into other residents? beds.
2. Failure to provide a safe environment and supervise Resident 1 to prevent him from getting in Resident 2?s bed.
3. Failure to separate Residents 1 and 2 and closely monitor them immediately after the physical altercation to prevent further incidents.
4. Failure to promptly report to the State agency the incident of Resident 2 hitting Resident 1.
As a result, on 5/1/16, at 8: 20 p.m., Resident 2 hit Resident 1 on the face causing abrasions to his face and the State agency was not notified of the incident within 24 hours.
On 5/9/16 at 12:03 p.m., Resident 1 was observed with a scabbed cut (approximately 2 centimeters) to the middle of his forehead and a fading bruise (purplish) to the bridge of the nose. At the time of the observation, an interview was with Resident 1 regarding the incident was attempted, but the resident stated he did not remember with a loud aggressive tone.
On 5/9/16 at 12:05 p.m., during an interview, Resident 2 stated, "Everything is fine, as long as he [Resident 1] stays off my bed." Resident 2 stated he punched Resident 1, because he got in his bed while he was occupying it and Resident 1 tried punching him first. Resident 2 also said Resident 1 had gotten in his bed a total of three times and two of the three times, he was already in his bed.
A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX15, with diagnoses including Alzheimer's disease (a type of dementia that causes problems with memory, thinking and behavior), dementia (memory loss and other intellectual abilities serious enough to interfere with daily life), and hypertension (high blood pressure).
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 4/8/16, indicated Resident 1 was able to communicate, had memory problems, had no mood or behavioral problems, and required extensive assistance with activities of daily living (ADLs) such us transfers, locomotion, ambulation, and personal hygiene.
According to the nursing progress note dated 4/7/16, Resident 1 was moved from his room due to the resident getting into his roommate?s bed to sleep.
According to the nursing note by Licensed Vocational Nurse 2 (LVN 2), on 5/1/16 at 8:20 p.m., Resident 1 was punched in the face and had abrasions to his forehead, bridge of the nose, and the upper lip. Further record review revealed no documented evidence the residents were closely monitored after the incident to prevent reoccurrence; there was no plan of care developed addressing Resident 1?s behavior of getting into other residents? beds which placed Resident 1 at risk of being attacked by an upset resident whose bed Resident 1 was using. There was no evidence the facility had developed a monitoring system to ensure close supervision of the Resident 1 to prevent him from using other residents? beds. The length of time and frequency of Resident 1 manifested the behavior were not determined as it was not monitored or documented.
A review of the clinical record indicated Resident 2 was admitted to the facility on XXXXXXX05, and readmitted on XXXXXXX14, with diagnoses including hemiplegia (unable to move or feel on one side of the body), and hypertension. A review of the MDS dated 2/12/16, indicated Resident 2 was able to communicate, had memory problems, had no mood or behavioral problems, was unable to walk, used a wheelchair for locomotion, and required extensive assistance with activities of daily living (ADLs). The MDS did not indicate the resident became easily upset.
On 5/9/16 at 1:25 p.m., during an interview with Certified Nursing Assistant 5 (CNA 5), who took care of both residents the night of the altercation, she stated that at around 8:30 p.m., she heard Resident 2 scream. She went to the residents? room and saw Resident 1 sitting on Resident 2's bed with a bleeding face and Resident 2 was lying in bed. CNA 5 reported the altercation to LVN 1 who told her to just continue to monitor both residents. CNA 5 stated Resident 1 was confused, had a history of getting in other residents? beds, and did not follow instructions. CNA 5 stated Resident 2 had complained twice about Resident 1 getting in his bed and she had reported the complaints to LVN 1 and LVN 2.
According to the facility's policy and procedures updated 4/30/13, titled "Prevention of Resident Abuse and Mistreatment," the facility would provide a safe environment as free of hazards and injury as possible. A plan of care would be implemented to address and prevent aggressive behavior. The behavior management program was used as facility guidelines for the policy and procedure. Any aggressive behaviors would be addressed immediately. The policy indicated the facility would provide behavior modification, calling the physician, separate residents involved, place resident with behavior on a 24 hour observation schedule, involve family/conservator/public guardian when appropriate, and call psychiatrist or psychologist to examine patient when necessary.
The policy also indicated to report any suspicion of a crime that is not a serious bodily injury to the state agency within 24 hour.
On 5/9/16 at 1:42 p.m. during an interview, the Director of Nursing (DON) stated Resident 1?s behavior of getting in other residents' beds was not documented and a plan of care was not entered until 5/3/16. She said residents involved in a resident to resident altercation should be monitored "at least every hour." The DON stated that since Resident 1 had a history getting in other residents? beds, the behavior should have been addressed sooner.
On 5/9/16 at 2:50 p.m., during a telephone interview, LVN 1 stated that approximately three weeks ago, during rounds, he saw Resident 1 on someone else's (another resident) bed and it was okay, because the resident was confused. LVN 1?s intervention was to redirect the resident to his bed.
The facility failed to ensure its abuse policies and procedures were implemented; failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being; and failed to ensure a safe environment to its residents and that each resident receives adequate supervision to prevent accidents; including:
1. Failure to develop and implement behavioral management interventions addressing Resident 1?s known behavior to get into other residents? beds.
2. Failure to provide a safe environment and supervise Resident 1 to prevent him from getting in Resident 2?s bed.
3. Failure to separate Residents 1 and 2 and closely monitor them immediately after the physical altercation to prevent further incidents.
4. Failure to promptly report to the State agency the incident of Resident 1 hitting Resident 2.
As a result, on 5/1/16, at 8: 20 p.m., Resident 2 hit Resident 1 on the face causing abrasions to his face and the State agency was not notified of the incident within 24 hours.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000084 |
CHATSWORTH PARK CARE CENTER |
920013112 |
B |
10-Apr-17 |
EU2811 |
8146 |
F-309 ?CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
F-328
?483.25 (k)(6) Treatment/Care for Special Needs - Respiratory Care.
iorofrefusingcare.Thelicensednursesandcertifiednurseassistants(CNAs)didnotfollowuponResident1'srefusalofcare,specificallyremovalofhersocks.Resident1developedmacerations(skinconditionthatoccurswhenfluidormoistureisincontactwiththeskinforextendedperiodsoftime,particularlywhentheskiniscovered)andfungalinfectiontoherfeet.Thisfailurecompromisedtheresident'shealthandhadthepotentialtocausepainandsuffering.
Duringanobservationon3/20/17at9:50a.m.,Resident1wasseatedonherbedandherfeetwereexposedtoaironamattress.Bothofherfeetandtoeshadmaceratedareas.
ReviewofResident1'sundatedAdmissionRecordformindicatedshewasadmittedtothefacilityonXXXXXXX13andhaddiagnosesincludingcerebralpalsy(permanentmovementdisordersthatresultedfrominjurytothebrainafterbirthorduringearlychildhood),quadriplegia(paralysisofallfourlimbs),rheumatoidarthritis(formofarthritisthatcausespain,swelling,stiffnessandlossoffunctioninaperson'sjoints),andchronicpain.Resident1wasself-responsibleformakingherownhealthcaredecisions.
TheMinimumDataSet(anassessmenttool),dated7/5/16,indicatedResident1didnothaveproblemswithdailydecision-makingskills,wasdependentonstaffforallADLssuchaseating,hadfunctionallimitationinrangeofmotion(movement)toherupperandlowerextremities,andwasatriskfordevelopingpressureulcer(woundthatoccursasaresultofprolongedpressureonaspecificareaofthebody,commonlyknownasbedsores).
Duringaninterviewon3/20/17at10:15a.m.,certifiednurseassistant(CNA)AstatedshehadbeentakingcareofResident1thelastcoupleofmonthsandshehadbeenrefusingcare.Theresidentworethesamepairofsocksformanydays,wouldnotletanyoneremovehersocksorcleanherfeet,andwould"getmad."
Duringaninterviewon3/20/17at12noon,CNABstatedResident1wasgivenabedbathon3/1/17becausesherefusedtobeshowered.Resident1would"cryalittle,"whensherefusedcare,suchashavinghersocksremoved.WhentheresidentwasbathedshehadhersocksonandCNABstatedshedidnotseeherfeet.Resident1'srefusaloftakingoffhersocksandnotcleaningherfeetwasnotreportedtothechargenurse.
Inafollow-upinterviewon3/20/17at12:10p.m.,CNAAstatedshedidnotrememberwhenshelastsawResident1'sfeetanddidnotreporttherefusalbecause"everyone"knewaboutResident1'srefusalforfootcare.
ReviewofResident1'sSkin/WoundNotedated5/25/16at2:10p.m.,indicatedawoundspecialistphysiciannotedResident1'stoenailswerelongonbothfeet.Theresidentrefusedpodiatry(specializedmedicalcareandtreatmentofthehumanfoot)servicesandwasinformedhernailscoulddigintotheskin.
Duringaninterviewon3/20/17at1:45p.m.,withthedirectorofnurses(DON)whoreviewedtherecord,shestatedtherewasnofurtherdocumentationafter5/25/16indicatingResident1wasofferedfurtherpodiatryservices.
ReviewResident1's"Alteredbehavior"careplanstartedon10/21/14identifiedproblemsbehaviorssuchasrefusinghelpfromstaffbutdidnotspecifyResident1'srefusalforremovinghersocksandreceivingfootcare.
Duringaninterviewon3/20/17at2p.m.,withtheDON,shestatedtherefusaloffootcareshouldhavebeenincludedinthecareplan.
ReviewofResident1'sNursingWeeklySummaryReview(NWSR)formdated3/1/17,indicatedResident1hadrashesonhergroin,abdominalfoldsandarms.UndertheBodyCheck/SkinInspectionoftheformtherewasacheckmarkindicating"Currentskinconcerns"buttherewasnonarrationindicatingwhattheconcernwas.
Duringaninterviewon3/20/17at3:10p.m.,thelicensedvocationalnurse(LVN)Cwhocompletedthe3/1/17NWSRstatedshedidnotdocumenttheconditionofResident1'sfeetbecausetheresidentrefusedtohavehersocksremoved.LVNCstatedsheshouldhavedocumentedtherefusal.
Duringaninterviewon3/20/17at2p.m.,theDONstatedwhenResident1wastransferredtoanacutecarehospitalonXXXXXXX17staffknewaboutherskinrashoverherbodybutdidnotknowabouttheconditionofherfeet.TheDONrecalledshewascontactedbyahospitalcasemanageraround3/9/17andwasinformedaboutthefeetmaceration.
Reviewoftheacutecarehospital"PODIATRYCONSULTNOTE,"dated3/7/17at8:44p.m.,indicatedResident1had"Severelyunmanagedfeetbilateral(both).Multiplegrosslyelongated(unusuallylong)andthickenednailsbilateral.Lefthallux(greattoe)partiallyavulsed(injuryinwhichabodystructureisforciblydetachedfromitsnormalpointofinsertion)withminimalproximalmedial(situatednearertothepointofattachment)borderattachedwhichwasremoved.Nopurulence(pus)underneath.Therearemacerationandthickamountsoffungal(yeast)debristhroughoutherinterspacesaswellaspeelingepithelialtissue(sheetofcellsthatcoversabodysurfaceorlinesabodycavity)throughout.Thereismorerawepitheliallayeroverlayingthedorsal(back)leftfoot."
ReviewofResident1'sSkinInspectionAssessment(SIA)formundertheBodyCheck/SkinInspectionsectionprovidedguidancetodocumentthetype,length,width,depthandstageoftheskin.TheSIAformdated3/11/17,afterResident1wasreadmittedtothefacility,indicatedshehadscatteredrednesstobothherfeetandlegs,scaly/dryskintobothlegs,andscatteredscabstoherleftarm.Therewasnonotationaboutthetoenailsandnofurtherdescriptionofthefeetsuchasindicatinglocationandsizeofmaceration.
Duringaninterviewon3/20/17at3:10p.m.,registerednurse(RN)Dwhoreviewedhis3/11/17SIAnotestatedResident1'sfeetwereredanddryandhedidnotrememberhowthetoeslooked.RNDstatedhisdocumentationoftheresident'swoundstoherfeetshouldhavebeenspecific.
ReviewofResident1'sNWSRformdated3/13/17,undertheBodyCheck/SkinInspectionSectionGnumber5:Allskinsheetsupdatedunderorderonlyidentified"bilateralfeet."
Duringaninterviewon3/20/17at3:20p.m.,RNE,whoreviewedhisNWSRnotedated3/13/17describedResident1'susualbehaviorofnotlettingstafftouchherfeet,takingoffherpinksocks,andscreamingatstaffwhensherefusedcare.RNEacknowledgedthe3/13/17documentationlackedadescriptionofResident1'sskincondition.
The"SkinIntegrity"policy,datedDecember2016,indicatedallnewadmissionsweretohaveaskinriskassessmentandaninitialheadtotoeskinassessmentbyalicensednurse.Weekly"headtotoe"assessmentsweretobecompletedforallresidentsbyalicensednurse.
The"JOBDESCRIPTION/PERFORMANCEEVALUATION"ofCNAsincludedatasktonotifythechargenurse/supervisorofconcernspromptlyincludingsafetyconcernsandresidenthealth/statuschange.
Duringaninterviewon3/20/17at2p.m.,theDONstatedwhenshefoundoutaboutResident1'sfoot,sheinterviewedCNAsfromtheweekendofMarch18thand19thandlearnedabouttheresident'srefusalofremovinghersocksandtheCNAsnotreportingtolicensednurses.TheDONfurtherstatedwhenresidentsrefusedcare,staffweresupposedtocontinuetoofferservices,workwithresidentsanddocument.TheydidnotdothisforResident1.
ThefacilityfailedtoprovidethenecessarycareandservicesforResident1whowasunabletocarryoutactivitiesofdailylivinginregardstofootcare.
Theaboveviolationsoftheregulationhaddirectorimmediaterelationshiptothehealth,safety,orsecurityofresidents. |
| 920000084 |
CHATSWORTH PARK CARE CENTER |
920013113 |
B |
10-Apr-17 |
EU2811 |
8229 |
483.12(a) The facility must-
(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
F-226
CFR 483.13 (c) Staff Treatment of Residents
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 1/14/17, an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 being subject of abuse by staff.
Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source, are reported no later than 24 hours if the events that cause the allegation do not result in serious bodily injury, to the administrator of the facility and to other officials; and failed to ensure written policies and procedures that prohibit abuse of residents were implemented including:
1. Failure to investigate two allegations of abuse made by Resident 1?s family member.
2. Failure to report within 24 hours, to the Department, the Ombudsman office, and the authorities, the incidents of alleged abuse.
As a result, Resident 1 was placed at risk for further abuse.
A review of the admission record indicated Resident 1 was re-admitted to the facility on XXXXXXX, 2016, with diagnoses which including pneumonia (an infection of the air sacs of the lung) and chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breath).
According to the Record of Admission form, Resident 1?s responsible party was a Public Guardian (PG 2) and the next of kin was Family Member 1.
The Minimum Data Set (MDS ? standardized assessment and care planning tool), dated 11/14/16, indicated Resident 1 was able to respond adequately to simple, direct communication; required extensive assistance during bed mobility and dressing; and was totally dependent for toilet use, personal hygiene, and bathing with one to two persons physical assistance.
During a telephone interview with PG 1?s supervisor (PG 2) on December 14, 2016 at 10 a.m., PG 2 stated she spoke with the facility's social worker (SW 1) on October 11, 2016.ÿ PG 2 advised SW 1 that Family 1 reported Resident 1 had a discoloration on his eye and scratches on his arms.
During a telephone interview on December 14, 2016 at 4:37 p.m., Family Member 1 stated Resident 1 had told him that a male staff was hitting and poking him and he had previously reported abuse allegations to PG 1 a few months ago.ÿ
Family Member 1 also stated he reported the abuse allegations to a staff member (did not recall the name) at the facility and to the police on or around December 10, 2016.ÿÿ
During a telephone interview on March 3, 2017 at 11:54 a.m., a sergeant with the Los Angeles Police Department (LAPD 1) confirmed detectives went to the facility on December 11, 2016 at 4:30 p.m., to investigate allegations of abuse.ÿ
A review of Resident 1's social service note dated October 17, 2016 indicated that SW 1 had received a call from PG 1 on October 11, 2016 regarding the allegation of abuse.ÿ SW 1 had discussed the concerns with the resident, nursing staff and dietary staff and then called PG 2 with her findings.ÿ There was no documentation in the resident?s clinical record of an investigation conducted related to the alleged abuse and there was no documentation the facility's abuse coordinator (the administrator), the local Ombudsman, the Department, or the local law enforcement were notified.
There was no documentation regarding the abuse allegation on December 10, 2016 and no documentation the police Department had visited the facility to investigate an allegation of abuse for Resident 1.
During an interview on December 14, 2016 at 3:45 p.m., the administrator stated no abuse allegations regarding Resident 1 were reported to him from October to present (December 14, 2016).ÿ The administrator added that SW 1 did not work at the facility since October 17, 2016.
According to the facility's policy and procedure revised on November 29, 2015, titled "Abuse Allegation Investigation," the facility will conduct an immediate investigation of any allegation of any form of abuse.ÿ If the alleged or suspected "physical abuse" does not result in "serious bodily injury," then the mandated reporter shall 1) make a telephone report to the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting the physical abuse; and 2) make a written report to the local ombudsman, the Department, and local law enforcement within 24 hours.
The facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source, are reported no later than 24 hours if the events that cause the allegation do not result in serious bodily injury, to the administrator of the facility and to other officials; and failed to ensure written policies and procedures that prohibit abuse of residents were implemented including:
1. Failure to investigate two allegations of abuse made by Resident 1?s family member.
2. Failure to report within 24 hours, to the Department, the Ombudsman office, and the authorities, the incidents of alleged abuse.
As a result, Resident 1 was placed at risk for further abuse.
A review of the admission record indicated Resident 1 was re-admitted to the facility on XXXXXXX 2016, with diagnoses which including pneumonia (an infection of the air sacs of the lung) and chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breath).
The Minimum Data Set (MDS ? standardized assessment and care planning tool), dated 11/14/16, indicated Resident 1 was able to respond adequately to simple, direct communication; required extensive assistance during bed mobility and dressing; and was totally dependent for toilet use, personal hygiene, and bathing with one to two persons physical assistance.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000089 |
COLLEGE VISTA POST-ACUTE |
920013323 |
A |
7-Jul-17 |
FKWD11 |
10706 |
?483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must?
(i) Meet professional standards of quality.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
On May 20, 2017, during annual survey, Resident 1 health status was investigated.
Based on observation, interview, and record review, the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, including pain management, by failing to:
1. Follow the physician order for Resident 1 to receive the pain medication 30 minutes before wound treatment.
2. Ensure Resident 1, who was unable to communicate verbally, was assessed for presence of pain during wound treatment.
3. Accurately assess and document Resident 1?s manifestation of pain during treatment.
4. Implement the facility?s policies and procedures on Pain Management and Medication Administration.
As a result, Resident 1 experiencing unnecessary pain during wound treatment.
A review of the admission record (Face Sheet) indicated Resident 1 was originally admitted to the facility on XXXXXXX 2016, and readmitted on XXXXXXX 2017, with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), pneumonia (lung infection), left foot gangrene (localized death of tissue), and unstageable (UTD - full thickness tissue loss in which the base of the sore is covered by dead tissue and the depth cannot be determined) pressure sores to the left and right t ischium .
A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool), dated January 27, 2017, indicated Resident 1 had impaired cognition (unable to comprehend) and communication, was dependent on a gastrostomy tube (GT- a tube surgically inserted through the abdomen for nutrition and medication administration), and was totally dependent on staff for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, eating, toilet use, and personal hygiene.
A review of Resident 1's Pain Assessment form dated May 6, 2017, indicated the resident had pain or potential for pain due to status post (after) debridement (removal of dead tissue) on the left foot, pressure sores, contractures (shortening and hardening of muscles), and osteoporosis (a condition in which bones become weak and brittle). The assessment indicated Resident 1 was unable to answer for determining pain intensity.
A care plan dated May 7, 2017, developed for Resident 1?s pain potential, had a goal to relieve Resident 1?s of pain or discomfort after nursing and or pharmacologic (drugs, including their composition, uses, and effects) interventions. The interventions included observing the resident for verbal or non-verbal pain complaints (such as moaning, crying, restlessness, etc.) and report to the attending physician; assessing for cause/s, site, location, duration and frequency of pain; administering pain medication; and monitoring for the need of routine pain management.
A review of Resident 1?s physician orders dated May 12, 2017 indicated the following:
1. Left foot (5th metatarsal head) wound, cleanse with Normal Saline, pat to dry and apply Gentamycin (topical antibiotic) 0.1 % ointment, then Santyl ointment (debriding ointment), and then calcium alginate ointment then cover with dressing daily and as needed (PRN) when soiled for 21 days.
2. Left and right ischium wound, cleanse with Normal Saline, pat to dry and apply Gentamycin (topical antibiotic) 0.1 % ointment, then Santyl ointment (debriding ointment), then calcium alginate ointment then cover with dressing daily and as needed (PRN) when soiled for 21 days.
A review of Resident 1's physician orders dated May 14, 2017, indicated the following:
1. Tylenol (brand name for acetaminophen - pain reliever) 500 milligrams (mg) by GT thirty minutes prior to wound treatments.
2. Norco (brand name for the combination of acetaminophen and the narcotic hydrocodone to treat moderate to severe pain) 5/325 mg by GT as needed every six hours for moderate pain.
On May 20, 2017 at 7:15 p.m., during observation of Licensed Vocational Nurse 2 (LVN 2) performing Resident 1's treatment to the pressure sore of the right ischium, Resident 1 was noted to be grimacing and groaning during the procedure. LVN 2 completed the treatment to the right ischium and then proceeded to provide wound treatment to the left foot wound. Resident 1 was observed grimacing, groaning and flinching when LVN 2 was measuring the left foot wound. LVN 2 continued with the treatment and dressing change and did not stop to the treatment to evaluate the resident for pain. Resident 1 was observed groaning and grimacing intermittently during the duration of the treatment.
During an interview at the time of the observation, LVN 2 stated he did not give Resident 1 pain medication prior to the wound treatment. LVN 2 stated Resident 1 was given Tylenol during the 7 a.m. - 3 p.m. shift.
On May 21, 2017 at 4:53 p.m., during another interview, LVN 2 stated during the pressure sore and wound treatment (May 20, 2017 at 7:15 p.m.,) he observed Resident 1 flinching and guarding the left foot when he (LVN 2) was patting the area with medicine. LVN 2 stated he was not familiar with the schedule of the resident's pain medication. LVN 2 stated, "Had I known, I would have medicated her."
A review of May 2017 Medication Administration Record (MAR) indicated Resident 1 was given Tylenol 500 mg via GT during the 7 a.m. to 3 p.m. shift. The MAR did not indicate the exact time the Tylenol was given to the resident. The MAR did not indicate the resident had received Norco PRN (as needed) from May 14, 2017 (the day it was ordered) through May 20, 2017. The MAR indicated Resident 1 had no signs of pain during the 7 a.m. to 3 p.m. shift and the 3 p.m. to 11 p.m. shift. The MAR did not indicate an assessment for pain was done before, during, and after treatment to determine Resident 1's need for pain medication.
A review of the May 2017 MAR Pain Scale Monitoring for every shift from May 7, 2017, to May 20, 2017 (the day of the treatment observation when the resident was grimacing in pain), indicated Resident 1 had no pain on each shift.
On May 21, 2017 at 7 a.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated he had observed Resident 1 with, "Discomfort in the face" and groaning when the resident was being turned in bed.
On May 21, 2017 at 9 a.m., Resident 1 was observed on her back in bed with her eyes closed.
On the same day, at 9:10 a.m., a second treatment observation of Resident 1's left foot wound was made. Registered Nurse 2 (RN 2) was performing the treatment and Resident 1 started groaning and grimacing when RN 2 held the resident's foot to remove the gauze dressing. Resident 1 continued to groan, grimace and flinch while RN 2 was cleaning the resident's foot wound with normal saline (solution of salt and water). RN 2 continued with the treatment and did not stop to assess Resident 1 for pain. At the time of the observation, RN 2 stated he did not give Resident 1 pain medication prior to the treatment of the wound and stated, "I think she is in pain because she was closing her eyes, grimacing, and withdrawing the foot."
During a follow up interview on May 21, 2017 at 9:35 a.m., RN 2 in the presence of the Director of Nurses (DON), stated, "It was a mistake. I should have stopped the treatment."
A review of the May 2017 MAR for May 21, 2017, prior to Resident 1's treatment, indicated the resident was not given Tylenol before the treatment was performed, as the physician ordered.
On May 21, 2017 at 4:35 p.m., during an interview, LVN 3 stated he gave Resident 1 Norco after the treatment (on May 21, 2017 at 9:10 a.m.). LVN 3 stated he observed Resident 1 grimaced while he was giving the pain medication and the pain was 7 (using a pain scale of 0-10, zero being no pain and 10 being the worst possible pain), indicating the resident had moderate pain. LVN 3 stated RN 2 did not inform him, that RN 2 was going to do wound treatment. LVN 3 stated Resident 1 was supposed to get Tylenol thirty minutes before the wound treatment.
A review of the facility's policy titled "Medication Administration," with a revised date of February 2013, indicated "Medications are administered in accordance with written orders of the prescriber and obtain and record any vital signs as necessary prior to medication administration."
A review of an undated facility?s policy and procedure titled "Pain Management? indicated "if there is a new onset of pain, worsening of pain, new pain medication, pain medication change and or other, the Licensed Nurse will complete the pain assessment and notify the Attending Physician and IDT (Interdisciplinary) for further recommendations.
The facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, including pain management, by failing to:
1. Follow the physician order for Resident 1 to receive the pain medication 30 minutes before wound treatment.
2. Ensure Resident 1, who was unable to communicate verbally, was assessed for presence of pain during wound treatment.
3. Accurately assess and document Resident 1?s manifestation of pain during treatment.
4. Implement the facility?s policies and procedures on Pain Management and Medication Administration.
As a result, Resident 1 experiencing unnecessary pain during wound 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. |
| 930001498 |
CITRUS VALLEY MEDICAL CENTER - IC CAMPUS, D/P SNF |
930008929 |
A |
24-Feb-12 |
VQ6T11 |
5739 |
T22 DIV5 CH3 ART3-72311(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. 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 January 7, 2011 at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding a patient's fall in the bathroom resulting in the patient sustaining a left hip fracture which required in surgical intervention. Based on interviews and record reviews, the facility's staff failed to implement its policy on "fall prevention" and failed to implement Patient 1's care plan. On October 20, 2010, Patient 1, who recently had a left total hip replacement on October 11, 2010, was assisted by one person in walking to the bathroom and fell. Patient 1 sustained a left hip fracture requiring surgery of an open reduction and internal fixation of the left femur (the bone between the hip and the knee joints). The care plan indicated Patient 1 required a minimum of two person assist in walking. Patient 1's medical record was reviewed on January 7, 2011. The admission document indicated Patient 1 was admitted to the facility's Transitional Care Unit (TCU) on October 14, 2010 with diagnoses of degenerative joint disease and status post left total hip replacement.A review of the "Admission Assessment" dated October 14, 2010, indicated Patient 1 was at risk for falls, had "mobility status issues" including but not limited to confusion, sedation, lack of muscle control and had " medication regimen issues " including, but not limited to psychotropic (any medication capable of affecting the mind, emotions, and behavior), hypnotics (induce sleep) and analgesics (pain relief).A review of the care plan, dated October 14, 2010, indicated Patient 1 had actual/potential injury related to actual fall and unsteady gait/weakness left leg status post surgery. The goal was for Patient 1 to be free of injury during hospitalization; and the interventions included the fall prevention protocol and strategies.A review of another care plan, dated October 15, 2010 indicated Patient 1 had an alteration in functional mobility. The Patient required a minimum of two person assist with bed mobility, transfer and gait/walking. There were no interventions for this care plan. A review of the facility's policy and procedure titled "Patient Plan of Care" dated September 2010, indicated an individualized patient plan of care would be initiated by the registered nurse, appropriate nursing interventions would be identified and updated by the registered nurse as indicated by the patient's condition, and that each patient plan of care must be reviewed and/or revised as needed.A review of the Nursing Notes dated October 20, 2010, indicated that at 12:40 p.m., the registered nurse was called to check a Patient in the bathroom. Patient 1 was found sitting on the floor with legs extended. Employee A was in the bathroom with the patient. The documentation indicated Employee A stated, "I assisted her to the bathroom because she wants to pee, she was beside the toilet using front wheel walker and I'm holding her arm. I'm closing the door when she tried to sit; she lost her balance and fell on the floor, her head bump on the wall." A review of the physician's order dated October 20, 2010, indicated Patient 1 complained of left hip pain, status post fall, and an X-ray of the left hip was ordered.The Radiology Exam dated October 20, 2010, revealed Patient 1 had a new fracture of the left proximal femur (the upper-most portion of the thigh bone).A review of the operative report dated October 25, 2010 under "Indications for Procedure" documented that Patient 1 was two weeks status post left total hip replacement and was discharged from an acute care unit to the transitional care unit. The Patient was doing well until she fell in the bathroom. The operative report indicated Patient 1 sustained a fall, landing on her hip and hitting her head. The x-ray indicated a fracture of the femur. Patient 1 was taken to the operating room where she received general anesthesia and underwent an open reduction and internal fixation of the left femur fracture with revision of the femoral stem.During an interview with the assistant director of nursing (RN 2) on January 7, 2011 at 10:50 a.m., she stated the care plan was in effect during Patient 1's fall. The assistant director of nursing also stated the care plan indicated Patient 1 required a two person assist for bed mobility, transfer and gait. During a telephone interview with CNA 1 on October 20, 2011 at 11:15 a.m., she stated she was not informed that Patient 1 required a two person assist and that whenever she was assigned to Patient 1, the patient was a "one person assist."A review of the facility's policy and procedure titled "Fall Precautions" dated May 2009 indicated safety measures would be implemented for patients identified as high risk for falls and that patients would be assessed and reassessed regarding risk for falls every shift and document in the "High Risk for Injury" care plan.The facility staff failed to implement its policy on "fall prevention" and failed to implement Patient 1's care plan.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. |
| 940000053 |
COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER |
940009393 |
B |
10-Jul-12 |
1W0211 |
4183 |
CFR 483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 6/12/12, an unannounced visit was made to the facility to conduct a standard recertification survey which was completed on 6/19/12. Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from hazards as is possible by failing to: Provide safe hot water temperatures, below 120 degrees Fahrenheit (F). Hot water temperatures above 120 degrees F were measured in one shower room and in the hand washing sinks in eight restrooms located in Rooms 15-16, 20, 21-22, 25, 27-28, 35-36, 37-38 and 39-40. The unsafe water temperature placed the residents at risk of burn and scalding. On 6/12/12, between 3:45 p.m. and 5:30 p.m., during the general environmental inspection of the facility, in the presence of the maintenance supervisor, the temperature of the hot water delivered to plumbing fixtures used by the residents was measured. The unsafe hot water temperature in the hand washing sink and in the shower room were as follows: Restroom in Room 20- 123.7 degrees F. Restroom in Room 25- 139.1 degrees F. Restroom between Rooms 15 and 16 - 126.1 degrees F. Restroom between Rooms 21 and 22 - 120.6 degrees F. Restroom between Rooms 27 and 28 - 129.8 degrees F. Restroom between Rooms 35 and 36 - 121.2 degrees F. Restroom between Rooms 37 and 38 - 130.9 degrees F. Restroom between Rooms 39 and 40 - 124.1 degrees F. Shower Room 1- 121.8 degrees F. According to the U.S. Consumer Product Safety Commission (http://www.cpsc.gov/), most adults will suffer third-degree burns if exposed to 130 degrees F. for 30 seconds. A temperature of 120 degrees F. 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 17 residents in the affected rooms and seven of the 17 residents were able to use the hand washing sink independently. The other ten residents required assistance by staff to use the hand washing sinks.On 6/12/12, at 5:30 p.m., during an interview, the maintenance supervisor stated the high temperatures could be related to malfunctioning of the mixing valve (temperature control valve that regulates the temperature of the hot water delivered to the plumbing fixtures used by the residents). At 5:40 p.m., during an interview, the administrator stated the maintenance staff members were not aware of the high water temperatures and explained the facility was not equipped with a hot water alarm to alert staff of unsafe water temperatures. The administrator further indicated a plumber was immediately called to assess and evaluate the problem on the same evening.The facility?s maintenance department policy and procedure on Water Systems and Temperature Control, dated 1/1/99, indicated to check daily the water temperatures in rooms used by residents (e.g. bathrooms, shower rooms etc.). Periodically check different rooms to ensure hot water used by residents is heated to 105-115 degrees F. The policy also indicated to check the regulating thermostatic or pressure valves monthly. A review of water temperature log revealed the temperatures taken daily prior to 6/12/12, were below 120 degrees F. The facility failed to ensure the resident environment remains as free from hazards as is possible by failing to: Provide safe hot water temperatures, below 120 degrees Fahrenheit (F). Hot water temperatures above 120 degrees F were measured in one shower room and in the hand washing sinks in eight restrooms located in Rooms 15-16, 20, 21-22, 25, 27-28, 35-36, 37-38 and 39-40. The unsafe water temperature placed the residents at risk of burn and scalding. The above violation had direct or immediate relationship to the health, safety, or security of the residents. |
| 940000034 |
COLONIAL CARE CENTER |
940009451 |
B |
21-Aug-12 |
MWEH11 |
9339 |
?72529 - Safeguards for Patients' Monies and Valuables. (c ) No licensee, owner, administrator, employee or their immediate relative or representatives of the aforementioned may act as an authorized representative of patients' monies or valuables, unless the patient is a relative within the second degree of consanguinity. On 10/28/11, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding misappropriation of property. Two facility employees were living in Patient 1?s house for several years without paying rent. Patient 1 was residing in the facility for approximately 10 years. Based on interview and record review, the facility failed to ensure no employee may act as an authorized representative of Patient 1?s monies or valuables by failing to: 1. Ensure Employee A, who worked in the business office, did not live in the house owned by the patient. 2. Ensure Employee B, who worked in the business office and was the supervisor of Employee A, reported her knowledge that Employee A was living in the house owned by the patient. Patient 1, who was assessed as unable to understand and make decisions and had periods of confusion, owned a house which was used by Employee A since 4/2005. Employee A did not pay the property taxes, resulting in Patient 1 receiving a notice of property auction dated 8/22/11, indicating the patient?s property would be for sale at a public auction from 10/17/11 through 10/18/11. Employee B was aware Employee A moved into the patient?s house since 2005. On 10/28/11, a review of the clinical record revealed Patient 1 was a 63-year old female originally admitted to the facility on 12/20/02, with the most recent readmission dated 4/5/11. The patient?s diagnoses included seizure disorder (epilepsy - a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions), diabetes mellitus, chronic obstructive pulmonary disease (COPD), psychosis (loss of contact with reality) and psychomotor retardation (slowing down of thought processes and physical activity, often associated with major depression). According to the Patient Transfer and Referral Record dated 12/20/02, from the transferring acute care hospital, the patient was alert with cognitive deficits and the nearest relative/friend listed was a church pastor. According to the acute care hospital history and physical examination dated 12/9/02, the patient was initially admitted to the hospital with altered mental status on 11/22/02, from home, a single-story house, where she lived by herself. The facility?s Admission and Discharge Summary forms (face sheet) of the first admission (2/20/02) and the recent admission (4/15/11), indicated the patient was self-responsible and no contact person was listed.The Psychosocial Assessment form dated 12/25/02, indicated the patient was alert with periods of confusion, was never married, had no visitors, had no relatives and prior to admission the patient lived alone in an apartment. The documentation did not indicate if the patient rented or owned the property. Further review of the social service documentation throughout the patient?s stay in the facility revealed no documentation the patient owned any real estate property and what had happened to the home the patient lived prior to been admitted to the facility.The facility?s physician?s History and Physical examination dated 12/31/02 documented the patient did not have the capacity to understand and make decisions.The Annual Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 2/8/05 and the Quarterly MDS assessment dated 5/9/05, indicated the patient had short-term memory problem, modified independence with cognitive skills for daily decision-making, had clear speech, and required limited to extensive assistance with activities of daily living (ADLs). The Significant Change in Status MDS assessment dated 7/28/11 indicated the patient had short and long-term memory problems, had modified independence with cognitive skills for daily decision-making, was able to communicate, required limited assistance with walking, transfers, dressing and personal hygiene, used a wheelchair as mobility device, received antipsychotic medications and used a trunk restraint daily. According to a Multidisciplinary Progress Record, dated 9/21/11, Employee C, the social service assistant, documented that a social worker from Adult Protective Services (APS) came to the facility regarding financial issues and property. Employee C documented directing the APS social worker to the business office who handled the patient?s finances. There was no further social services documentation regarding the APS social worker?s concerns related to the patient?s finances.On 10/28/11, at 10:09 a.m., during an interview, Employee B stated she was the business office manager and denied living in Patient 1?s home, however, Employee B stated she learned that Employee A lived in the patient?s home when the APS social worker came to the facility for an investigation.On 10/28/11, at 10:24 a.m., during an interview, Employee A stated that in 2005, while she was employed by the facility as the business office assistant and while the patient was residing in the facility, she came to an agreement with the patient for her (Employee A) and her family to move in and reside in the home owned by the patient.On 10/28/11, at 10:46 a.m., during an interview, the administrator stated she was not informed by any of her staff about the APS investigation related to Patient 1 and that Employee A was living in Patient 1?s home.On 10/28/11, at 12:10 p.m., during an interview, Employee D, the social service director, stated he was aware the APS social worker was conducting an investigation but did not know the specifics. Employee D stated Employee C was the one who spoke to the APS social worker. Employee D further indicated he did not inform the administrator about the APS investigation because he assumed Employee C did.On 10/28/11, at 5:12 p.m., Employee A provided a document titled "Basic Rental Agreement and/or Lease" dated 5/11/05, signed by Employee A and the patient indicating a $500.00 monthly rent. However, Employee A could not provide documentation she paid the monthly rent. Employee A also provided a document titled, ?County of Los Angeles, Treasurer and Tax Collector Official Notice of Auction,? dated 8/22/11, addressed to Patient 1 and to the same address indicated in the lease agreement. The Official Notice of Auction documented that the County of Los Angeles Treasurer and Tax Collector Official would auction Patient 1's home from 10/17/11 to 10/18/11 if the property taxes were not paid.Employee A further stated she made a payment on the property taxes on 10/13/11, but there was still a balance owed.On 11/1/11, a review of Employee A personnel file revealed she was hired on 1/12/99 as a certified nursing assistant (CNA), on 1/1/04 assumed the position of director of staff development (DSD) assistant and since 1/1/05, held the position of business office assistant. The personnel file also included an address change request dated 7/5/05, which indicated the address of the property owned by the patient. The employee file also included employee signed training on the facility?s policy and procedure on Theft and Loss of Patient Personal Property and Elder and Dependent Adult Abuse Reporting which included financial abuse. On 11/1/11, a review of Employee B personnel file revealed she was hired on 1/1/94, as the business office manager. The personnel file included employee signed training on the facility?s policy and procedure on Theft and Loss of Patient Personal Property and Elder and Dependent Adult Abuse Reporting which included financial abuse.The facility failed to ensure no employee may act as an authorized representative of Patient 1?s monies or valuables by failing to: 1. Ensure Employee A, who worked in the business office, did not live in the house owned by the patient. 2. Ensure Employee B, who worked in the business office and was the supervisor of Employee A, reported her knowledge that Employee A was living in the house owned by the patient. Patient 1, who was assessed as unable to understand and make decisions and had periods of confusion, owned a house which was used by Employee A since 4/2005. Employee A did not pay the property taxes, resulting in Patient 1 receiving a notice of property auction dated 8/22/11, indicating the patient?s property would be for sale at a public auction from 10/17/11 through 10/18/11. Employee B was aware Employee A moved into the patient?s house since 2005. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 940000004 |
COUNTRY VILLA BAY VISTA HEALTHCARE CENTER |
940009484 |
B |
12-Sep-12 |
1EJE11 |
9553 |
483.25(g)(2) A resident who is fed by a nasogastric 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. Based on observation, interview, and record review, the facility?s staff failed to ensure Resident 7, who had a nasogastric (NGT/NG) tube ( plastic tube inserted through the nose past the throat, and down into the stomach), received services to prevent aspiration pneumonia and vomiting, by not: 1. Reading the complete chest x-ray results, after the resident?s HOB was observed almost flat (at approximately 10 degrees) with the nasogastric (NGT) infusing at 65 milliliter (ml), to rule out aspiration pneumonia.2. Informing the physician the resident?s NGT was in the resident?s distal esophagus, and not the stomach.3. Holding the NGT feeding, until the NGT was properly placed in the resident?s stomach. These failures resulted in Resident 7 receiving 2080 milliliter (ml.) of NGT feeding while the NGT was in the resident?s esophagus, which put the resident at risk for aspiration pneumonia (fluid in the lungs) and other complications. According to an article written in Advance for Nurses, titled, Verifying Feeding Tube placement, dated March 5, 2012, improperly positioned feeding tube can cause serious injury and even lead to fatal events at Http://www.nursingadvanceweb.com.On March 12, 2012, at 2:50 p.m., during an observation, Resident 7 was observed lying in supine (on the back) position in the bed with the HOB almost in a flat position, while the NGT feeding was infusing at 65 ml via a pump. LVN 1 was called to Resident 7's room and was questioned about the HOB position and she stated the resident's HOB was too flat and she immediately raised the HOB to 45 degrees. LVN 1 stated, ?It is important to keep the head of bed at least 30-45 degrees to prevent aspiration pneumonia.?A review Resident 7's clinical record Face Sheet indicated the resident was an 81 year-old female who was admitted to the facility on January 9, 2012, from an acute hospital. The resident?s diagnoses included cerebral vascular accident (CVA [stroke]) with left side hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) hypertension (high blood), pneumonia (an inflammation of the lungs caused by infection fluid in the lung), esophagus reflux (reverse of food or liquid into the esophagus), and dysphagia (difficulty swallowing) with an NGT placement. On March 12, 2012, a review of the registered occupational therapist (OTR) care plan dated January 10, 2012, indicated the resident was a risk for aspiration pneumonia due to delay swallowing reflex, reduce laryngeal (throat) elevation and NGT feeding. The plan was to maintain the resident?s HOB elevated at all times. The admission Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 23, 2012, indicated Resident 7 was able to make her-self understood and understand others. The MDS indicated Resident 7 required extensive assistance with bed mobility. A review of an electronic clinical nurse?s note, dated March 12, 2012, and timed at 5:36 p.m., indicated LVN1 charted, ?the resident was found almost flat in bed while NGT feeding was on and the feeding was then turned off.? The noted indicated Physician 2 was notified and ordered a STAT (done immediately) chest x-ray.On March 13, 2012, at 9 a.m., during a medication pass observation, LVN 2 administered medication to Resident 7 via the NGT. The resident complained of nausea and stated she felt like vomiting. This was 12 hours after the facility had read the chest x-ray to rule-out aspiration pneumonia, which indicated the NGT was improperly placed.According to the facility?s policy, dated January 2001, titled, ?Nasogastric Tube Insertion? indicated as ?CAUTION: After tube placement, vomiting indicates tubal obstruction or incorrect position. Assess the cause immediately.? On March 14, 2012, at 10 a.m., a review of the STAT CXR results, dated March 12, 2012, to rule out aspiration pneumonia, after the resident was seen receiving NGT feeding with the HOB too low, indicated the resident?s lungs were clear, but the NGT was in the distal esophagus, instead of the resident?s stomach.During an interview, on March 14, 2012, at 10:15 a.m., the acting director of nurses, RN 1, was shown the CXR results that indicated the NGT was in the resident?s esophagus. RN 1 stated the NGT was not supposed to be in the resident?s esophagus, but in the stomach. RN 1 quickly ran down the hallway into Resident 7?s room and turned off the NGT feeding. He stated he would notify the physician and get an order to advance the NGT into the resident?s stomach and repeat the chest x-ray. On March 14, 2012, at 11:15 a.m., during an interview, the facility's medical director (Physician 1) stated he received a call from the facility's nurse informing him Resident 7's chest x-ray results showed the resident?s lungs were clear without aspiration pneumonia. The medical director was asked did the nurse inform him the NGT was in the resident?s esophagus. He replied, "No,? the nurse focus was only to tell him there was no aspiration pneumonia. He stated, "The NGT should be in the resident's stomach, and the nurse was not too keen, and should have read the complete chest x-ray results to him." He stated if the nurse would have told him the NGT was not in the stomach he would have told them to advance it, get a repeat CXR, and restart the feeding once in the stomach on that day (March 12, 2012). The medical director stated when the nurse (RN 1) did call him on March 14, 2012, (two days later, after the resident had being receiving the NGT feeding with the tube improperly placed) and he told him to push the NGT down into the resident?s stomach and get another chest x-ray. On March 16, 2012, at 10:05 a.m., during a telephone interview, the night shift nurse (RN 2) stated she documented the results for the March 12, 2012 CXR, while RN 1 called the physician. RN 2 was asked if she reviewed the CXR results and she stated, both she and RN 1 read the CXR results. She stated, "I did not read the complete x-ray results because the physician only wants to hear was the patient?s lungs clear of aspiration pneumonia, and it was okay for the NGT to be in the resident?s esophagus."On March 19, 2012, at 12:10 p.m., during an interview, the facility's nurse consultant stated the nurse should have read the complete CXR results to the physician, especially the part about the NGT being in the resident's esophagus. The nurse consultant stated the NGT should be in the resident's stomach, not the esophagus. A review of the facility's policy titled, "Nasogastric Tube Placement and Patency Check, Dislodging and Pulling Out,? dated January 25, 2012, indicated NGTs are passed through the nose and down through the nasopharynx (nose/throat) to the esophagus into the stomach. The policy also indicated if correct tube placement is not completely assured, do not administer feeding or medication and do not attempt to reinsert tube; contact the physician for further instruction. Placement may be verified by x-ray if ordered by the physician. Do not use the NGT until the position is confirmed and verified by the radiologist.On March 19, 2012, at 3:50 p.m., during a subsequent interview and a written declaration RN 1 stated the CXR was done on March 12, 2012, and he did read the results to physician. RN 1 stated, "I did not read the part about the NGT being in the distal part of the esophagus. I focused on the part about the lungs being clear." RN 1 stated he should have read everything to the physician. On March 20, 2012, at 10:50 a.m., RN 3 was presented with Resident 7's CXR results, dated March 12, 2012, and she immediately circled the part indicating the NGT was in the resident's esophagus. RN 3 stated after the CXR was done to rule out aspiration pneumonia, and indicated the NGT was in the resident's esophagus, the feeding should not have been restarted and the physician should have been notified for advancement of the NGT into the resident's stomach. RN 3 reviewed the resident's record and calculated that from March 12-14, 2012, after the CXR, and the feeding restarted, the resident had received approximately 2080 ml of Isosource formula with the NGT improperly placed. An article written by the American Journal of Nursing (AJN) titled, Bedside Assessment of Enteral Tube Placement? dated February 2012, Vol. 112, No. 2, indicated the severity of resulting complications depends on whether the mal-positioned tube has been used to deliver feedings or medications, the possible outcomes included aspiration, pneumothorax (a collapsed lung), and sepsis (a potentially life-threatening complication of an infection).The facility failed by not: 1. Reading the complete chest x-ray results, after the resident?s HOB was observed almost flat (at approximately 10 degrees) with the nasogastric (NGT) infusing at 65 milliliter (ml), to rule out aspiration pneumonia. 2. Informing the physician the resident?s NGT was in the resident?s distal esophagus, and not the stomach.3. Holding the NGT feeding, until the NGT was properly placed in the resident?sThe above violation had a direct relationship to the health, safety, and security for Resident 7. |
| 940000074 |
California Post-Acute Care |
940009719 |
B |
25-Jan-13 |
SV2Q11 |
5639 |
42CFR 483.65 Infection Control The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.(a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections.(b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.(c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.On 11/9/12, at 1:30 p.m., an unannounced visit was made to the facility to investigate the entity reported outbreak of a gastrointestinal infection. Based on observation, interview and record review, the facility failed to maintain an infection control program to prevent the development and spread of infection by not implementing written infection control policies and procedures and failing to:1. Immediately report to the local health department. 2. Immediately report to the Licensing and Certification district office an outbreak of gastroenteritis.The facility identified a gastroenteritis outbreak 11/7/12, but did not report the outbreak until 11/9/12, to seek guidance and ensure proper management of the outbreak. A total of 17 residents out of a census of 91 were affected. Failure to report immediately the outbreak resulted in delayed control of the gastroenteritis outbreak. On 11/9/12 at 8:30 a.m., the Department was informed via telephone the facility had a gastroenteritis outbreak. RN Supervisor 1 stated the gastroenteritis outbreak in the facility started on 11/7/12, but the outbreak was not reported to the local public health officer through the Communicable Disease Reporting System. RN Supervisor 1 indicated she was not aware of the contact number of the local health officer for the facility?s jurisdiction and was not aware of a main number to report. RN 1 was then given information regarding Communicable Disease Reporting System. At 1:30 p.m., an unannounced visit was made to the facility to investigate the entity reported outbreak. At 1:35 p.m., during a tour of the facility, staff members were moving residents who exhibited nausea/vomiting and/or diarrhea to Nursing Station A. At 1:50 p.m., during an interview, the DON stated the first resident who exhibited vomiting and diarrhea was identified on 11/5/12 at 5 a.m. but the outbreak started on 11/7/12. The DON stated since the onset of the outbreak, 11 residents were identified exhibiting nausea/vomiting and/or diarrhea. The DON also stated the local health officer was notified of the outbreak this morning and a public health nurse visited the facility at 11 a.m., and gave them guidance regarding infection control measures, cohorting (imposed grouping of resident exposed to an infection) of the symptomatic residents in one area, food service monitoring and reporting to the local health department. The DON could not explain the reason for the two day delay in reporting the outbreak to the Department and to the local public health officer. A review of the Change of Condition Assessment of the 11 residents identified by the DON indicated that seven of them exhibited nausea/vomiting and/or diarrhea within 24 hours.According to the facility's policy and procedure for reporting unusual occurrences, undated, an outbreak is defined as when there are occurrences of cases of a disease or illness above the expected or baseline level, usually over a given period of time in a geographic area facility. It may also be two or more identified cases. According to the facility's policy and procedure for management gastroenteritis outbreak, dated 10/2006, all outbreaks must be reported immediately to the local health department and the Licensing and Certification district office with jurisdiction over the facility. On 11/13/12, a report was submitted via facsimile (fax) to the Department indicating a total of 17 residents out of a census of 91 residents were affected by the gastroenteritis outbreak.The facility failed to maintain an infection control program to prevent the development and spread of infection by not implementing written infection control policies and procedures and failing to: 1. Immediately report to the local health department. 2. Immediately report to the Licensing and Certification district office an outbreak of gastroenteritis.The facility identified a gastroenteritis outbreak 11/7/12, but did not report the outbreak until 11/9/12, to seek guidance and ensure proper management of the outbreak. A total of 17 residents out of a census of 91 were affected.Failure to report immediately the outbreak resulted in delayed control of the gastroenteritis outbreak. The above violation had direct or immediate relationship to the health, safety or security of the all residents in the facility. |
| 940000053 |
COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER |
940009762 |
AA |
21-May-13 |
HY1211 |
12866 |
F-322 483.25 (g) Naso-Gastric Tubes. Based on the comprehensive assessment of a patient, the facility must ensure that-- 483.25 (g) (2) A patient 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 3/10/11 at 1:15 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1's quality of care and patient rights. Based on interview and record review, the facility failed to ensure Patient 1, who was fed by a gastrostomy tube (GT - a tube surgically inserted into the stomach through the skin and the stomach wall to provide nutrition and medications) which had been inserted for the first time on 1/26/10, received the appropriate treatment and services to prevent complications by failing to: Implement the facility?s policy and procedures that indicated to insert the GT only as per physician?s order, not to reinsert a new GT (less than four weeks old) and not to replace a PEG [percutaneous (procedure performed through the skin) endoscopic gastrostomy] tube.On 1/27/10 at 1:30 p.m., after the patient pulled out the GT and one day after the GT surgical insertion, License Vocational Nurse 1 (LVN 1), reinserted a new GT and resumed the feeding formula. On 1/28/10, 5:50 a.m., (sixteen hours after the GT reinsertion), the patient had coffee ground vomit, elevated temperature, rapid heartbeat and low blood pressure. The patient was transferred to General Acute Care Hospital 2 (GACH 2) where she was diagnosed with acute peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs) secondary to GT displacement into the peritoneal cavity [a space between the layers of the peritoneum (serous membrane lining the walls of the abdominal and pelvic cavities) and septic shock (is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure). Patient 1 remained in GACH 2 until 2/3/10, (seven days after admission) when she expired at 3:24 p.m. Patient 1 expired nine days after the GT was inserted by LVN 1.On 12/4/12, a review of Patient 1's clinical record revealed the patient was a 92 years old female, initially admitted to the facility from GACH 1 on 5/6/09, and readmitted 7/31/09, with diagnoses including dysphagia (difficulty swallowing), nasogastric tube (NGT- tube inserted through the nasal cavity for the purpose of nutrition and medication administration) and advanced dementia (loss of brain function).The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/12/08, indicated the patient was moderately impaired in her cognitive skills for daily decision-making (decisions poor; cueing needed), required extensive to total assistance with all activities of daily living (ADLs) and received nutrition only through the NGT.A physician?s order dated 7/31/09, indicated to give the feeding formula Novasource Renal at a rate of 45 cubic centimeters (cc) per hour, to provide 810 cc, 1620 kilocalories (kcal) in 18 hours per day, by the way of a feeding pump. All medications were ordered to be administered through the NGT. A physician order dated 8/3/09, indicated to flush the feeding tube with 300 cc of water every six hours.On 1/22/10, the physician ordered a PEG placement (to replace the feeding tube from a NGT to a GT) to be performed on 1/26/10, at GACH 1.According to the nursing notes on 1/26/10, at 7:30 a.m. the patient went to GACH 1 and returned back to the facility the same day at 5:30 p.m. with the new GT. The stoma (insertion) site had a dry dressing and the patient had no discomfort. A nursing note dated 1/27/10, 11 p.m. to 7 a.m. shift, timed at 6:30 a.m., indicated the patient had no signs and symptoms of respiratory or cardiac distress, the GT stoma site had no bleeding, the patient was tolerating GT feeding well and the tube was flushed with water as ordered.According to a nursing note dated 1/27/10, timed at 1:30 p.m., LVN 2 documented the patient removed the GT, an order was obtained to reinsert the GT, the GT was replaced and all medications were given and tolerated. Nursing notes dated 1/27/10, timed at 11 p.m., and at 1/28/10, timed at 12:30 a.m., indicated the patient tolerated the GT feeding well. A nursing note dated 1/28/10, timed at 5:50 a.m., indicated the patient had a coffee ground vomit, had a body temperature of 101.2 degrees Fahrenheit and cooling measures were provided. The blood pressure was 80/64 (millimeters of Mercury ?mmHg) and the heart rate was 122 (heart beats per minute). Normal vital signs are: blood pressure- 120/80mm/Hg; heart rate 60-80 beats per minute; and temperature 97.8- 99.1 degrees Fahrenheit (National Institute of Medicine/National Institutes of Health website. www.nlm.nih.gov/medlineplus/ency/article/002341.htm). The nursing note further indicated Physician 1 was called and a message was left. At 6 a.m., the on-call physician called back, was made aware of the patient?s condition and ordered to transfer the patient to GACH 1A late entry nursing note written by LVN 1dated 1/28/10, timed at 8 a.m., for 1/27/10 (without time specified) indicated she assisted the charge nurse (LVN 2) with the GT replacement and inserted a 20-French GT to the abdominal stoma and a small amount of bleeding was noted. LVN 1 also documented Nurse Practitioner 1 was in the building, was aware the patient pulled out the GT, and ordered to re-insert the GT as needed. A review of the physician?s telephone orders revealed an order obtained by LVN 1 1/27/10, no time stated, indicating Physician 1 ordered to re-insert GT size 20 French /30 cc as needed if dislodged/pulled out. However, the telephone order was not signed by Physician 1 and had a hand written note stating, ?I did not give this order ? cannot sign.? In addition, there was no documented physician?s order to resume the administration of enteral feeding (feed delivered directly into the stomach) after the patient returned to the facility after the PEG procedure on 1/26/10.According to the ambulance Medical Transport form dated 1/28/10, at 6:48 a.m., the patient?s blood pressure was 80/48 and the heart rate was 132. At 7:02 a.m., the blood pressure was 63/49 and the heart rate was 141. The patient required emergency transportation and the transfer was diverted to GACH 2 (nearest hospital).According to the clinical record from GACH 2, while in the ER on 1/28/10, a chest x-ray was performed which indicated pneumoperitoneum (air or gas in the peritoneal cavity), and an abdominal x-ray indicated the GT appeared to be in the region of the stomach and recommended a computed tomography (CT) scan (an imaging method that uses x-rays to create pictures of cross-sections of the body) to confirm. The patient was transferred to the intensive care unit where at 10:50 a.m., had a cardiac arrest (heart stops beating) and was resuscitated. The History and Physical dictated 1/28/10, indicated there was suspicion the patient had a perforated viscous (rupture of an abdominal organ) and a surgical consultation was obtained. The patient had a Code Blue (medical emergency to revive an individual in cardiac arrest), was intubated [placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway] and placed on a ventilator (machine that supports breathing). The diagnostic impression included possible perforated viscous and displaced GT. A Surgical Consultation dated 1/29/10, indicated the patient?s abdomen was tender and had a GT in the left upper quadrant with what appear to be tube feeding draining around it. The impression diagnoses included cardiac arrest upon arrival to the intensive care unit, septic shock, and suspicion the GT was not in the stomach but in the free peritoneal cavity. The patient was not a surgical candidate.According to the Death Summary dates 2/15/10, the patient was suspected to have a perforated viscous (rupture of an abdominal organ) and a CT scan of the abdomen could not be done because of the patient?s critical state. The patient remained critically ill with poor prognosis and expired on 2/3/10. The impression diagnoses included acute peritonitis secondary to GT displacement into the peritoneal cavity, septic shock and renal failure. According to the Certification of Vital Record, Certificate of Death - Physician/Coroner?s Amendment, the patient expired on 2/3/10, at 3:24 p.m. The first three listed causes of death diagnoses were septic shock, acute peritonitis and gastrostomy tube displacement into peritoneal cavity. On 12/4/12, a review of the personnel file disclosed LVN 1 was hired on 7/23/09, and had no documented evidence an enteral feeding and GT care competency check was done. There was also no evidence of training related to GT care.On 12/4/12 at 2 p.m., an interview with the Director of Staff Development (DSD) regarding LVN 1?s competency to insert GT was conducted. The DSD stated she was unable to find documentation to indicate LVN 1 had received any type of training and skill evaluation related to the care and insertion of GTs during her employment in the facility.On 12/21/12 at 2 p.m., a telephone interview with Nurse Practitioner 1?s supervisor was conducted. The supervisor explained it was against company (Health Maintenance Organization ? HMO) policy and procedure for support nurses (LVNs or registered nurses ? RNs) to reinsert GTs. Also a nurse practitioner would not give such order without the physician?s authorization.On 12/26/12 at 11:04 a.m., a telephone interview with Physician 1 was conducted. Physician 1 stated she would never give an order to have a nurse insert a GT and would not even reinsert the GT herself. She also stated the facility?s nurse should have sent the patient to the hospital for the GT reinsertion.On 12/26/12 at 2 p.m., during an interview followed by a written declaration, LVN 1 stated she was the treatment nurse on 1/27/10, during the 7 a.m. to 3 p.m. shift and she re-inserted the GT using a house supply size 20 French tubing into the patient?s stomach. LVN 1 stated she performed the procedure without any problems, checked the GT for placement and residual and the patient appeared, "Okay.? LVN 1 indicated she resumed the patient?s feeding without any problem. LVN 1 stated she did not call Physician 1 because Nurse Practitioner 1 was in the building and gave a verbal order to reinsert the GT. LVN 1 stated the facility did not provide her with training regarding insertion of the GT. On 2/15/13 at 9:50 a.m., during a telephone interview, Nurse Practitioner 1 stated she could not remember if she gave the verbal order to LVN 1 to reinsert the patient?s GT. According to the facility's policy and procedure on Gastrointestinal Tube Change and Reinsertion dated 12/2000, gastrointestinal tubes will be changed and reinserted, per physician's order, in patients with established tracks in order to maintain patency for nutritional maintenance. The procedures indicated to obtain a physician's order. The policy further noted it was recommended a new GT (less than four weeks old) not to be reinserted by facility licensed nurses and PEG tubes should not be removed or replaced by a licensed nurse at the facility.The facility failed to ensure Patient 1, who was fed by a GT, which had been inserted for the first time on 1/26/10, received the appropriate treatment and services to prevent complications by failing to: Implement the facility?s policy and procedures that indicated to insert the GT only as per physician?s order, not to reinsert a new GT (less than four weeks old) and not to replace a PEG tube.On 1/27/10 at 1:30 p.m., after the patient pulled out the GT and one day after the GT surgical insertion, LVN 1 reinserted a new GT and resumed the feeding formula. On 1/28/10, 5:50 a.m. (sixteen hours after the GT reinsertion), the patient had coffee ground vomit, elevated temperature, rapid heartbeat and low blood pressure. The patient was transferred to GACH 2 where she was diagnosed with acute peritonitis secondary to GT displacement into the peritoneal cavity, and septic shock. Patient 1 remained in GACH 2 until 2/3/10, (seven days after admission) when she expired at 3:24 p.m. Patient 1 expired nine days after the GT was inserted by LVN 1.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 and was a direct proximate cause of the death of Patient 1. |
| 940000053 |
COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER |
940010743 |
B |
10-Jun-14 |
2P7V11 |
4414 |
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.(c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code.(d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11(commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code.The Department received an entity reported incident (ERI) from the facility on March 31, 2014, which was three days after the alleged abuse incident. A review of a Report of Suspected Dependent Adult/Elder Abuse(SOC 341), dated March 31, 2014, indicated Resident 1?s family member was visiting in the dining room during dinner time and was observed hitting Resident 1 on both arms after she told him to ?shut up.? The family member was asked to leave the facility and the police was notified. The Resident was assessed with no physical injury observed Based on interview and record review, the facility failed by not: Reporting an abuse allegation regarding Resident 1 to the Department timely as stipulated in its policy and procedure. This deficient practice had the potential to put Resident 1 and others at risk for further harm. On April 15, 2014, at 8:03 a.m., an unannounced visit was made to the facility to investigate the ERI.On April 15, 2014, at 9:25 a.m., an interview was conducted with the facility?s administrator. He stated he contacted the police, Ombudsman and Adult Protective Services (APS). When asked when he was supposed to report abuse to the Department, he stated, ?Within 24 hours.? However, a review of the faxed report had a date of March 31, 2014, three days after the abuse incident. The administrator stated he was informed it was a courtesy to contact our Department since the abuse did not involve staff. A review of a Clinical Electronic Note, dated March 28, 2014, indicated at around 5:25 p.m., the resident and Family Member 1 had an argument to the point Family Member 1 was aggravated because the resident told him to ?shut up!? He was very upset and hit the resident on both her arms.A CNA (CNA 1) intervened and stepped between the resident and Family Member 1 while he was becoming violent. Family Member 1 grabbed the chair and raised it in the air and slammed it to the Floor. He was pacing back and forth in the dining room and suddenly went to CNA 1 made a fist and attempted to strike her. According to the note, a licensed vocational nurse and a registered nurse stopped him in the hallway and escorted him outside the facility.On April 15, 2014 at 12 p.m., during a interview with the administrator in training (AIT) he stated he did not know why the SOC 341 was sent late to the Department. On April 22, 2014 at 5 p.m., the administrator stated he was supposed to report the abuse incident within 24 hours, but since it occurred on a weekend he did it on Monday March 28, 2014, because he was not there on March 28, 2014. He stated he realize he and all the facility?s staff were mandated to report the abuse timely. A review of the facility?s policy dated February 1, 2000 and , titled, ? Reporting Guidelines for State/Federal Agencies,? indicated ?It is the policy of the facility to comply with Federal, State and other agency reporting requirements in a timely and appropriate manner.? The policy also stipulated they should contact DHS within 24 hours and follow- up by a written report within 5 days. The facility failed by not: Reporting an abuse allegation regarding Resident 1 timely The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 940000053 |
COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER |
940010746 |
A |
10-Jun-14 |
2P7V11 |
11815 |
F223 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Department received an entity reported incident (ERI) on March 31, 2014 alleging that Resident 1?s Family Member (FM1) was observe hitting the resident on both of her arms after she told him to ?shut up.? On April 15, 2014, at 8:03 a.m., an unannounced complaint investigation was conducted. Based on interview and record review, the facility failed to: 1. Monitor Resident 1?s visits with FM 1 after a prior physical and verbal abuse altercation between the resident and the family member.2. Ensure Resident 1 was free from physical and verbal abuse by a family member. This failure resulted in Resident 1 being physically and verbally assaulted and had the potential for harm to other residents and staff in the area. During a tour, at 8:14 a.m., Resident 1 was observed awake and alert in the room with a caregiver at the bedside.On April 15, 2014, at 8:16 a.m., during an interview, Resident 1?s caregiver stated she has been caring for the resident and her husband for many years at their home, prior to their January 2014 facility admission. She stated Resident 1 was confused sometimes, but usually remembered her name. When asked about the relationship between the resident and FM 1, the caregiver stated they often would verbally fight. The caregiver stated once they were verbally fighting in the bedroom at home, while she was in the kitchen, and overheard them. The caregiver stated Resident 1 told her all FM1 wants is her money and he fights because he wants more money.The caregiver stated the staff told her that on February 12, 2014, FM 1 was arguing with the resident in the facility. The staff told him to get out and he hit Resident 1 on the head with a book and proceeded to go to Resident 1?s husband (Resident 2) room stating, ?You are not a good father.? The caregiver stated, this was the first time she heard of FM 1 hitting Resident 1 until the other incident on March 28, 2014.The caregiver stated Resident 1 told her FM 1 hit her two -three times and he was not good, because he moved into her home.The caregiver started to cry during the interview and stated FM 1 threw Resident 1?s expensive clothes, shoes, make-up, and other items into the trash.A review of Resident 1?s record indicated the resident was a 92 year-old female who was admitted to the facility with the multiple diagnoses that included abnormality of gait and muscle weakness that kept her wheelchair bound. Deep vein thrombosis (DVT) of the lower extremities (a blood clot that forms in a vein deep in the body usually occur in the lower leg or thigh), squamous cell cancer (a skin cancer), irritable bowel syndrome (IBS/ affects the large intestine causing abdominal cramping, bloating, and a change in bowel habits), asthma ( a chronic disease that affects your airway) and osteoporosis (a disease of the bone causing it to become porous bone and easily to break). A review of a Minimum Data Set (MDS), is a standard assessment and care-screening tool, dated January 19, 2014, indicated the resident was alert with memory problems, that included moderately impaired cognitive skills, but speech was clear and easily understood. According to the MDS the resident was non-ambulatory requiring assistance with care. On April 15, 2014 at 10:35 a.m., an interview was conducted with the facility?s social service designee (SSD). She stated the first physical abuse incident occurred on February 12, 2014, between the resident and FM1. The SSD stated that they; the administrator, director of nurses (DON), activity director and herself had an interdisciplinary team (IDT) meeting after the incident. The SSD stated they collectively decided since the resident wanted to continue to see FM1 and FM2 was aware of the incident and agreed to continue with the visits, they would monitored the visits. However, the SSD when asked to produce the IDT meeting documentation, she could not.On April 15, 2014 at 10:55 a.m., the DON stated FM2 still wanted FM1 to be allowed to visit the resident after the incident of physical assault on February 12, 2014. On April 15, 2014 at 11:35 a.m., during an interview, Resident 1 was not able to recall the month, year, or her birthday, but was able to state her age. The resident stated she remembered a family member hitting her, but stated the wrong family member.According to the facility?s investigative report, dated February 12, 2014, indicated at approximately 7:45 p.m., FM1 was yelling and arguing with the resident from the hallway in front of the nursing station, and hit the resident on the head with a book. The report indicated after hitting the resident, FM1 threw the book at staff members and left the facility.A review of another facility investigative report indicated on March 28, 2014, at approximately 5:30 p.m., FM1 was visiting the resident in the dining room and started to argue with the resident after Resident 1 told FM1 to shut up. FM 1 than proceeded to hit the resident on both arms. Resident 1, who was frail and had a diagnosis of osteoporosis, was put at risk for fractures. Certified nursing assistants, CNA1, CNA3, and a restorative nursing assistant (RNA) intervened. FM1 picked up a chair and threw, but it did not hit anyone.On April 15, 2014, at 12:05 p.m., during a meeting with the administrator, administrator in training (AIT), and DON, they stated after the first abuse incident on February 12, 2014, the team discussed that FM1 would be allowed to visit the resident. The administrator stated the plans were to have someone to observe the visitation ?within the vicinity,? but they stated there was not a specific person assigned to monitor the visits. There was no documentation of the plan or a plan of care to address how they were going to protect Resident 1 from the FM1. The administrator was unable to present any such document. During a telephone interview on April 15, 2014, at 3:35 p.m., CNA1 stated she was in the dining room on March 28, 2014 at approximately 5-5:30 p.m., on her 15-minute break drinking coffee, when she heard yelling. CNA1 stated there was at least 10 other residents in the dining room at the time. FM1 was yelling at Resident 1, while standing over the resident after she said shut-up. CNA 1 stated FM1 started hitting the resident with open hands striking the resident?s arms and face. CNA 1 was asked was there anyone in the dining room assigned to monitor the visits CNA 1 stated, ?No.? CNA 1 was asked if she received instructions that FM1 had to be monitored during the visitation with Resident 1 she stated, ?No.? CNA 1 stated she went over and stood between the resident and the family member and stated, ?You can?t hit your mother. ? FM1 looked at her with a ?mad face? and picked up a chair, kicked at her and tried to strike her in the face with the chair, but CNA 3 stood between them, while RNA1 called for the supervisor.On April 15, 2014 at 3:47p.m., during another telephone interview, CNA 2 stated she did not see anything, just heard CNA 1 say ?Don?t do it? speaking about FM1 hitting Resident 1. CNA 2 stated, CNA1 did not say anything bad to FM1, he just got up with the chair. He was very angry and tried to hit CNA 1 with the chair. He walked away yelling at other employees and then came back trying to hit CNA 1, but CNA 3 stood in the middle to prevent him from hitting her. CNA 2 was asked if there was anyone in the dining room assigned to monitor the visits of Resident 1 and FM1 and the CNA stated, ?No.?CNA2 was asked if she was told that Resident 1?s visits had to be monitored and she stated, ?No.?On April 15, 2014 at 3:54 p.m., during a telephone interview, RNA 1 stated he was in the dining room passing trays and saw CNA1 get up and say, ?You cannot hit your mom.? He stated he did not see FM1 hit Resident 1. RNA1 stated FM1 got mad and said, ?I am not taking this? CNA 3 told him to call the supervisor. I step out to call the supervisor and heard CNA 1 say, ?I will call the police.? He came back mad and kicked CNA3 on the leg. RNA 1 was asked if there was anyone in the dining room assigned to monitor the visit and the RNA stated, ?No.?On April 22, 2014, at 1:47, the DON was asked when the staff was notified to monitor Resident 1 during visitation with FM1. The DON stated the staff was informed during unit huddles, but no one particular was assigned to monitor the visitations. On April 22, 2014, at 2:06 p.m., Licensed Vocational Nurse 2 (LVN2) was asked about specific instructions given to staff regarding FM1 visiting Resident 1. LVN 2 stated after the March 28, 2014 incident, during the huddle the specific instructions were ?To keep an extra eye? because Family Member 1 was not allowed in the facility and to notify the DON, administrator, and the police. LVN2 stated prior to the incident of March 28, 2014, FM1 stayed in a certain area with staff assigned to watch over the visit. However, she stated there was no specific person assigned to the area. On April 22, 2014 at 2:10 p.m., during an interview, a registered nurse (RN1) was asked about the monitoring of the FM1 1 during visitation with Resident 1. RN1 stated there was no one assigned to monitor the visits between the resident and family member. She stated It was everyone?s responsibility to watch when he was visiting.On April 22, 2014, at 3:37 p.m., during a subsequent face-to-face interview, CNA 1 stated FM 1 was gesturing with his fists ball up to fight her and raised the chair in a higher position over his head to strike her during the March 28, 2014 altercation. At 4:10 p.m., on April 22, 2014, during an interview, Resident 3 stated he was in the dining room when Resident 1?s family member fought her. Resident 3 stated he did not see it, but saw when CNA1 got up and stood between the family member and the resident to prevent him from hitting her again. He stated he saw the family member pick up the chair and throw it down. Resident 3 stated he was aware of FM1?s behavior because he had spoken to FM2 before, and he had informed him that FM1 was different, and had problems hitting the resident (Resident 1). A review of the local police department report, dated March 28, 2014, indicated the police was called at 5:39 p.m. to the facility due Elder/dependent adult cruelty upon Resident 1 by FM 1. The reports? narrative indicated upon the officer?s arrival several staff members stated they witnessed the suspect (FM!) slap the resident and threaten several other staff members in the dining room. The report indicated the victim (Resident 1) was battered before by suspect on February 18, 2014. The officer interviewed Resident 1 and the report indicated the resident stated, ?I think he gets pleasure from assaulting me, he scares me and he is so unkind to me.? The report further indicated witness heard the suspect yelling and screaming, while holding a chair, ?I hate you, I want you dead.? A review of the facility?s policy dated October 1, 2002 and titled, ?Abuse Prevention,? indicated 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. Monitor Resident 1?s visits with FM 1 after a prior physical and verbal abuse altercation between the resident and the family member.2. Ensure Resident 1 was free from physical and verbal abuse by a family member. The above violations jointly, separately, or in any combination presented a substantial probability that death or serious physical or mental harm would result. |
| 940000098 |
COURTYARD CARE CENTER |
940011469 |
B |
13-May-15 |
H9J711 |
6673 |
F225: CFR 483.13(c) (2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). HSC: 1418.91 Reports 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. Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to: 1. Notify the Department (State licensing and certification agency) regarding abuse allegation immediately or within 24 hours of the alleged abuse in accordance with the facility?s policy.On 7/17/14 at 2:55 p.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged staff to resident physical abuse. Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to: 1. Notify the Department (State licensing and certification agency) regarding abuse allegation immediately or within 24 hours of the alleged abuse in accordance with the facility?s policy. On 7/17/14, at approximately 4:00 p.m., during an interview, LVN-1 stated that Resident A's family member approached and told him that Resident A reported, that CNA - 1 was rough with him and CNA - 1 hit him (Resident A) when she was providing care to him. The resident's family member stated Resident A reported the abuse incident to two granddaughters who were visiting him. LVN -1 stated he immediately went to the resident and did a body and neurological assessments. LVN -1 said he did not observe any discoloration, bruising or swelling on the resident's body and the resident did not express any discomfort. LVN-1 stated that CNA-1 denied rough handling or hitting Resident A, but stated that the resident was resistive to care sometimes.In an interview on the same date (7/17/14), at 4:10 p.m., CNA -1 stated she neither rough handled nor physically abused Resident A whenever she was assigned to him. On 7/3/14, (the day of alleged incident) at 5:15 p.m., CNA-1 stated she fed the resident at dinner time, changed his wet brief and sewed his torn pajamas. CNA 1 stated the resident's granddaughters came to the resident's room after she finished with his care. CNA 1 stated LVN-1 later approached and told her Resident A reported to his family members that she had been rough with him. CNA - 1 stated she explained how she changed the resident's brief and was not rough with him. On 7/17/14, 4:25 p.m., a review of Resident A ' s admission record indicated he was an 80 year old male initially admitted to the facility on 12/14/13, with diagnosis which included Pontine Hemorrhagic Stroke, Muscle Weakness, Parkinson's and Aphasia. The admission record also indicated French as the resident's primary language and had poor English speaking ability. The initial Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 12/21/13, indicated that Resident A had a long/short-term memory problems, moderately impaired cognitive skills for daily decision-making, rarely/never understood and sometimes understood others. The resident required extensive assistance with bed mobility, transfers dressing, eating, personal hygiene, and totally dependent on staff with locomotion, bathing and toilet use. On 7/18/14, at 8:50 a.m., Resident A was observed sitting in his wheelchair in the dining room. He was able to make eye contact with everyone around him and was alert to his name and the staff developer's name. The resident was unable to respond to question regarding the incident. However, a review of Interdisciplinary Progress Notes dated 7/3/14, indicated that at 5:50 p.m., Resident A was alert, able to speak some words and follow simple command.On 11/4/14, at 10:55 a.m., during a telephone interview, Resident A's family member stated that on 7/3/14, her daughters (resident granddaughters) visited the resident. As soon as CNA-1 entered the room the resident pointed at CNA 1 and reported to her daughters in Arabic language that CNA 1 rough handled and hit him. The family member stated she came to the facility and reported the incident to LVN-1. The family member added that one of her daughters provided a written statement of the abuse incident to the facility. According to the written statement dated 7/7/14, Resident A's granddaughter indicated that when she and her sister were visiting the resident, they saw CNA 1 changing Resident A's diaper and sewing his pajamas that was torn. The resident reported to them in Arabic language that CNA 1 was not nice and he said, "she hit me." The resident's granddaughter stated she immediately called and reported to their mother. When Resident A's family member arrived at the facility she approached CNA-1 and repeated what the resident said she did to him but CNA-1 got very defensive. The family member stated that CNA-1 denied any wrong doing, got upset and told her she was in the facility to make money to pay her bills and if she was not happy she could request for another CNA.In an interview on 7/18/13, at 10:40 a.m., the administrator stated the facility investigated the abuse allegation but did not report the alleged abuse incident to the State licensing and certification because Resident A's family member said it was not necessary to report alleged incident. The administrator stated the family member said that all she wanted is to make sure that CNA-1 is trained on how to communicate properly without getting defensive.The facility's policy and procedure indicated that all alleged/suspected incidents of abuse will be promptly reported (verbally and written) within 24 hours after the occurrence to the State Licensing/Certification Agency, Local/State Ombudsman, Law Enforcement Officials, the resident representative, Adult Protective Services, resident's attending physician and the facility Medical Director. The facility failed to implement its abuse policies and procedures by failing to: 1. Notify the Department (State survey and certification agency) regarding abuse allegation immediately or within 24 hours of the alleged abuse in accordance with the facility?s policy. The above violation had direct or immediate relationship to the health, safety, or security of Resident A. |
| 940000098 |
COURTYARD CARE CENTER |
940011853 |
A |
03-Dec-15 |
QPB311 |
13997 |
F-323 ? 42 CFR483.25(h)(1). The facility must ensure that the resident environment remains as free from accident hazards as is possible.Based on observation, interview, and record review, the facility failed to prevent an accident by failing to: 1. Ensure a newly hired licensed vocational nurse (LVN) was able to competently put together and operate the portable oxygen equipment (the cylinder tank containing compressed oxygen and the regulator that controls the amount of oxygen flow).2. Replace an empty oxygen cylinder tank with a full tank in a position where Resident 8 could see the procedure.LVN 4 replaced the empty oxygen cylinder tank behind Resident 8?s wheelchair. When LVN 4 opened the full oxygen tank, it created a loud hissing sound. The loud hissing sound, which came from the released pressure of the compressed gas (oxygen), was created when the oxygen equipment was attached to the regulator and opened improperly. The loud sound scared the resident. The resident immediately got up from the wheelchair in an attempt to walk away from the perceived threat and fall to the floor.As a result, Resident 8 sustained a dark purple discoloration on the right side of the face and neck; a laceration on the upper right eyelid; right raccoon eye (dark purple discoloration around the eye, giving an appearance similar to that of a raccoon); red spots on the sclera (the white part of the eye), fracture of the right maxillary sinus (the area under the eye and above the upper teeth), and fracture of the right arm that required the use of a sling (a device to immobilize an injured arm). Resident 8 was transported to the acute care hospital via 911 emergency services. On 12/18/14 at 8:25 p.m., during the initial tour in the presence of Registered Nurse (RN) 1, Resident 8 was observed lying in bed. The right side of the resident's face (from the right eyebrow to the jaw) and neck had a dark and light purple discoloration. The area around the resident's right eye was swollen and had a dark purple discoloration. The sclera of the resident's eye had red spots. On 12/18/14 at 8:28 p.m., during an interview, RN 1 stated, "The resident was re-admitted last night and had a right humerus (a long bone in the arm that runs from the shoulder to the elbow) fracture."On 12/19/14 at 7:50 p.m., during an interview, Resident 8 stated the purple discoloration on her face was caused by a fall in the dining room. Resident 8 stated LVN 4 was replacing the empty oxygen tank behind her (the resident) wheelchair. The resident stated she did not know if LVN 4 knew what she (LVN 4) was doing because she (the resident) could not see what was happening behind her wheelchair.During the interview with Resident 8, she stated that when the oxygen from the tank started escaping from the tank, a loud noise occurred. The resident stated the loud noise scared her and so, she stood up from her wheelchair in attempt to flea and fell to the floor. Resident 8 stated there were two people who tried to help LVN 4, but it took them awhile to turn off the sound from the tank. On 12/19/14 at 10 p.m., during an inspection of the oxygen tank storage room conducted with LVN 3, the evaluator observed that there were 15 portable tanks that were full of oxygen. LVN 3 took an oxygen regulator (a device that adjusts the precise air flow from the oxygen tank that has been prescribed by the doctor) from the storage cabinet and stated during an interview, that only the licensed nurses were allowed to set up and operate the portable oxygen equipment (the cylinder tank and the regulator).On 12/19/14 at 10:10 p.m., during an observation, LVN 3 demonstrated how to set up the parts of the portable oxygen equipment to prepare it for use. LVN 3 attached the regulator to the top area of the oxygen cylinder tank (the cylinder post), opened the oxygen tank valve (a device that controls the flow of oxygen out of the tank) slowly, and then opened the liter flow rate meter (a device that controls how fast oxygen flows to the resident as ordered by the physician) on the regulator slowly. There was no loud hissing sound that came out from the oxygen tank.During the interview, on 12/19/14 at 10:10 p.m. LVN 3 stated that if the oxygen equipment was set up properly and the oxygen tank valve opened slowly, the pressure released from the oxygen tank would not create a loud sound. During the interview with LVN 3, he stated he had been working in the facility for about a year and he learned how to set up and operate the portable oxygen equipment prior to his employment to the facility. LVN 3 stated he did not remember if he received an orientation when he was newly hired at the facility and an in-service after his new hire orientation regarding how to correctly set up and operate the portable oxygen equipment.On 12/20/14 at 8:45 a.m., during an interview, the director of staff development (DSD) stated that during the new hire orientation, she would show the newly hired licensed nurse the oxygen storage room, but sometimes she would not conduct a demonstration of how to properly attach the oxygen regulator to the oxygen tank and then operate the equipment. During an interview with the DSD on 12/20/14 at 8 p.m., she stated LVN 4 started working in the facility on 9/18/14 and her previous nursing experience was in home health services. On 12/20/14 at 9:10 a.m., during an interview, the director of nursing (DON) stated she expected the licensed nurse to know how to set up and operate the portable oxygen equipment. The DON stated a newly hired licensed nurse would receive a two day orientation with the DSD and a one-to-one (1:1) training with a licensed nurse in the unit. The DON stated LVN 4 had been working in the facility for four months.During the interview with the DON, she stated the loud sound that startled Resident 8 was created by the leakage (released pressure) of the compressed gas (oxygen) from the oxygen tank that was full. The DON stated she had always informed the licensed nurses to explain to residents what they were about to do before executing a procedure.On 12/20/14 at 12:20 p.m., the DON stated the loud sound that the oxygen tank released occurred when LVN 4 opened the oxygen tank valve. On 12/20/14 at 1:25 p.m., during an interview, the director of rehab stated Resident 8 was receiving physical therapy (PT) and occupational therapy (OT) and had two to three weeks more of therapy remaining at the time the resident had a fall. The director of rehab stated that prior to the fall, Resident 8 was already able to walk about at least 200 feet using a walker before she would feel tired and would sit down. The director of rehab stated that after the accident, Resident 8 could not walk. During the interview with the director of rehab, he stated Resident 8 had a big decline in her function. According to the director of rehab, Resident 8 needed only stand by assist in bed mobility (turning) and transfer (such as sitting to standing), but currently, the resident was totally dependent on staff for bed mobility and transfer. The director of rehab stated, "She (Resident 8) had to stay longer here now."On 12/20/14 at 6:30 p.m., during an interview, LVN 5 stated the portable oxygen tank would release pressure when the valve is opened. In order for the pressure from the tank not to create a loud sound, LVN 5 stated, the oxygen regulator should be tightly placed on the oxygen tank and the valve should be opened slowly. LVN 5 stated she had trained new nurses in the evening shift and she would have the new nurse conduct a return demonstration because some new nurses had not set up and operated portable oxygen equipment before. A review of Resident 8's clinical record indicated the resident was admitted to the facility on 10/7/14 and she was transferred to the hospital on 12/13/14. Resident 8 was re-admitted to the facility on12/17/14 with diagnoses that included fracture of the humerus and COPD (chronic obstructive pulmonary disease). The resident was receiving oxygen continuously at two liters per minute via nasal cannula. According to the admission assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/14/14, Resident 8 was alert, able to make her needs known and understand others, and required extensive assistance in bed mobility, transfer, walking in the corridor, dressing, and eating. A review of Resident 8's Fall Risk Evaluation, dated 10/7/14, the resident had a score of 14 (total score of 10 or above represents high risk). A review of the Licensed Personnel Progress Notes, dated 12/13/14, indicated Resident 8 was in the activity room at 2 p.m. when the resident requested to have her oxygen tank replaced. While being assisted by the charge nurse (LVN 4), the oxygen tank started releasing oxygen. Resident 8 panicked and stood up from the wheelchair and attempted to walk away from the wheelchair. Resident 8 lost her balance and fell on the floor on her right side. According to the licensed nurse progress notes, Resident 8 had a laceration on the right eyebrow and ice was applied right away. The resident did not have a change in level of consciousness and behavior. Upon physical assessment conducted by LVN 4, Resident 8 was noticed to have decreased mobility on her right arm. The resident complained of right should pain, 10/10 pain level (10 being severe pain using the pain scale from zero as no pain to 10). 911 emergency services were called and the resident was transported to the emergency room at 2:30 p.m. A review of the hospital's History and Physical, dated 12/13/14, indicated Resident 8 had a fall at the facility. Resident 8's physical examination indicated the resident had a right raccoon eye with a small laceration in the upper eyelid with sutures intact. There was surrounding ecchymosis (bruising) in the right periorbital (around the eye) area, with minimal focal tenderness in the orbital (eye) floor area as well as the right maxillary sinus (the area under the eye and above the upper teeth).The History and Physical, dated indicated Resident 8 also had moderate tenderness to palpation (a method of clinical examination using gentle pressure of the fingers) on the right lateral (side) aspect of the right shoulder, with limited range of motion (refers to the distance and direction a joint can move to its full potential) due to pain. Shoulder sling is in place. Resident 8 complained of intermittent diplopia (double vision) on the right eye. According to the History and Physical, the CT scan (x-ray computed tomography, a technology that uses computer-processed x-rays to produce images allowing the user to see inside the object without cutting) of Resident 8's brain indicated there was a fracture of the right maxillary sinus with hemorrhage (bleed) extending through a non-displaced (a break in a bone in which the bone remains aligned properly, despite being broken) right orbital (eye) floor fractures. Orbit (eye) is intact. The x-ray of Resident 8's right shoulder showed an impacted (a fracture in which the bone breaks into multiple fragments which are driven into each other) right humeral head and neck fracture (a break in the upper arm bone). A review of the facility's untitled document regarding Resident 8?s fall incident, dated 12/15/14, indicated Resident 8's laceration on her right eyebrow measured 1 centimeter (length) x 2 centimeters (width) x « centimeter (depth) and first aid was provided.A review of the Licensed Personnel Progress Notes, dated 12/17/14, indicated Resident 8 was admitted back to the facility. On 12/18/14, Resident 8 was noted with difficulty feeding self due to limited use of her right upper extremity because of the recent fracture. A recommendation was made to provide the resident with a chopped diet to increase with self feeding using her left hand until the right upper extremity is healed. The rehab therapist recommended a plate guard to increase self feeding.A review of the initial Joint Mobility Assessment, dated 10/8/14, indicated Resident 8 was able to move her right shoulder within her functional limitations (WFL). After the fall on 12/13/14, the Joint Mobility Assessment, dated 12/18/14, indicated Resident 8's right shoulder had a severe joint mobility limitation (a reduction in the ability to move or perform the range of motion [ROM, refers to the distance and direction a joint can move to its full potential] from full ROM or WFL to zero thru 25% ROM). A review of the physician's order, dated 12/18/14, indicated an order for the dietary services to serve all meals to Resident 8 with a plate guard to increase with self-feeding with meals.A review of the Dietary Order Form, dated 12/18/14, indicated Resident 8 would need her food cut (chopped) in order to increase her self-feeding using her left hand until her right upper extremity is healed. A review of the facility's policy and procedure titled "Oxygen Therapy," undated, indicated "...Explain the procedure to the resident ...Connect flowmeter in the oxygen outlet. Be certain flowmeter is locked in place properly ..." The facility's policy and procedure did not indicate an instruction to guide the licensed nurses on how to open an oxygen tank valve that would prevent or minimize the release of a loud hissing sound.The facility failed to prevent an accident by failing to: 1. Ensure a newly hired licensed vocational nurse (LVN) was able to competently put together and operate the portable oxygen equipment (the cylinder tank containing compressed oxygen and the regulator that controls the amount of oxygen flow).2. Replace an empty oxygen cylinder tank with a full tank in a position where Resident 8 could see the procedure.This 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. |
| 940000053 |
COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER |
940012660 |
A |
1-Nov-16 |
X0NL11 |
20524 |
?483.25(c)(1-2) 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 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. ?483.25 F309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Department received a complaint on 7/1/16, alleging that a resident (Resident 1) arrived to the acute hospital, requiring a transfer to the intensive care unit (ICU) due to numerous Stage 3-4 pressure wounds on the hips, abdomen, and thigh area. Family expressed concerns regarding lack of care and treatment at the SNF. 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 who enters the facility without pressure sores does not develop pressure sores; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, including but not limited to: 1. Failure to accurately assess Resident 1's risk for pressure ulcer development. 2. Failure to implement the facility?s policy, dated 1/1/12, and titled, ?Pressure Ulcer Prevention." 3. Failure to follow Resident 1?s plan of care in pressure sore prevention in turning every two hours and keeping her clean and dry. 4. Failure to identify Resident 1?s change in condition, which required an immediate attention, until Resident 1?s family member insisted Resident 1 be transferred to the hospital. These deficient practices resulted in Resident 1 not being identified as a high risk for pressure sores development; developing many Stage III and IV pressure sores; (Stage III =a deep wound, the loss of skin usually exposes some fat; Stage IV a pressure sore that is very deep, reaching into muscle and bone and causing extensive damage) that became infected; becoming unresponsive and requiring an emergency transfer (911) to a general acute care hospital (GACH) on 6/29/16. Resident 1 required an intensive care unit admission, fluid intravenously ([IV] into vein), multiple IV antibiotics and aggressive wound care twice a day, and pain medications. Resident 1 required a 21-day hospital stay for care and treatment of the many infected pressure sores that led to sepsis (a life-threatening condition in which the body is fighting a severe infection that has spread via the bloodstream) and was discharged on 7/19/16. A review of Resident 1's Admission Face Sheet indicated Resident 1 was a 66 year-old female, who was initially admitted to the facility on 11/10/15, and most recently readmitted on 6/1/16. Resident 1's diagnoses included hypertension (high blood pressure), diabetes (high blood sugar) respiratory failure with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) requiring ventilator support (mechanical life support; breathing machine), dysphagia (difficulty swallowing) with a gastrostomy tube ([G-tube] feeding tube surgically placed through the skin and abdominal wall, for the introduction of food and fluids), end stage renal disease ([ESRD] last stage of chronic kidney disease [CKD] and dialysis or transplant is required to stay alive) requiring dialysis treatments (process of removing waste products and excess fluid from the body) three times a week (Monday, Wednesday, and Fridays [MWF]), morbid obesity (too much body fat for your height; is when the excess body fat becomes a danger to ones' overall health).. A review of Resident 1's skin assessment upon admission, dated 11/10/15, indicated Resident 1 had redness to the perineal area (between the vulva [external genital organs] and anus [rectum]) and surrounding the G-Tube area was a hard mass (a lump that can be within the skin, in the tissues, under the skin or attached to the skin and/or underlying tissues) to the lower abdominal fold area with no pain. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/30/15, indicated Resident 1 was alert and oriented to person, place, and time as evidenced by the brief interview of mental status (BIMs) with a score of 15 (score of 8 to15=inter-viewable). The MDS, under Section G, Functional Status, indicated Resident 1 was totally dependent on staff requiring a two+ physical assist for turning in bed and of any slight position changes, movement on and off the unit, dressing, eating, toilet use, and personal hygiene, with the exception of eating, Resident 1 required a one-person physical assist. According to the MDS, Resident 1 was non-ambulatory and incontinent (unable to control) of bowel and bladder. On 7/15/16 at 1:26 p.m., the treatment nurse (a licensed vocational nurse [LVN 1]) was asked for Resident 1's Braden Scale (an assessment tool for predicting pressure sore risk) from admission. LVN 1 and the facility's staff were unable to provide Resident 1's admission Braden Scale, but presented a Braden Scale, dated 3/2016. LVN 1 stated Resident 1 did not have any pressures sores upon admission to the facility. On 7/15/16 at 2:40 p.m., during an interview, a certified nursing assistant (CNA 1) stated she took care of Resident 1 during the first week of admission and stated Resident 1 had no pressure sores, only redness under Resident 1?s breast and stomach folds. CNA 1 stated there was a pubic area mass. CNA 1 was asked how often she turned the residents in the subacute unit. CNA 1 stated the residents were supposed to be turned every two hours, but sometimes the residents were only turned once a shift when she was busy. CNA 1 stated, "I would like to turn the residents every two hours, but sometimes it?s not possible, because it's only two CNAs in Sub Acute Unit (a higher level of care than a skilled nursing facility [SNF]). We have 10 residents each on an average shift and sometimes up to 12 residents on a shift, with most of the residents being bedbound (spends most of the time in bed) on ventilators. " A review of Resident 1's skin assessment, dated 12/23/15, indicated Resident 1's right and left buttock and right groin area were excoriated (damage or remove part of the surface of (the skin) and the abdomen at the GT site was ulcerated. A review of Resident 1's care plan, dated 12/25/15 (a month and half after admission), and titled, " High risk for skin breakdown, " related to abdominal surgical dehiscence (a surgical complication in which a wound ruptures along a surgical incision) abdominal wound, G-Tube ulceration (a sore on the skin or a mucous membrane), and excoriation of the left ischial (lower and back part of the hip bone), bilateral (both) buttocks, left abdominal fold, and the right groin, and diabetes, incontinence of bowel and bladder (B/B), fragile skin, limited mobility, and obesity. The staff's interventions included using pillows, pads, wedges to reduce pressure on heels and pressure points; and to turn and reposition Resident 1 every two hours and PRN (as needed). A review of Resident 1's Braden Scale, initiated on 3/2/16, indicated the facility's staff scored Resident 1 with a score of 16 on 3/2/16 and 4/20/16; a score of 18 on 4/29/16; 17 on 5/9/16 and 5/11/16 and a score of 18 on 5/18/16. According to the Braden scale, a total score of 10-12 represented a high risk and 15-18 was a mild risk for developing pressure sores. A review of Resident 1's laboratory results, dated 4/5/16, indicated a low albumin level at 2.8 g/dl ( NRR 3.5-5.2) and a low pre-albumin level at 9.5 (NRR 18-33.8). An article by NPUAP (National Pressure Ulcer Advisory Panel), dated 2009, indicated the nutrition was an important aspect of a comprehensive care plan for prevention and treatment of pressure ulcers and it was essential to address nutrition in every individual with pressure ulcers. Adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown. On 7/15/16 at 3:02 p.m., during a concurrent interview and record review of Resident 1's Braden Scale, the director of nursing (DON) stated, after recalculating Resident 1's score, Resident 1 should have had a score of 12 (high risk) on all the assessments, as opposed to the score of 16-18 (a mild risk). The DON stated Resident 1's pressure sore risk was inaccurately assessed, which resulted in an inaccurate Braden Scale score. The DON stated an inaccurate assessment can result in an inaccurate plan of care for Resident 1. The DON stated the facility's Subacute Unit has 23 beds with only two CNAs to care for the high acuity (the level of severity of an illness) residents. A review of the facility's policy, dated 1/1/12, and titled, ?Pressure Ulcer Prevention," indicated the Licensed Nurse will develop a care plan that contains interventions for residents who have a Braden Scale score of 12 or less, and therefore considered to be a high risk for developing pressure ulcers. The policy stipulated the nursing staff will develop a care plan specific to the resident's risk factors and implement interventions identified in the care plan, which may include, but are not limited to pressure redistributing devices (per the attending physician's order), repositioning, heel and elbow protectors, use of pillows and linen rolls, moisturizers, and bowel and bladder training. A review of a wound care assessment of pressure sores for Resident 1, dated 6/9/16, indicated the following: * Pubic region necrotic wound measured 10 centimeter (cm) by 15 cm by UTD (unable to determine). * 12. Right hip necrotic wound measured 8 cm by 4 cm by UTD. * Left lower abdomen necrotic wound measured 11 cm by 7 cm by UTD. * Left lateral thigh necrotic wound measured 1.5 cm by 2 cm by UTD. On 7/18/16 at 9:12 a.m., during a telephone interview, Resident 1's family member (FM 1) stated he visited Resident 1 every day in the SNF and sometimes twice a day. FM 1 stated the facility did not provide good care in cleaning Resident 1 and he would have to ask them to turn her and or get her up out of the bed, as was ordered by the physician. FM 1 stated he was first informed in 5/2016 of Resident 1 having a blister (a small pocket of fluid within the upper layers of the skin) on the abdomen, but was told by a licensed nurse there was nothing to be concerned about. FM 1 stated it was not until 6/2016, when a certified nursing assistant (CNA 4) asked him if he had seen Resident 1's wounds. He stated he then spoke to the wound care physician and was told there were several wounds that were large and infected with a foul smell. FM 1 stated the facility did not do any wound cultures of the Resident 1's wounds, although the wounds smelled and had drainage. FM 1 stated when he would ask the staff if they turned Resident 1, they would tell him Resident 1 refused, but Resident 1 would tell him they never asked. FM 1 stated on 6/29/16, at approximately 10 a.m., he called the facility and spoke to the registered nurse supervisor (RN 1) in the sub-acute unit. FM 1 stated RN 1, informed him Resident 1 was doing well without any problems. However, FM 1 stated he arrived at the facility about one hour later to find Resident 1 back on the ventilator with the oxygen saturation decreased to 92 to 93 percent (%), which was normally at 98 %, lying on her back, and unresponsive with eyes rolled back. FM 1 stated he was upset and had to insist that the facility called 911 due to Resident 1's change in mental status. FM 1 stated Resident 1's blood pressure was low upon his arrival at 60/30. FM 1 stated he was told by the GACH's physician Resident 1 was septic secondary to the many infected pressure sores. At 10:07 a.m., on 7/18/16, during a telephone interview, RN 1 (supervisor of the subacute unit) stated FM1 would visit Resident 1 and called all the time regarding her care and condition. RN 1 stated on the morning of 6/29/16, FM 1 had called and came to the facility. RN1 stated FM1 wanted Resident 1 transferred to the hospital, but he thought she was alright and did not need to go. RN 1 stated Resident 1 was lethargic and her heart rate was elevated, but her oxygen saturation was normal, but RN 1 stated they put Resident 1 back on the ventilator [sic]. RN 1 stated FM 1 was persistent in getting Resident 1 transferred to the hospital, so he called 911, because the basic ambulance would not have taken her with an elevated heart rate. A review of a the SNF's (skilled nursing facility) physician orders, dated 5/8/16, indicated Resident 1 can be up in chair from 8-10 a.m.,12-2 p.m. (on non-dialysis days), and 4-6 p.m. every day (7 days a week). A review of the Paramedic's Report, dated 6/29/16, and timed at 12:54 p.m., indicated Resident 1's GCS ([Glasgow Coma Scale] a scoring system for assessing the severity of brain impairment with sum of scores given for eye-opening, verbal, and motor responses [maximum of 15]). Resident 1's GCS score was 9 (GCS 9 -12 is Moderate impairment [3 for eye opening, 1 for verbal, and 5 for motor]) prior to being transported to the GACH. At 12:57 p.m., 6/29/16, Resident 1 had a low systolic blood pressure ([top number of blood pressure] amount of pressure that blood exerts on the vessels while the heart is beating) was under 78 (normal reference range [NRR]=120), the heart rate was 106 (NRR=60-100 BPM [beats per minute]), oxygen saturation was WNL (within normal limits) at 95 percent while Resident 1 receiving Bag-valve-mask (BVM) ventilation (an essential emergency technique used for residents who are not breathing or not breathing adequately).Resident 1's respiratory rate was 16 and the blood sugar was elevated at 240 (NRR is 135 to 140 milligrams per deciliter [dl]). Resident 1's weight was 240 lbs. A review of Resident 1's GACH's emergency department [ED] record, dated 6/29/16, and timed at 1 p.m., indicated Resident 1's mental status was altered upon arrival to the GACH. Resident 1, who typically on a ventilator only at night, while at the SNF was placed on a ventilator continuously. A review of the GACH?s history/physical for Resident 1 indicated Resident 1 was transferred from the SNF to the GACH due to an altered level of consciousness and shortness of breath. The ED's record indicated Resident 1 was lethargic (sluggish slow-moving or inactive) and unable to answer any questions. Resident 1's vital sign at 1:45 p.m. on 6/29/16 were as follows: Temp: 99.8 F (rectally [NRR= 99.6øF]), pulse at 100 BPM, Blood Pressure 111/33, respiratory rate at 16, and a pulse oximetry (saturation of oxygen in the blood) was 99 percent (%) on 100% FIo2 (fractional inspired oxygen). A review of Resident 1's GACH laboratory report, dated 6/29/16, indicated Resident 1 had a low albumin level (albumin is a serum protein produced in the liver that is essential for proper blood circulation, metabolism, and wound healing) of 2.4 grams per deciliter (g/dl), with a NRR listed as 3.2 - 4.8 g/dl, elevated white blood cell ([WBC] indicative of an infection) of 20.1 (NRR 4.3-10.0). The ED physician documented on the ED Encounter Form that Resident 1 was in moderate severe distress with a change in mental status that worsened due to underlying pneumonia versus sepsis with respiratory failure. The ED note indicated Resident 1 had multiple Stage IV decubitus ulcers with a foul odor. The ED physician documented Sepsis secondary to pneumonia and decubitus ulcers. The GACH?s infectious disease (ID) consultation, dated 6/30/16, indicated Resident 1 was awake, but did not readily respond and had multiple decubitus ulcers. The ID physician (are trained in internal medicine and specialize in diagnosing, treating, and managing infectious diseases) documented Resident 1 had multiple Stage III-IV decubitus ulcers with some exposing bone and having necrotic tissue and having a foul smell. The ID physician indicated there was a large necrotic wound over Resident 1's inferior pannus (an abnormal layer of tissue) on the suprapubic (of the abdomen located below the umbilical [naval]) region. A review of the pictures of Resident 1's various stages of Stage III-IV pressure sores from the GACH, dated 6/30/16 and 7/6/16, taken by a registered nurse treatment nurse indicated Resident 1 had foul smelling pressure sores on the following sites upon admission: * Left upper posterior thigh * Left lower abdomen * Right hip with 50 % necrotic tissue; exposed bone measuring 10 cm by 4.5 cm by 2 cm in depth. * Left thigh * Right lower abdomen * Lower abdomen (black in color unstageable; documented as larger wound with black eschar and foul smelling drainage) * Coccyx (unable to determine stage by looking at the picture) A review of Resident 1's GACH discharge summary, dated 7/19/16 indicated all of Resident 1's wounds had improved with less necrotic tissue with an improved clean base. The discharge summary indicated Resident 1's wounds no longer required a wound vacuum (a device which conducts negative pressure wound therapy (NPWT); device consists of a dressing which is fitted with a tube and attached to the wound). According to the discharge summary, Resident 1 was treated for drug resistant organism and placed in isolation receiving multiple IV antibiotics and antifungal medications. Resident 1 was weaned off ventilator support and was placed on 40% FIO2 trach collar (one-piece collar that secures tracheostomy tubes). Resident 1 transferred to another subacute facility on 7/19/16. 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 who enters the facility without pressure sores does not develop pressure sores; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, including but not limited to: 1. Failure to accurately assess Resident 1's risk for pressure ulcer development. 2. Failure to implement the facility?s policy, dated 1/1/12, and titled, ?Pressure Ulcer Prevention." 3. Failure to follow Resident 1?s plan of care in pressure sore prevention in turning every two hours and keeping her clean and dry. 4. Failure to identify Resident 1?s change in condition, which required an immediate attention, until Resident 1?s family member insisted Resident 1 be transferred to the hospital. The above violations, jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result, or a substantial probability that death or serious physical harm would result. |
| 940000074 |
California Post-Acute Care |
940013046 |
B |
15-Mar-17 |
8TFL11 |
6049 |
Abuse
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
During the course of a Certification Survey on 9/13/16 it was found that the facility had not investigated an allegation of abuse from CNA 1 to Resident 13.
Based on interview and record review, the facility failed to:
1. Investigate an allegation of abuse to Resident 13. CNA in lieu of answering the call light, threw water at the resident while he was lying in bed.
2. Send a written notification of Resident 1?s allegation of abuse to the State Survey and Certification agency within 24 hours.
Findings:
A review of Resident 13's Face Sheet indicated the resident was initially admitted to the facility on 7/6/16 and readmitted on 8/12/16 with diagnoses that included, but not limited to, pneumonia (inflammatory condition of the lung), generalized muscle weakness, bipolar disorder (a disorder associated with episodes of mood swings), and Parkinson's disease (degenerative disorder affecting the motor system resulting to movement-related symptoms such as shaking, rigidity, slowness of movement and difficulty with walking).
A review of Resident 13?s - 14 day prospective payment systems (PPS) Minimum Data Set ([MDS] assessment and care screening tool), dated 8/25/16 indicated Resident 13's brief interview of mental status ([BIMS] brief screener that aids in detecting cognitive impairment) score was 8 (a score of 8-12 represents moderately impaired cognition). Resident 13 had episodes of disorganized thinking and verbal behavioral symptoms directed toward others. Resident 13 also required extensive assistance with toilet use and limited assistance with activities of daily living (ADL) specifically bed mobility, transfer, walking, bathing, dressing, and personal hygiene.
On 9/13/16 at 10:35 a.m., during the initial tour of the facility, Resident 13 stated that a staff threw water on his body while he was lying in bed last week. Resident 13's responsible party (RP) stated that Resident 13 asked for staff for assistance, but instead, the staff member threw water on him. Resident 13 told RP about the incident and RP reported to the social service designee (SSD) and case manager (CM) on 9/9/16.
On 9/14/16 at 11:00 a.m., during an interview, the CM stated that sometime last week, Resident 13's RP reported to her, SSD, and SS Director that Resident 13 had his call light for a long time. When the certified nurse assistant (CNA) finally came to the room, the CNA threw water on Resident 13. The CM added that Resident 13's RP also stated that she knows her son makes up stories and lies to her.
On 9/14/16 at 11:18 a.m., during an interview, the SSD stated that on 9/9/16 Resident 13's RP reported to her and the SS Director that Resident 13 told her that a CNA had thrown water on him. The SSD stated that she did not report this to the administrator at that time because Resident 13's RP said that she will not pursue the complaint because she does not know whether the incident happened or not. The SSD stated that she should have reported this allegation of abuse to the administrator despite RP's statement so an investigation could have been performed. The SSD stated that when similar incidents happened in the past, SSD had always reported it to the administrator for investigation.
On 9/14/16 at 11:26 a.m., during an interview, the CM stated she did not report it because she assumed that the SSD would report it to the administrator.
On 9/14/16 at 11:26 a.m., during an interview, the assistant administrator stated that this allegation of a staff throwing water on Resident 11's body was not reported to him, but they will start an investigation immediately.
On 9/15/16 at 12:30 p.m., during an interview, assistant administrator stated that the investigation was initiated on 9/14/16. He added that the allegation of abuse was reported on 9/14/16 to the Department of Public Health and local Ombudsman. Police department also came in last night to do an investigation. The licensed vocational nurse (LVN) who was alleged to have thrown water on Resident 13's body was also suspended starting 9/14/16.
A review of the facility's policy and procedure titled, "Abuse Policy," dated 7/2015, indicated that if the suspected abuse does not result in serious bodily injury, the incident must still be reported by telephone within 24 hours to the local law enforcement. It further indicated that a written report will be provided to the local Ombudsman, the licensing and certification program (L&C program), and the local law enforcement agency within 24 hours utilizing California Report of Suspected Dependent Adult Elder Abuse Form (SOC 341).
An "All Facility's Letter," dated 12/19/12, from the California Department of Public Health, sent to California health facilities, including Nursing and Skilled Nursing Facilities, indicated that if the suspected abuse does not result in serious bodily injury, the mandated reporter must still report the incident by telephone within 24 hours to local law enforcement agency and provide a written report within 24 hours to local law enforcement agency, the L&C (Licensing and Certification - agency responsible for ensuring health care facilities comply with state laws and regulations) Program, and the local Ombudsman (public advocate).
The facility failed to investigate an allegation of abuse and failed to notify the Department of Health Services of allegation of abuse within 24 hours.
The facility?s failure to implement their abuse policy and procedure put all residents at risk for potential abuse.
These violations had a direct relationship to the health, safety, or security of the residents. |
| 940000074 |
California Post-Acute Care |
940013048 |
B |
14-Mar-17 |
FQT811 |
4865 |
F225 - Abuse
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
During the course of an Entity Reported Incident investigation on 1/12/17, the following violation was identified.
The facility failed to report the witnessed incident of a physical altercation between Resident 2 and Resident 1, within 24 hours to the State licensing and certification agency (the Department), the Long Term Care Ombudsman and the local enforcement agency within 24 hours.
Findings:
On 1/11/17 at 4:00 p.m., a review of the Admission Record of Resident 1 indicated the resident was admitted to the facility on 6/12/15, with diagnoses that included liver disease, anemia, and anxiety disorder (increased anxiety that interferes with daily life). A review of the Minimum Data Set (MDS / an assessment and care screening tool) dated 9/12/16, indicated Resident 1 was cognitively intact and needed extensive assistance in most of her activities of daily living (ADLs) by one person.
On the same day at 4:05 p.m., a review of the Admission Record of Resident 2 indicated the resident was admitted to the facility on 4/29/16, with diagnoses that included Alzheimer's disease (a disease that destroys memory and other important mental functions), anxiety disorder, and bipolar disorder (a mental disease with episodes of mood swings ranging from depressive lows to manic highs). The MDS dated 12/6/16, indicated Resident 2 had a severely impaired cognition and needed supervision for ambulation but required extensive assistance in all other ADLs by one person.
During an interview on 1/11/17 at 4:15 p.m., the administrator (ADM) stated the ombudsman was making her rounds on 12/28/16, when Resident 1 stated Resident 2 had slapped her. The ADM stated the ombudsman then informed the staff of the incident. The ADM stated she reported the abuse altercation to the department on 12/28/16.
On 1/11/17 at 4:30 p.m., the Director of Nurses (DON) was asked about the incident reported by the facility. She stated on 12/26/16, a staff heard a commotion outside the dining room and ran to inquire. The DON stated the staff saw Residents 1 and 2 having an altercation. The DON further stated Residents 1 and 2 were separated, assessed, and the doctor and family were notified.
During an interview on 1/11/17 at 5 p.m., the ADM stated she informed the health department about the incident on 12/28/16. The DON stated she did not inform the department on 12/26/16, when the incident occurred.
During a telephone interview on 1/12/17 at 10:46 a.m., the Administrative Assistant (AADM) stated Resident 1 told her on 12/27/16, that she had informed social services about her altercation with Resident 2.
During a telephone interview on 1/12/17 at 11 a.m., the Registered Nurse Supervisor (RN 1) stated she witnessed Resident 2 hit Resident 1 and notified the ADM the same day on 12/26/16.
A review of the facility ' s incident investigation summary titled, " California Post-Acute Resident to Resident Alleged Abuse Verification of Investigation Report, " the staff indicated the incident occurred on 12/26/16, but was not reported to the to the State licensing and certification agency ( the Department ), until 12/28/16.
A review of the facility's policy and procedure titled, "Abuse Policy," dated 7/2015, indicated that if the suspected abuse does not result in serious bodily injury, the incident must still be reported by telephone within 24 hours to the local law enforcement. It further indicated that a written report will be provided to the local Ombudsman, the licensing and certification program (L&C program), and the local law enforcement agency within 24 hours utilizing California Report of Suspected Dependent Adult Elder Abuse Form (SOC 341).
An "All Facility's Letter," dated 12/19/12, from the California Department of Public Health, sent to California health facilities, including Nursing and Skilled Nursing Facilities, indicated that if the suspected abuse does not result in serious bodily injury, the mandated reporter must still report the incident by telephone within 24 hours to local law enforcement agency and provide a written report within 24 hours to local law enforcement agency, the L&C (Licensing and Certification - agency responsible for ensuring health care facilities comply with state laws and regulations) Program, and the local Ombudsman (public advocate).
The violation had a direct relationship to the health, safety and security of the residents. |
| 950000014 |
COVINA REHABILITATION CENTER |
950008890 |
A |
31-Jan-12 |
396911 |
9099 |
F323 483.25 (1) AND (2) Accidents and Supervision: The facility must provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes implementing intervention?s to reduce hazards and risk.On December 10, 2009, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding the fall of Resident 1 which resulted in a fracture of the right femur. Based on interview and record review, the facility failed to ensure that: 1. Resident 1 received adequate assistance in accordance with his assessment to prevent accidents. 2. Ensure that Resident 1?s care plan reflected his assessment for the need to be transferred by two staff members so as to prevent an unsafe transfer.3. Implement the facility?s ?Positioning and Moving Resident?s? policy to use a hydraulic lift or mechanical lift whenever residents require moderate or extensive assistance in movement or positioning.As a result of the above failures, Resident 1 fell and sustained a fractured femur and was transferred to the Emergency room and was treated conservatively with pain medication and a knee immobilizer for one day.A review on the Admission and Discharge Summary Form dated December 10, 2009, indicated that Resident 1 was admitted to the facility on October 10, 2007, with diagnoses that included hypertension (High Blood Pressure), cerebrovascular accident with right hemiparesis (weakness of one side of the body), transient ischemic attack ( a stroke that comes and goes quickly. It happens when the blood supply to part of the brain stops briefly.), non-insulin dependent diabetes mellitus, diabetic neuropathy (a family of nerve disorders caused by diabetes) and history of intracranial hemorrhage (Bleeding within the skull). According to the Minimum Data Set (MDS-a standardized assessment Tool) dated June 22, 2009, indicated that Resident 1 had a short term memory problem, had modified independence in daily decision making, was non-ambulatory, and used a wheelchair for locomotion. It further indicated that Resident 1 required extensive assistance with bed mobility, transfers, and locomotion, required two-person physical assistance for bed mobility and transfers, had hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) and did not ambulate.A review of the clinical record revealed that a care plan titled ?Falls, Osteoporosis, ADL, and Falls? (with an unknown date) was developed. The intervention indicated to assist Resident 1 with all transfers and ambulation as needed. However, the plan of care did not include the assessed requirement for two person physical-assistance during transfers. A review of the licensed nurse notes dated November 24, 2009, at 11 a.m. indicated that Employee 1 assisted the resident with ADLS at 11 a.m., and while she was transferring the resident from the bed to the wheelchair, the resident let go of her right arm from the C.N.A?s neck, thereby, causing uneven distribution of the resident?s weight and sudden shift of the weight and the C.N.A was not able to prevent the fall.During an interview with Resident 1 on December 10, 2009, at 3 p.m., she stated ?I slid. Staff lost her grip on me.? During an interview with CNA 1 on December 10, 2009, at 3:15 p.m., CNA 1 stated that when she was transferring Resident 1 from the bed to the wheelchair, she had instructed Resident 1 to grab her neck with her good arm (left arm). When she was about to transfer Resident 1, Resident 1 let go of her hand which was around her neck and her body gave way. C.N.A 1 stated that she was not able to prevent the fall, so she slowly put the Resident in a sitting position and called for help and three staff came and assisted Resident 1 back to bed. She further stated ?Sometimes I get some help, but most of the time I?m by myself. They told me to get some help before the fall, but I don?t remember when.? A review of the multidisciplinary progress record dated November 24, 2009, at 11 a.m. indicated that Resident 1 complained of pain to the right extremity and was assessed by licensed Nurse 1 to have slight swelling to the right knee. Therefore, Vicodin and Ultram 50 milligrams (mg.) (Pain Medication) were administered. The review of the multidisciplinary progress record dated November 24, 2009, further indicated that the licensed nurse called the exchange at 2:15 p.m. and an order was given by the Nurse Practitioner to obtain a stat (Immediately) x-ray of the right knee and the right hip. A review of the Diagnostic Imaging Report dated November 24, 2009, indicated that Resident 1 had sustained a fracture involving the right distal femur with no displacement. (A break in the thigh bone, with no removal from the normal or usual position).During an interview, with Employee 3 on December 11, 2009, at 1:15 p.m., she stated ?Employee 1 was by herself. It should be two person assist.? Employee 3 further stated ?If the MDS assessment indicated two person assist, it should be reflected in the care plan.? During an interview with Employee 4, on December 11, 2009, at 2 p.m., (MDS Coordinator), he stated that ?Resident 1 still needs extensive assistance due to right side weakness, and If the Resident requires two person assist, it should be reflected in the ADL?s careplan and it should be specific.? He further stated that the staff should know that Resident 1 is two person assist. They were given in-services by the staff developer.?During an interview with Employee 5 (DON), on December 14, 2009, at 1:15 p.m., she stated that the care plan should have reflected a ?two-person-assistance?. A review of the multidisciplinary progress record dated November 24, 2009, at 9 p.m. indicated that Physician 1 was made aware of the x-ray results and ordered the following: 1) keep the resident on bed rest, 2) Right leg immobilizer 3) Call the orthopedic physician in the morning (Physician 2) and inform him of the resident?s x-ray results and 4) Obtain an appointment or opinion with the orthopedic physician as needed.Further review of the multidisciplinary note dated November 25, 2009; at 9 a .m. indicated Physician 2 was informed that Resident 1 had a fracture of the right distal femur. Physician 2 then ordered to transfer Resident 1 to the acute hospital emergency room.A review of the acute hospital emergency room summary dated November 25, 2009, indicated that Resident 1 complained of a sharp and constant pain to the right leg. It further indicated that an X-ray of the leg revealed a nondisplaced femur fracture.A review of the facility?s undated policy and procedure titled ?Positioning & Moving Residents,? indicated to obtain assistance from other professionals as needed and to use a hydraulic lift or mechanical lift whenever residents required moderate or extensive assistance in movement or positioning. According to the State Operations Manual Interpretive Guidelines for 483.25(h)(1)(2), it is important to train staff regarding resident assessment, safe transfer techniques, and the proper use of mechanical lifts including device weight limitation. According to the fundamentals of Nursing, (2005), Transfer of a client from a bed to a wheelchair by one nurse requires assistance from the client and should not be attempted with a client who cannot help.A safe transfer is the first priority. The nurse who is doubtful about personal strength or the client?s ability to help should request assistance. Often a hydraulic lift can be used to transfer clients. Additionally, it notes that an assessment of the client provides important information relative to the client?s ability, physical status, ability to comprehend, and the number of individuals needed to provide safe transferring. (Potter & Perry. (2005). Fundamentals of Nursing, 6th edition. St. Louis Missouri: Elsevier Mosby). The facility failed to ensure that: 1. Resident 1 received adequate assistance in accordance with his assessment to prevent accidents. 2. Ensure that Resident 1 ?s care plan reflected his assessment for the need to be transferred by two staff members e so as to prevent an unsafe transfer.3. Implement the facility?s ?Positioning and Moving Resident?s? policy to use a hydraulic lift or mechanical lift whenever residents require moderate or extensive assistance in movement or positioning. The facility?s failure to transfer Resident 1 with two staff members as indicated in the assessment, and the failure of the facility to implement its policy and procedure for positioning and moving, placed Resident 1 at risk for injury and as a result, Resident 1 fell and sustained a fractured femur and was transferred to the Emergency room and was treated conservatively with pain medication and a knee immobilizer for one day.These violations presented a substantial probability that death or serious physical harm would result. |
| 950000022 |
COMMUNITY CARE CENTER |
950009403 |
B |
18-Jul-12 |
BE9Q11 |
7589 |
Health & Safety-1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. On February 13, 2012, at 1:55 p.m. the Department received a report of a Suspected Dependent Adult/Elder Abuse (SOC 341), from the facility which indicated that Patient A had reported that Patient B had hit her in the face with her fists. The report further indicated Patient A had a one inch laceration above her right eye and a 0.5 inch laceration on her right cheek. According to the report, Patient B denied the incident. The incident occurred on February 11, 2012 at 5 a.m. On February 28, 2012 at 2 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding patient abuse. Based on interview and record review the facility failed to: 1. Report an allegation of abuse to the Department within 24 hours as required by statute. 2. Implement the facility?s policies and procedures for patient abuse reporting which indicated that, mandated reporters were required to report alleged instances of physical abuse to the local ombudsman or local law enforcement agency as required by state regulations.A review of Patient A?s ?Face Sheet? indicated that the patient was a 50 year old female who was admitted to the facility on October 15, 2003. The patient?s diagnoses included Schizophrenia (a group of severe brain disorders in which people interpret reality abnormally and may result in some combination of hallucinations, delusions and disordered thinking and behavior). A review of Patient A?s quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 9, 2012, indicated that Patient A was able to make herself understood and was able to understand others. The MDS further indicated that the patient suffered from delusions and had continuous behaviors such as inattention, disorganized thinking (unpredictable switching from subject to subject), altered level of consciousness (startled easily, difficult to arouse), and psychomotor retardation (decreased level of activity such as sluggishness, staring in space, staying in one position, and moving very slowly). A review of Patient B?s, ?Face Sheet?, indicated the patient was a 62 year old female who was admitted to the facility on September 2, 2008. The patient?s diagnoses included paranoid schizophrenia, and depression (a disorder of the brain symptoms can include sadness, loss of interest or pleasure in activities you used to enjoy, change in weight, difficulty sleeping or oversleeping, and thoughts of death or suicide). A review of a Patient B?s quarterly Minimum Data Set dated December 6, 2011, indicated that Patient B spoke Vietnamese and required an interpreter to communicate with a doctor or employee. The MDS indicated that the patient did not exhibit any signs or symptoms of delirium such as inattention, disorganized thinking, altered level of consciousness, or psychomotor retardation nor did the patient exhibit any physical or verbal behavioral symptoms.Review of the form titled, ?Resident Abuse Investigation Report Form?, dated February 13, 2012, indicated that on February 11, 2012, at approximately 5 a.m., Patient B went over to Patient A?s bed and hit Patient A in the face while she was sleeping. Patient A went to the nurse?s station with blood on her face. Patient A had a laceration (a jagged wound or cut may be deep or superficial) above her right eye that was approximately one inch in length and a laceration on her right cheek that was approximately 0.5 inches in length. The staff then cleaned the lacerations with water and applied triple antibiotic ointment to both lacerations and covered them with steri-strips (thin adhesive strips which can be used to close small wounds, generically known as butterfly stitches). Patient A was offered a room change which she refused. The staff then moved Patient B to another room where she was placed on ?line of sight? (LOS), where she would be observed during night shift (11p.m. to 7 a.m.) in order to ensure the safety of her roommates, until further notice. The report indicated that Patient B denied hitting Patient A. A review of a physician?s order for Patient B, dated February 13, 2012, indicated to discontinue Depakene {(valproic acid-250 milligrams (mg)} by mouth two times a day for manic behavior. Depakene, an anticonvulsant medication often prescribed as a mood stabilizer for those with bipolar disorder (also known as manic depression). Another physician?s order dated February 13, 2012, indicated to start Patient B, on Depakene 250 mg by mouth every morning for manic behavior and Depakene 500 mg by mouth at hour of sleep for manic behavior. On February 28, 2012 at 2:40 p.m., an attempt was made to interview Patient A. The patient refused to be interviewed. In an interview on February 28, 2012 at 3 p.m., Staff 1 stated he had not noticed any physical behavior issues from Patient B in the recent years. In an interview on February 28, 2012 at 3:15 p.m., Patient B, in the presence of a translator (Staff 2), stated she did not remember hitting Patient A. Patient B would not say anymore regarding the incident.In an interview on March 28, 2012 at 3:10 p.m., Staff 3 stated incidents like this one tend to happen every so often but the incidents usually don?t result in any serious harm. Staff 3 stated since this incident had happened on a weekend, the facility had not reported the incident to the Department within 24 hours, but instead had waited until Monday February 13, 2012, at an unspecified time to report.The Department received a faxed report from the facility of a Suspected Dependent Adult/Elder Abuse (SOC 341), on February 13, 2012, at 1:55 p.m., which was more than 56 hours after the incident occurred.In an interview on April 3, 2012 at 7:05 a.m., Staff 4 stated that on the day of the incident, the patient (Patient A) walked out of her room to the nurse?s station and stated she had been hit in the face by her roommate (Patient B). According to Staff 4, after Patient A reported that Patient B had hit her, Staff 4 asked Patient B about the allegation. However, Patient B did not remember having hit her roommate. Staff 4 also stated in all the years he had worked at the facility (7 years), he had never seen Patient B hit any other resident. A review of the facility?s policy, ?Abuse Reporting?, dated December 2011, revealed that mandated reporters are required to report known, suspected or alleged instances of physical abuse, abandonment, isolation, financial abuse, or neglect to the local ombudsman or local law enforcement agency as required by state regulations. A written report will be sent as mandated.? There was no evidence that the facility reported Patient A?s allegation of abuse by Patient B, to the department immediately, or within 24 hours, as required by State regulation or implement the facility?s policies and procedures for patient abuse reporting.The facility failed to:1. Report an allegation of abuse to the Department within 24 hours as required by statute. 2. Implement the facility?s policies and procedures for patient abuse reporting that indicated mandated reporters are required to report alleged instances of physical abuse, to the local ombudsman or local law enforcement agency as required by state regulations.These violations had a direct relationship to the health and safety of residents. |
| 950000047 |
COAST CARE CONVALESCENT CENTER |
950009689 |
B |
26-Dec-12 |
U71W11 |
5292 |
?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. 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. Adhere to the facility?s policy that required to test hot water temperatures in all the faucets of the bathrooms, restrooms, and shower rooms at random from Monday to Friday, at least once a week to maintain a temperature between 105 and 120 degrees Fahrenheit. Hot water temperatures in resident rooms 1, 2, 3, 4, 5, 7, and shower room A, were measured at unsafe temperatures above 120 degrees Fahrenheit that placed the residents at an increased risk for burns caused by scalding.During the environmental tour of the facility on November 30, 2012, between 12:12 p. m. and 12:25 p. m., the evaluator tested the water temperature of hot water coming out of the faucets in residents? bathrooms with a probe thermometer. The following readings were obtained:Room # Temperature (Degrees Fahrenheit) 1 & 2 145 3150 4 140 5 & 7140 Shower Room A145 On November 30, 2012 at 12:30 p. m, the administrator and the director of nurses were made aware of the unsafe hot water temperature readings. The maintenance supervisor was not in the facility and could not be found at the time of observation.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 a review of a list of ambulatory residents provided by the director of nurses on November 30, 2012 at 3:30 p. m., the list indicated that two residents in rooms 1 and 5, and one resident in room 4 ambulate independently. The administrator stated these residents had been kept safe and away from the bathroom immediately after the facility was made aware of the unsafe hot water temperature readings in the residents? bathrooms and that the residents would be allowed to return to the rooms only when it was safe to do so.On November 30, 2012 at 12:35 p.m., the administrator immediately reduced the hot water temperature setting of the control knob of the hot water boiler located outside the building that provided hot water to resident rooms 1 through 9. The water heater had a thermostat which indicated a temperature of 135 degrees Fahrenheit at the hot water boiler gauge located on the top of the hot water boiler. The entire hot water content of the hot water boiler was drained via the hand washing sinks in the residents? bathrooms by facility staff.A review of the facility hot water log sheet indicated that on November 30, 2012 at 1:10 p. m, the temperature of the hot water in the residents?? bathroom faucets were measured at 118 degrees Fahrenheit.During an interview with the administrator on November 30, 2012 at 12:35 p.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.A review of the temperature monitoring log sheet for October 1, 8, 15, 22, and 29, and November 5, 2012, completed by the maintenance supervisor indicated that hot water temperatures in the resident rooms ranged from 118 to 120 degrees Fahrenheit. However there was no documented evidence that the hot water temperature was being monitored after November 5, 2012. When asked why the maintenance supervisor had not checked the hot water temperature after November 5, 2012, the administrator stated he did not know. The maintenance supervisor was still not available in the facility to respond to the evaluator?s question.A review of the facility policy on ?Water Temperatures in the building? revealed that ?The Maintenance Director will test the hot water temperature in all the faucets of the bathrooms, restrooms, and shower rooms at random from Monday to Friday, at least once a week. This facility maintains an on-going water temperature within the range of 105 to 120 degrees Fahrenheit to all the faucets of the bathrooms, restrooms, and shower rooms used by the residents.? The facility failed to:1. Adhere to the facility?s policy to test hot water temperatures in all the faucets of the bathrooms, restrooms, and shower rooms at random from Monday to Friday, at least once a week to maintain a temperature between 105 and 120 degrees Fahrenheit. Hot water temperatures in resident rooms 1, 2, 3, 4, 5, 7, and shower room A, 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. |
| 950000047 |
COAST CARE CONVALESCENT CENTER |
950009735 |
B |
08-Feb-13 |
U71W21 |
6782 |
Health & Safety Code Section 1418.21(a)(1)(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 councilmeetings, or activities. (2) The information shall be posted on white orlight-colored paper that includes all of the following, in the following order:(a) The full name of the facility, in a clear and easily readable font of at least 28 point.(b) The full address of the facility in a clear and easily readable font of at least 20 point.(c) The most recent overall star rating given by CMS to thatfacility, except that a facility shall have seven business days fromthe date when it receives a different rating from CMS to include theupdated rating in the posting. The star rating shall be aligned inthe center of the page. The star rating shall be expressed as thenumber that reflects the number of stars given to the facility byCMS. The number shall be in a clear and easily readable font of atleast two inches print.(d) Directly below the star symbols shall be the following text ina clear and easily readable font of at least 28 point:"The above number is out of 5 stars."(e) Directly below the text described in subparagraph (D) shall be the following text in aclear and easily readable font of at least 14 point:"This facility is reviewed annually and has been licensed by theState of California and certified by the federal Centers for Medicareand Medicaid Services (CMS). CMS rates facilities that are certifiedto accept Medicare or Medicaid. CMS gave the above rating to thisfacility. A detailed explanation of this rating is maintained at thisfacility and will be made available upon request. This informationcan also be accessed online at the Nursing Home Compare Internet Website at http://www.medicare.gov/NHcompare. Like any information, theFive-Star Quality Rating System has strengths and limits. Thecriteria upon which the rating is determined may not represent all ofthe aspects of care that may be important to you. You are encouragedto discuss the rating with facility staff. The Five-Star QualityRating System was created to help consumers, their families, andcaregivers compare nursing homes more easily and help identify areasabout which you may want to ask questions. Nursing home ratings areassigned based on ratings given to health inspections, staffing, andquality measures. Some areas are assigned a greater weight than otherareas. These ratings are combined to calculate the overall ratingposted here."(f) Directly below the text described in subparagraph (e), thefollowing text shall appear in a clear and easily readable font of atleast 14 point:"State licensing information on skilled nursing facilities isavailable on the State Department of Public Health's Internet Website at: www.cdph.ca.gov, under Programs, Licensing andCertification, Health Facilities Consumer Information System." (3) For the purposes of this section, "a detailed explanation ofthis rating" shall include, but shall not be limited to, a printoutof the information explaining the Five-Star Quality Rating Systemthat is available on the CMS Nursing Home Compare Internet Web site.This information shall be maintained at the facility and shall bemade available upon request. (4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements.(a) Violation of this section shall constitute a class Bviolation, as defined in subdivision (e) of Section 1424 and,notwithstanding Section 1290, shall not constitute a crime. Finesfrom a violation of this section shall be deposited into the StateHealth Facilities Citation Penalties Account, created pursuant toSection 1417.2.(b) This section shall be operative on January 1, 2011.During an annual re-certification survey on November 27, 2012, at 3:30 p.m. theevaluator noted that the facility failed to post the required overall facility Five-StarQuality Rating System information determined by the federal Centers for Medicareand Medicaid Services (CMS). Based on observation and interview, the facility failed to comply with the California Health & Safety Code requirement by:1. Failing to post the most current and overall facility?s Five Star Quality ratinginformation determined by the federal Centers for Medicare and MedicaidServices (CMS).During an initial tour of the facility on November 27, 2012 at 10:00 a.m., the evaluator did not observe the required posting of the facility?s most current Five-Star Quality Rating System information either at the consumer board by the nursing station or by the front lobby entrance where the list of the department head names was posted or at any other location in the facility.The Five-Star Quality Rating System was created to help consumers, their families, and caregivers, compare nursing homes more easily and help identify areas where the public, caregivers, residents and consumers may want to ask questions and/or make informed choices as to which facility, based on Five-Star Quality Rating System may meet their care needs.Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating. During an interview with the administrator on November 30, 2012 at 3:30 p.m., he stated that he was not aware of the requirement to post this information. The facility failed to comply with a California Health & Safety Code requirement by:1. Failing to post the most current and overall facility?s Five Star Quality ratinginformation determined by the federal Centers for Medicare and MedicaidServices (CMS). The above violation had a direct relationship to the health, safety and security of the residents in the facility. |
| 950000033 |
CHINO VALLEY HEALTH CARE CENTER |
950009835 |
AA |
25-Mar-14 |
XV4H11 |
17184 |
F223 483.13(b)?The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. On November 30, 2010 at 8:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident that occurred when Resident A was found with a bloody face and an injured right arm from an unknown origin at 9 a.m., on November 23, 2010. The facility failed to ensure that Resident A was free of physical abuse by failing to: 1. Develop Resident B?s care plan to include specific time tables to meet the supervision/monitoring needs of the resident who had physically abusive and socially inappropriate aggressive behavior toward others. 2. Revise Resident B?s care plan interventions when the resident did not meet the expected care plan goal of less than two episodes of sudden angry outburst behavior every month to address the resident?s physically abusive and socially inappropriate behavior.3. To appropriately address Resident B?s aggressive behaviors and intervene to prevent abuse of Resident A.As a result, Resident B physically assaulted Resident A which subsequently resulted in Resident A?s emergency hospitalization at an acute care hospital. Resident A received acute hospital treatment on November 23, 2010 at 10:06 a.m., where he was diagnosed with traumatic open elbow dislocation and facial trauma.Resident A remained in the acute care hospital from November 23, 2010 until his death on December 4, 2010. Resident A?s death was due to multiple blunt force injuries including injury to the right elbow / amputation of the right arm. A review of Resident A?s medical record indicated he was a 91 year old male who was admitted to the skilled nursing facility (SNF) on September 11, 2009, with diagnoses that included diabetes mellitus, vascular dementia (cognitive [mental] and intellectual deterioration) and prostate cancer. The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated September 6, 2010, indicated that Resident A had short and long term memory problems, had severely impaired cognitive skills for daily decision making and rarely made himself understood. The resident sometimes was able to understand others and had unclear speech. The MDS further indicated that Resident A was non-ambulatory, used a wheelchair for locomotion and was totally dependent on others for most activities of daily living. A review of Resident A?s a care plan initiated on September 11, 2009, titled ?At risk for fall and injury due to poor safety awareness related to diagnosis of dementia?, indicated that staff would maintain visual checks when Resident A was up in wheelchair and when in bed. A review of Resident B?s admission record indicated that the resident was a 46 year old male resident who was originally admitted to the SNF on February 24, 2009, and was readmitted to the SNF on May 21, 2010, with diagnoses of altered level of consciousness, status post (S/P, refers to a state that follows an intervention) craniotomy (brain surgery) and VP shunt (ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull) placement, seizure disorder dementia with behavior disturbance and paraplegia. The annual MDS of February 9, 2010, indicated that Resident B had short and long term memory problems and was moderately impaired in cognitive skills, had persistent anger with self or with others, required limited assistance with locomotion on the unit and with eating, had paraplegia (paralysis of the lower part of the body), and had an anxiety disorder. The Resident Assessment Protocol Summary (RAPS) dated February 9, 2010, indicated that the resident had angry outbursts, aggressive behavior toward others and the facility would proceed with a care plan. According to the SNF transfer record dated September 3, 2010 at 6 p.m., Resident B was transferred to an acute care hospital for having destructive behavior. A ?Nursing Alert? from the SNF dated September 3, 2010, indicated that Resident B was ?destructive to equipment ... had very strong upper body strength.? The psychiatric evaluation assessment from the acute hospital dated September 4, 2010, indicated that Resident B had multiple prior admissions due to destructive behavior. The medical and history from the acute hospital dated September 4, 2010, disclosed that Resident B was admitted to an acute hospital for psychiatric treatment and that Resident B stayed at the acute hospital for ten days and was readmitted to the SNF on September 13, 2010. A review of Resident B?s physician?s orders dated September 13, 2010, indicated the following medications were ordered: 1. Seroquel (an antipsychotic medication) 100 mg by mouth twice a day. 2. Seroquel 150 mg every bedtime for psychosis manifested by constant talking to self. 3. Ativan one mg by mouth every four hours whenever necessary for anxiety manifested by sudden angry outburst behavior. On September 13, 2010, a care plan was initiated due to Resident B receiving Ativan resulting from sudden angry outburst behavior due to anxiety. The care plan approaches included the following: 1. Administer medication as ordered 2. Monitor and record episodes of sudden angry outburst behavior 3. Summarize effectiveness of data monthly The SNF Roster of November 23, 2010, revealed Resident A was a roommate of Resident B.Resident B?s MDS dated September 23, 2010, (2 months prior to his discharge of November 23, 2010), revealed that Resident B was assessed to have verbally abusive, physically abusive, socially inappropriate, and disruptive behaviors. The resident was also assessed as non-ambulatory, used a wheelchair for locomotion and needed extensive assistance for most activities of daily living. The care plan goal of September 13, 2010, indicated that Resident B would have less than two episodes of sudden angry outburst behavior every month. The care plan intervention of monitoring episodes of sudden angry outburst behavior did not include the method of monitoring or supervising the resident and did not specify time tables for supervision or monitoring of Resident B to ensure that Resident A and other residents were not subjected to Resident?s B?s angry and aggressive outbursts. Additionally, the care plan indicated to summarize effectiveness of data monthly, however, the care plan did not indicate how to intervene in the event that the medication (Ativan) was not effective in reducing Resident B?s sudden angry outburst behavior to less than two episodes of this type of behavior every month as indicated in the care plan goal. A review of the medication administration record (MAR) of September 13, 2010 to September 30, 2010 revealed Resident B was given Ativan one milligram (mg) by mouth 6 times during this time frame.A review of the medication administration record (MAR) of October 1, 2010 to October 31, 2010, revealed Resident B was given Ativan one milligram (mg) by mouth 25 times during this time frame.A review of the medication administration record (MAR) of November 1 to 23, 2010, revealed Resident B was given Ativan as needed one milligram (mg) by mouth 17 times during this time frame. However, there was no evidence that the resident?s sudden angry outburst behavior episodes diminished during the same time period from September 13, 2010 to November 22, 2010.A review of the medication administration record (MAR) behavior monitoring for sudden angry outburst behavior of Resident B revealed the following: a. Resident B had 31 episodes of sudden angry outburst behavior (in 16 days) from September 13, 2010 through September 30, 2010. b. Resident B had 72 episodes of sudden angry outburst behavior (in 31 days) from October 1, 2010 through October 31, 2010. c. Resident B had 55 episodes of sudden angry outburst behavior (in 23 days) from November 1, 2010 through November 23, 2010. Resident B?s sudden angry outburst behaviors had been summarized on the Psychotropic Summary Sheet as follows: September 13, 2010 to September 30, 2010 - 30 behaviors October 1, 2010 to October 31, 2010 - 72 behaviors The behavior data was signed by the nurse, however, there was no indication that the behavior was analyzed from September 13, 2010 to November 23, 2010, to determine if Resident B?s behavioral disturbance could be minimized by an increase in the dose or time interval of the Ativan. The physician progress note dated November 5, 2010, indicated that Resident B had no new medical problems but had psychiatric aggression and that the resident?s mental status was very labile (undergoing frequent change). There was another physician progress note of November 18, 2010, indicating that the resident?s Seroquel was decreased on November 18, 2010, from Seroquel 100 mg twice a day and Seroquel 150 mg at bedtime to Seroquel 100 mg twice a day and Seroquel 100 mg at bedtime. On November 23, 2010 at 10:30 a.m., Staff 1 was interviewed. Staff 1 stated on November 23, 2010 at approximately 8:45 a.m., she responded to ?Stat? (immediately) paging by a licensed staff in the secured unit (South Station) for Room 126. During an interview on December 23, 2010 at 1:05 p.m., Staff 2 stated that on November 23, 2010, she passed the breakfast trays for Residents A and B in Room 126 at approximately 7:30 a.m. At approximately 7:50 a.m., she picked up the breakfast tray for Resident B, while Staff 4 was feeding Resident A in bed at that time. Staff 2 stated that she observed Residents A and B in their beds at 8:30 a.m., 15 minutes prior to the incident. Staff 2 also stated that at approximately 8:45 a.m. on November 23, 2010, she brought the wheelchair into the room for Resident B, and saw Resident A in his bed and his face was covered with blood. During an interview on December 23, 2010 at 2 p.m., Staff 3 stated on November 23, 2010, between 8:45 a.m., and 9 a.m., he followed Staff 2 to Room 126. Staff 3 stated that Staff 2 screamed for someone to call 911 while at the entrance door of Room 126. Staff 3 stated that Resident A had blood on his face with swelling and discoloration below the eyes. The resident?s right upper arm was pointed up over the right side rail and his right forearm was twisted around and pointed down between the bedside rail and mattress. The resident?s right fingers were gripping the bottom of the right side rail, his humerus (the longest and largest bone of the upper arm) bone was fully exposed approximately four inches and his right elbow joint was totally displaced. The resident was awake but non-communicative in bed, his side rails were up and he was leaning towards the right side of bed. There was blood on the right side rail and the right side of the mattress of Resident A. According to Staff 3, Resident B was sitting on the floor at the foot of Resident A?s bed. Resident B had blood on his hands and gown. Staff 3 stated Resident B had behavioral problems such as being loud, using foul language and tossing meal trays to the ground. Resident B was able to transfer himself from bed to wheelchair using both arms and would scoot on his buttocks on the floor to use the bathroom. Staff 3 stated there was no specific frequency as to how often Resident B would be monitored by staff for his sudden angry outburst behavior. During an interview on October 2, 2012 at 2:35 p.m., Staff 4 disclosed that she did not remember going to Room 126 until approximately 8:50 a.m., when another co-worker had told her that an incident occurred in Room 126. According to Resident B?s licensed nurse note dated November 23, 2010 at 2 p.m., Resident B was discharged to an acute hospital for further evaluation of his behavior because he was observed with blood on his hands and gown on the floor at the foot of Resident A?s bed. The acute hospital psychiatric initial evaluation and mental status examination dated November 23, 2010, indicated that Resident B who lived at the SNF, became aggressive and pulled the arm of a resident in the facility.According to licensed nurse record dated November 23, 2010 at 9 a.m., Resident A was observed in bed with blood on his face and the skin on his right elbow was bleeding. On November 23, 2010 at 9:30 a.m., the physician ordered Resident A to be transferred to an acute hospital via 911. Resident A required transfer from the SNF by EMS helicopter to an acute hospital emergency department where Resident A was diagnosed with traumatic open elbow dislocation, and facial trauma. The Emergency Nursing Data Base and Flow Record indicated Resident A arrived at the acute facility on November 23, 2010 at 10:06 a.m. According to the acute hospital orthopedic consult note dated November 23, 2010, at 4:56 p.m., Resident A per EMS (emergency medical services) was found (at the SNF) wedged between his bed and a wall.The acute hospital orthopedic consult note dated November 23, 2010 at 4:56 p.m. also indicated the resident?s right arm injury was described as follows: There was a 14 centimeter laceration (cut) overlying the anterior antecubital fossa (front aspect of the elbow) proceeding around the medial and lateral (middle and back side of the elbow) aspects. There was a 4 centimeter skin bridge posteriorly (back side) behind which part of the triceps tendon seems to be intact. The resident?s right elbow joint was reduced (restored to the normal place), irrigated (washed) and was placed in stabilization splint. Further the consult note indicated the resident was a candidate for an emergency operative reduction and external fixator placement (surgery to correct the injury) at right elbow but was the surgery was cancelled when the resident was designated for comfort care only (on December 2, 2010). Resident A remained in the acute care hospital from November 23, 2010, until his death on December 4, 2010. The death memorandum record disclosed that Resident A had passed away on December 4, 2010, at 5:04 a.m. and the cause of death was due to amputation of the right arm and facial trauma. The Autopsy report dated December 14, 2010, revealed that Resident A?s death was due to multiple blunt force injuries. The injuries included ecchymosis (bruising) of face and upper extremities, laceration of the right arm and status post dislocation of the right elbow. According to the opinion of the deputy medical examiner, the resident?s manner of death was homicide. Attempts to obtain the police department investigation report of the incident, during the Department investigation failed. A review of the facility?s undated policy and procedure for abuse prevention stipulated the following ??any aggressive behaviors will be addressed immediately?? using intervention methods, including ??Place resident with behaviors on a 24-hour observation?? and ??Transfer resident if necessary?.??Residents with possible needs and potential for behavioral symptoms and manifestations that may lead to conflict and anger and neglect shall be identified through comprehensive assessments, initially upon the resident?s admission, and continuously thereafter, as deemed appropriate and necessary.? ?Residents identified to have behavioral symptoms potential for conflict and anger shall be monitored in accordance with plans of care developed to address such problems. Monitoring of such residents shall be the responsibility of, but not limited to, direct caregivers, Charge nurses, Nursing Supervisors, and members of the interdisciplinary team.? The facility failed to ensure that Resident A was free of physical abuse by failing to: 1. Develop Resident B?s care plan to include specific time tables to meet the supervision/monitoring needs of the resident who had physically abusive and socially inappropriate aggressive behavior toward others. 2. Revise Resident B?s care plan interventions when the resident did not meet the expected care plan goal of less than two episodes of sudden angry outburst behavior every month to address the resident?s physically abusive and socially inappropriate behavior. 3. To appropriately address Resident B?s aggressive behaviors and intervene to prevent abuse of Resident A. As a result, Resident B physically assaulted Resident A which subsequently resulted in Resident A?s emergency hospitalization at an acute care hospital. Resident A received acute hospital treatment on November 23, 2010 at 10:06 a.m., where he was diagnosed with traumatic open elbow dislocation, and facial trauma.The facility failed to develop and revise Resident B?s care plan, appropriately address Resident B?s aggressive behaviors, and intervene to prevent abuse of Resident A. These failures led to Resident B?s assault on Resident A that resulted in a severe, traumatic, open elbow dislocation injury to the right elbow and facial trauma that led to the death of Resident A on December 4, 2010. 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, and was a direct proximate cause of the death of Resident A. |
| 950000052 |
CASA BONITA CONVALESCENT HOSPITAL |
950010088 |
A |
21-Sep-16 |
RR2311 |
11896 |
Citation A: F157 ? 483.10(b)(11) ? Notification of changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and if known, notify the resident?s legal representative or an interested family member when there is? (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (i.e.; a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) 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 (D) A decision to transfer or discharge the resident from the facility as specified in 483.12(a) 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. Based on interview and record review, the facility's staff failed to provide the necessary care and services to attain or maintain Resident 1?s highest practicable physical well-being. The failures include but are not limited to: 1. Failure to follow their own policy and procedure in contacting a physician or an alternate physician regarding Resident 1?s change of condition for over 7 hours. 2. Failure to inform the attending physician who was also the medical director, about the changes in Resident 1?s condition for over 7 hours, These failures caused a delay of medical intervention. After 7 and « hours, Resident 1 was transferred to an acute hospital with low oxygen saturation, low blood pressure, and altered level of consciousness. Resident 1 died approximately 29 hours after admission to the acute hospital. The above violations were determined during a complaint investigation conducted at the facility on 4/15/15, at 1:45 p.m. and 9/17/15, at 2 p.m. Record review indicated Resident 1 was readmitted to the facility on 12/17/12 with diagnoses that included chronic airway obstruction (a lung disorder also known as chronic obstructive pulmonary disease (COPD), such as emphysema or chronic bronchitis, characterized by long-term poor airflow in the lungs), hypertension (high blood pressure), muscle weakness and congestive heart failure (CHF, inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and nutrients). The Minimum Data Set (MDS, an assessment and care screening tool) dated 1/12/15 indicated the resident required extensive assistance with or was totally dependent on staff to perform daily activities such as transfers, dressing and personal hygiene. The Multidisciplinary Progress Record dated 3/10/15, at 6:40 p.m., indicated the resident complained of dysuria (painful urination). The physician was notified and an order was received to obtain urine analysis with culture and sensitivity tests on the following morning. The laboratory results, dated 3/11/15, at 4:02 p.m., indicated that a urine sample was collected on 3/11/15, at 3:50 a.m., with urine culture results still pending. The urine analysis results indicated the following: Test Results Reference Range Protein 1+ Negative Blood 1+ Negative Nitrite Positive Negative Leukocyte esterase 3+ Negative Appearance Turbid Clear, Sl. Cloudy Red Blood Cell 3 ? 5 0 ? 2 White Blood Cell >50 0 ? 5 White Blood Cell Clump Present None Seen Bacteria Moderate None Seen Mucous Threads Few None Seen There was a note at the bottom of the urinalysis result dated 3/11/15 at 9:30 p.m. that indicated there was no new physician?s order, ?wants to wait for cultures?. A short-term care plan for the dysuria was generated on 3/10/15, with a target date that it will be resolved within 7 days by 3/17/15. The approaches included to notify the physician of laboratory test results, encourage fluid intake, monitor urine output for color, odor and sediments, and to notify the physician for any changes. On 3/12/16, the following notations are the exact charting of RN1 (a Registered Nurse) on the Licensed Progress Notes: At 1 a.m., ?Resident was found vomiting. Vomitus appeared dark brown. Resident vitals were taken at 1:15 a.m. Temp (temperature) 99.1, P (pulse) 84, BP (blood pressure) 163/93 (normal range 120/80). A wet, cold towel was placed on patient?s forehead as cooling measure. Doctor (Physician 1) was paged at 1:05 am. Waiting for the doctor to call back.? At 3 a.m., ?Temp 98.2, BP 150/83. Still waiting for MD to call back.? At 5 a.m., ?Temp 101.5, BP 142/78. Paged Doctor again. Waiting for call back.? At 7 a.m., ?Temp 98.5 (after cooling measures), BP 105/58 (after BP med), Pulse 97/min. Still waiting for Doctor to call back. Patient is complaining of pain in right inner thigh. Administered the ordered PRN (as needed) pain medication to patient.? There was no evidence RN 1 assessed Resident 1?s gastro-intestinal status related to the brown vomitus, or the resident?s respiratory status. There was no documentation that RN 1 consulted with the Director of Nurses. A licensed nurse?s progress notes dated 3/12/15, at 8 a.m., indicated the resident refused to eat breakfast. On 3/12/15 at 8:30 a.m., (after 7-1/2 hours waiting for Physician 1's call back), the licensed nurse?s progress notes, indicated BP was 140/110, and oxygen saturation was 83% (normal range 95 to 100%). Oxygen at 2 liters per minute was administered via nasal cannula (a thin, plastic tube that delivers oxygen directly into the nose through two small prongs). The oxygen saturation rose to 87%. At this time, the licensed nurse documented that 911 was called due to Resident 1?s low oxygen saturation and the physician was paged to notify regarding the transfer to the hospital. A review of the Schaefer Ambulance Service notes dated 3/12/15, at 8:40 a.m., indicated the resident was in moderate distress being assessed by L.A. County Fire Department. It also indicated that the resident had altered level of consciousness, and that the resident was more lethargic and confused than usual. An intravenous (IV) line was started. A review of the Los Angeles County Fire Department Emergency Medical Services Report Form indicated that on 3/12/15, at 8:46 a.m., the resident?s blood pressure was 80/P (palpable, unable to determine the diastolic pressure), with pulse rate at 96 beats per minute and respirations at 22 per minute. At 9:05 a.m., blood pressure was 82/P, pulse at 94, and respirations at 20. The acute hospital's emergency department (ER) records dated 3/12/15, at 9:10 a.m., indicated Resident 1 was admitted with altered level of consciousness, was alert and oriented to her name only. The ER records also indicated the resident's blood sugar level was low at 54 milligrams per deciliter (mg/dl) (normal fasting: 70-99 mg/dl). Resident 1 was started on intravenous (IV) fluids and the blood sugar improved. The resident was started on IV antibiotics due to elevated white blood cells (WBC) of 17.6 K/UL (normal range is between 3.6 ? 11.2). Resident 1?s History and Physical dated 3/12/15 at the acute hospital indicated the following diagnoses: urinary tract infection (an infection in any part of the urinary system (kidneys, ureters, bladder and urethra), sepsis (severe blood infection that can lead to organ failure and death), metabolic encephalopathy (a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), history of hypertension, history of idiopathic thrompocytopenic purpura (a blood disorder characterized by a decrease in the number of platelets in the blood. Platelets are cells in the blood that help stop bleeding), hyponatremia (low sodium concentration in the blood), and mild dementia (conditions involving cognitive impairment, with symptoms that include memory loss, personality changes, and issues with language, communication, and thinking). Urine sample was collected at the acute hospital on 3/12/15, at 11 a.m. The results of which indicated the resident had approximately 100,000 colonies per milliliter of Klebsiella pneumonia. ?Klebsiella pneumoniae is a bacterial organism that causes pneumonia, sepsis, and urinary tract infection (UTI). The physician?s progress notes dated 3/13/15, at 3:15 p.m. indicated Resident 1 was in cardiopulmonary arrest and CPR (Cardio-pulmonary Resuscitation) was initiated. According to the Certificate of Death, Resident 1 died at the acute hospital on 3/13/15, at 3:46 p.m. It indicated the immediate cause of death was cardiopulmonary arrest (absence of heartbeat, blood circulation, and breathing). The Certificate of Death also indicated the resident had atherosclerotic heart disease (hardening and narrowing of the arteries). During a telephone interview on 9/18/15, at 10 a.m., RN 1 stated that she tried to call Physician 1 numerous times to report Resident 1's vomiting, elevated blood pressure, elevated temperature, and the pain on the right inner thigh. When asked why she did not call for the alternate physician, RN 1 stated she was not aware of an alternate physician and did not know that she was supposed to call an alternate physician. RN 1 stated she did not receive any training or instruction to call an alternate physician, if the primary physician did not return the call. During a telephone interview on 11/6/15, at 1:46 p.m., Resident 1?s primary physician (Physician 1) (who was also the Medical Director), stated that he did not receive any call from the exchange services regarding Resident 1 on the early morning of 3/12/15. Physician 1 stated that if he did not respond to the exchange?s first call to his cell phone, then the exchange was to call his home directly. However, he did not receive any call. The facility's undated policy and procedures, Section C, Policy titled ?Change of Condition? indicated: 2. Physician shall be called promptly. If for some reason physician cannot be reached, alternative physician shall be contacted. If alternate cannot be reached, Medical Director is to be contacted." The policy and procedures further indicated: ?D. In Cases of Emergency changes in the condition of a resident, the following actions are options: 1.The nurse may dial 911, if necessary; 2. The resident may be transferred to the local acute hospital for evaluation; 3. The Director of Nurses may be notified, and offer guidance as needed. 4. The administrator may be notified, and offer guidance as needed.? The facility's staff failed to provide the necessary care and services to attain or maintain Resident 1?s highest practicable physical well-being. The failures include but are not limited to: 1 Failure to follow their own policy and procedure in contacting a physician or an alternate physician regarding Resident 1?s change of condition for over 7 hours. 2. Failure to inform the attending physician who was also the medical director, about the changes in Resident 1?s condition for over 7 hours, These failures caused a delay of medical interventions. After 7 and « hours, Resident 1 was transferred to an acute hospital with low oxygen saturation, low blood pressure, and altered level of consciousness. Resident 1 died approximately 29 hours after admission to the acute hospital. The 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. |
| 950000052 |
CASA BONITA CONVALESCENT HOSPITAL |
950010089 |
B |
12-Aug-13 |
UJWR11 |
6204 |
F309 ? 483.25(a) 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 4/25/12, at 3 p.m., an unannounced visit was made to the facility to conduct a complaint investigation. Based on observation, interview and record review, the facility failed to follow its written care plan to prevent the occurrence of a fracture to Resident A who had osteoporosis. Findings: A review of the admission information record indicated Resident A was admitted to the facility on 1/17/06. The resident's diagnoses included osteoporosis - a condition that affects especially older women and is characterized by decrease in bone mass with decreased density and enlargement of bone spaces producing porosity and fragility (Merriam-Webster, 2013). One of the care plans, dated 3/16/12, indicated the resident was at risk for pathological fractures related to reduction in the mass or inflammation of the bone causes by osteoarthritis. The goal indicated the resident will not have any injury or pathological fractures, and will be able to move her extremities without discomfort. One of the approaches was to ?handle/reposition/transfer resident gently.? Other diagnoses included diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS, a standardized assessment tool) dated 3/20/12 (18 days prior to the fracture), indicated Resident A was assessed as being oriented with no short- and long-term memory impairment and was able to verbalize her needs appropriately. The MDS assessment also indicated the resident was totally dependent on staff for transfers, toilet use, and bathing. She required extensive assistance with dressing and personal hygiene. Section J (Health Conditions) of the MDS indicated that she did not have any pain in the last 5 days. On 4/8/12, the resident was transferred to the acute hospital for evaluation of severe pain to her right lower extremity (leg/foot). The acute hospital?s x-ray report dated 4/8/12 indicated, ?Nondisplaced fracture involving the right medial malleolus and proximal metatarsal bone.? Simply, the resident sustained fractures on the right ankle/foot. During an interview on 4/25/12, at 3:45 p.m., the resident stated she had been in constant pain since she sustained the fracture on 4/8/12, whereas she did not have any pain prior to it. She stated CNA 1 was wheeling her toward the front patio (both front glass doors were closed) when the CNA ?picked up speed? as she approached the doors as if the CNA was going to open the doors with the wheelchair?s foot rests. She stated she rose both her feet, as a defensive reaction, and both her feet hit the glass door. She, then, stated she felt/heard a crack and was in extreme pain of 8 on a scale of 0-10 (0 at no pain, 10 at worst possible pain). She stated she was crying from the pain and was eventually transferred by paramedics to the acute hospital where x-rays revealed fractures to her right ankle/foot.The acute hospital?s emergency room (ER) records indicated the resident was administered Dilaudid (narcotic analgesic) 2 milligrams (mg) IM (intra-muscular injection) for the pain and Zofran 4 mg IM to prevent nausea and vomiting (side effects of Dilaudid). A right ankle splint was also applied to immobilize the fractured areas and promote healing. A physician?s order dated 4/25/12 indicated to keep the splints for another four weeks (a total of approximately six weeks from its initial application). On 4/8/12, at 6 p.m., after the return from the acute hospital, the physician ordered: 1) Voltaren (to treat pain and inflammation) 75 mg twice daily for 10 days, and 2) Dilaudid 2 mg every six hours as needed for pain. However, on 4/10/12, the physician discontinued the Dilaudid 2 mg every six hours, and increased it to Dilaudid 2 mg every four hours due to the resident?s continued complaint of severe pain from the right foot. A review of the Medication Administration Records revealed the resident received a total of 25 doses of Dilaudid 2 mg from 4/9/12 to 4/24/12. According to the manufacturer?s label, some of the adverse reactions of this medication included: respiratory depression, hypotension, and drug dependence; the most common adverse effects included: lightheadedness, dizziness, sedation, nausea, vomiting, dry mouth and rash.According to the Pain Assessment/Management, dated 4/10/12, the resident?s pain was between 5 (moderate pain) and 7 (severe pain), on a scale of 0 to 10 (0 at no pain, 10 at worst possible pain). In comparison, the Pain Assessment/Management dated 12/22/11 indicated the resident did not have any pain (0). During an interview on 4/18/13, at 11:15 a.m., CNA 1 stated when she was wheeling the resident towards the double doors; she stopped and pushed the left door open with her left hand while still holding the wheelchair with her right hand. She, then, started to push the wheelchair forward, but the door started to close again. She reached her left hand out to catch the door, but the resident lifted her feet out and the closing door hit the resident?s feet that caused the fracture to the right ankle. During an interview on 11/27/12, at 9:15 a.m., the facility?s Administrator stated there was nobody else to blame but CNA 1, which resulted in the resident?s fracture. The Administrator added CNA 1 should have slowed down to not scare and make the resident raise her legs/feet. During a follow-up interview on 7/2/13, at 4:20 p.m., the Resident stated that she still gets scared whenever the facility?s staff members wheel her, especially when she sees the double glass doors where she fractured her ankle/foot. She stated she couldn?t forget the pain that she went through during the time her foot was injured. The facility failed to follow its written care plan to prevent the occurrence of a fracture to Resident A who had osteoporosis. The above violation had a direct relationship to the health, safety or security of the resident. |
| 950000042 |
COUNTRY VILLA CLAREMONT HEALTHCARE CENTER |
950011212 |
B |
02-Jan-15 |
LW4S11 |
6931 |
F241 483.14(a) The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident?s dignity and respect in full recognition of his or her individuality. In response to the facilities report that Employee A allegedly made threats to resident 1, the department conducted an unannounced complaint investigation on July 24, 2013. The facility failed to treat one resident (resident 1) in a manner that demonstrated respect, cultivated feelings of self-worth, and maintained an environment that supported the resident?s sense of safety and security by failing to: Ensure Employee A communicated with Resident 1 in a respectful and courteous manner. Resident 1 reported feeling threatened and humiliated when Employee A pointed her finger at resident 1 and she was ?trained to kill?. A review of Resident 1?s clinical record produced a form entitled, ?Face Sheet?, which contained documentation that Resident 1 was first, admitted to the skilled nursing facility (SNF) on November 10, 2010. The patient?s diagnoses included airway obstruction (a disease of the lungs/respiratory disease, or COPD). The resident was also diagnosed with cervical spinal stenosis, a condition brought on by injury, aging process, or disease, in which the spinal cord in the neck (cervical), and the long bundle of nerves (cord) attached to the brain is pinched, narrowed, or contracted (stenosis). The most recent minimum data set (MDS), a standardized assessment and care-planning tool, dated July 26, 2013, contained documentation noting Resident 1 was able to communicate well enough to understand and be understood. The resident retained recent and remote memory, and had no mood or behavior issues. Primarily wheelchair bound, Resident 1 required extensive assistance with mobility, toileting and certain activities of daily living (ADLs). During an interview on July 24, 2013, at 2:10pm, Employee B divulged Resident 1 refused to speak with her, and as a result, her information came from sources other than Resident. ?I just know what I learned from the investigation report; I wasn?t involved in [the investigation] myself?, Employee B stated. She explained that during their investigation, Employee A disclosed that she was joking with Resident 1 when she said that she was trained to kill. ?She?s proud of her time in the military. Maybe she thought the resident would be impressed?, Employee B speculated. ?We were unable to substantiate the allegation?, she concluded. According to the facility?s documentation of their investigation, Resident 1 reported during a patient council meeting held on July 18, 2013, that Employee A said to him, ?I could kill you?. The investigative records included documentation of a subsequent interview the facility conducted with Employee A regarding the alleged incident. During that interview, the employee alleged Resident 1 was making sexual remarks about her legs, and she had ?responded in jest? that she was ?trained to kill?. Employee A stated that she served in the military for nine (9) years, and ?I often share that with my residents?. Upon learning Resident 1 was upset about the comment, Employee A reported she apologized to the resident. During an interview on July 25, 2013, at 3:45pm, Resident 1 recalled the incident: ?We were talking about something, and she (Employee A) pointed her finger at me and said, ?Remember I was in the service for 9 years; I could kill you.? Resident 1 stated, ?She was intentionally trying to put me down. I felt humiliated and threatened. I didn?t know if she was going to hit me.? Employee A was out of the office during the on-site complaint visit on July 25, 2013, and unavailable for interview. Another resident, Resident 2, who performs the duties of president for the resident council meetings, stated during an interview on July 25, 2013, at 4:30pm, ?I haven?t heard any complaints from other residents about Employee A.? He described the employee in question, who was new to the facility, as ?Abrupt?, and ?fast-moving at times? which ?makes some residents feel uncomfortable.? He added, ?Some people have trouble adjusting to change. But none of the residents have taken offense or complained about employee A.? In the absence of Employee A, the employee?s personal file was examined in the presence of Employee B. According to the file, the company that?s owned the SNF hired Employee A on October 22, 2007. Employee B explained, the employee took over the current position at this facility ?just recently,? and previously worked at other unknown location (s) with the company. Further review of the file revealed Employee A?s new-hire orientation was completed on October 22, 2001. One job performance evaluation, dated October 15, 2008, was in the file. The location the orientation and job evaluated were not identified. Employee A completed one harassment training on November 11, 2010, and abuse training in October 2007, and one on January 17, 2013. There was no other training or facility- specific orientation documented in the employees file. According to a report in Employee A?s file entitled, ?Licensing & Certification Verification Detail page,? from the Department of public Health (DPH), Employee A?s certification for her current position as an administrator in a skilled nursing home expired June 30, 2013, there was no other evidence of a current nursing home administrator license in the employee?s file. At 5pm, on July 25, 2013, Employee B discussed the lack of current documentation in Administrator A?s personnel file. ?I don?t know about her license. She has been with the company a long time; they probably have all her documents somewhere else.? Employee B was unable to obtain additional information from another resource, and Employee A remained unavailable for interview. According to the facilities job description for administrator, qualifications include ?Current California Nursing Home Administrator License,? and, the capacity to ?serve as a positive role model by displaying cooperative, professional behavior in all interactions;? ?promptly/protect patient rights, comply with abuse preventions and ?act as advocate for resident rights and ensure respectful, courteous interactions between staff, residents, and visitors.? The facility failed to ensure that one resident (Resident 1) was treated in a manner that demonstrated respect, cultivated feelings of self-worth, and maintained an environment that supported the resident?s sense of safety and security by failing to: Ensure Employee A communicated with Resident 1 in a respectful, courteous manner. Resident 1 reported feeling threatened and humiliated when Employee A pointed her finger at Resident 1 and said, ?I could kill you.? This violation had a direct relationship to the health, safety or security of Resident 1. |
| 950000042 |
COUNTRY VILLA CLAREMONT HEALTHCARE CENTER |
950011266 |
A |
06-Feb-15 |
Z1LV11 |
9348 |
F323 483.25 (H) (1) and (2) 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. F353 ?483.30 Nursing Services The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. On December 9, 2013, at 3 p.m., an unannounced visit was made to the facility to investigate a facility reported incident of Resident 1?s elopement (when a resident leaves the facility without authorization) that resulted in a fall and injury to Resident 1. The facility failed to ensure Resident 1 who had a diagnosis of Alzheimer?s disease, and poor safety awareness was provided with adequate supervision to prevent accidents, by failing to: 1. Follow its own policy and procedure to ensure ?all exits are under visual supervision by staff? to prevent elopement.2. Provide sufficient staff to adequately supervise the unit to ensure Resident 1 did not leave the facility undetected. 3. Develop and implement a care plan to address the resident?s confusion, poor safety judgment and need for required supervision on and off the unit. As a result, Resident 1 eloped from the facility unnoticed through a front entrance door, subsequently fell and sustained a right femoral (thigh) neck fracture. Resident 1 was transferred to the acute hospital where she required a percutaneous (through the skin) treatment with internal fixation of the right femoral neck on November 17, 2013. The admission record indicated Resident 1 was a 90 year old female who was admitted to the facility on December 4, 2011, with diagnoses that included Alzheimer?s disease (loss of mental functions such as thinking, memory, and reasoning that is severe enough to interfere with a person's daily functioning) dementia (a disorder that affects brain functions, such as memory loss and impaired judgment or language, and the inability to perform some daily activities).The Minimum Data Set (MDS) of April 1, 2012, indicated the resident?s balance during transitions and walking was not steady, and she was only able to stabilize with staff assistance.The change of condition assessment completed on May 13, 2013, indicated the resident was disoriented/confused, had poor safety judgment, an unsteady gait, impaired standing balance, and used pain medications.The facility?s Certification/Recertification for Part B Rehabilitation Service dated May 23, 2013, indicated the long term goals as follows: gait (a person's manner of walking) with front wheel walker with supervision.The most recent quarterly Minimum Data Set (MDS-a standardized assessment form), dated September 17, 2013, indicated Resident 1 required supervision from staff for locomotion on and off the unit. There was no documented evidence that the facility developed a plan of care to address the resident?s confusion, poor safety judgment and need for required supervision on and off the unit.The facility?s Internal Investigation dated November 18, 2013, indicated Resident 1 was assigned to CNA 1 who reported to the Charge Nurse that she saw Resident 1 in her bed at 11:35 p.m. CNA 1 (at an unspecified time) went to Station 2 to get diapers and after that she started her care in Room 38. At 11:50 p.m., on November 15, 2013, the Charge Nurse went to Room 15 on Station 2 to hang the intravenous (IV) medications. The charge nurse returned to station 1 at 12:15 a.m. on November 16, 2013. The Charge Nurse (at an unspecified time) heard the front doorbell ring and there was knocking at the front door. The Charge Nurse went to the lobby, opened the door and was told by two individuals that someone was sitting on the curb outside. The charge nurse went outside and saw Resident 1 sitting on the curb with a woman. The woman sitting with Resident 1 stated that she was driving northbound and saw Resident 1 lying on her back on the street in the middle of the northbound right lane. The woman reported pulling her car over to the right and helping the resident out of the street to the curb. When the charge nurse arrived on the scene, the woman was encouraging the resident to go back inside the facility. The resident was alert and talking but was unable to recall the events that occurred. There was no front wheel walker (FWW) in sight (the resident usually ambulates with FWW). The charge nurse assessed the resident and she noted blood on her gown, two skin tears to the right elbow and one skin tear to the right knee. Initially, the resident denied pain. When the resident stood up, she stated, ?Ouch, it hurts like a dickens.? On January 20, 2015, in an interview with RN 1 regarding the 11 pm to 7 am shift of November 15, 2013, she stated she was not sure if anyone was at Station 1 to see Resident 1 go out the door, and she was unaware Resident 1 had left the facility. On January 20, 2015, at 4:10 pm in an interview with LVN 1, she stated she had supervised the exit door by doing a round at 2 am or 2:30 am, (when the RN went on a break), and she was not aware Resident 1 had left the facility. She further stated that a regular door alarm may have prevented the resident from leaving the facility.On August 27, 2014, at 8 a.m., an interview was conducted with the CNA 1 who was assigned to Resident 1 on November 15, 2013, 11:00 p.m. to 7 a.m. According to the CNA, she did not hear the door alarm going off the night the resident eloped, and stated the resident was never on a Wander Guard (a system used to prevent persons at risk from leaving a facility unless they are accompanied).The facility?s undated policy and procedure titled ?Elopement? indicated, that ?exits are under visual supervision by all staff.? Additionally, the job description for all licensed nurses indicates to provide a safe environment for residents. On January 5, 2015, at 12:19 p.m., in an interview with the administrator she stated that visual supervision means all of the facility staff, charge nurses on each shift, RN supervisors, and certified nursing assistants, are aware of where the exits are and will keep an eye on the exits. She further stated there was no specific timeframes for checking the doors and she agreed that checking was done at random.The facility?s Nursing Staffing Grid which is used to determine the staffing level required for any day in relationship to the facility census, indicated for a census of 87 patients the 11 pm to 7 am shift was to have five (5) certified nursing assistants (CNAs), one (1) licensed vocational nurse and one (1) registered nurse to meet 3.26 hours of patient per day ratio of care. On November 15, 2013, the 11 pm to 7 am shift did not meet the usual staffing as indicated as there were only three (3) CNAs on duty, instead of 5 CNAs, with a workload of 29 residents assigned to each CNA.On January 22, 2015, at 8:50 am, in an interview with CNA 2 she stated that 29 residents is too much of a workload and if the charge nurse had not left Station 1 unit alone it would have prevented Resident 1 from leaving the facility. There was no evidence the facility provided sufficient staff to adequately supervise the unit to prevent Resident 1 from leaving the facility undetected. There was no evidence that Station 1?s exit door was under visual supervision by staff? to prevent elopement of Resident 1.The Emergency Department Stat Admit Report dated 11/16/2013, at 1:23 p.m.; indicated Resident 1 had an unwitnessed fall and was diagnosed with a right femoral neck fracture. The acute hospital discharge summary dated December 2, 2013, indicated the resident was admitted to the acute hospital on November 16, 2013, and was discharged on November 19, 2013, three days later.The resident had an initial work up in the emergency department that included computed tomography (CT scan is an imaging method that uses x-rays to create pictures of cross-sections of the body) of the hip area.The CT scan result confirmed a fracture. The resident required percutaneous treatment of the right femoral neck with internal fixation.Therefore, the facility failed to ensure Resident 1 who had a diagnosis of Alzheimer?s disease, and poor safety awareness was provided with adequate supervision to prevent accidents, by failing to: 1. Follow its own policy and procedure to ensure ?all exits are under visual supervision by staff? to prevent elopement.2. Provide sufficient staff to adequately supervise the unit to ensure Resident 1 did not leave the facility undetected. 3. Develop and implement a care plan to address the resident?s confusion, poor safety judgment and need for required supervision on and off the unit. As a result, Resident 1 left the facility undetected, fell and sustained a femoral neck fracture. This put the resident at additional risk for serious medical complication such as blood clots in legs or lungs, bedsores, urinary tract infection and pneumonia These violations presented a substantial probability that death or serious physical harm would result. |
| 950000052 |
CASA BONITA CONVALESCENT HOSPITAL |
950012150 |
A |
07-Apr-16 |
PMRJ11 |
5614 |
F 323 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices On 2/19/16 the Department of Health completed an investigation of an Entity Reported Incident regarding Resident 1?s assisted fall during a transfer from the shower to the chair. Resident 1 sustained a laceration on top of the head. Based on interviews, observation, and record review the facility failed to prevent an accident for 1 of 4 residents reviewed for accidents/incidents (Resident 1) when CNA 1 transferred Resident 1 from a shower chair using one person assist, instead of two person assist, in accordance with the resident assessment. The deficient practice resulted in Resident 1 falling out of a Vander-Lift (an assistive device that allows residents with limited mobility to be transferred between a bed and a chair or other similar resting places, using hydraulic power); and sustaining a laceration (cut) to the right parietal scalp (area near the side and top of the head), requiring five staples (used in surgery in place of sutures to close skin wounds). Findings: Record review indicated Resident 1 was re-admitted to the facility on 10/01/14, with diagnoses that included cerebrovascular accident (stroke, a sudden interruption of the blood supply to the brain caused by rupture of an artery in the brain or the blocking of a blood vessel), hypertension (high blood pressure) and muscle weakness.A review of the Minimum Data Set [(MDS) a comprehensive assessment tool] dated 5/29/15, indicated Resident 1 was moderately impaired in daily decision making, and was totally dependent with two plus-person physical assist during transfers. The MDS Section G0300 "Balance During Transitions and Walking" indicated Resident 1 was "not steady and was only able to stabilize with staff assistance during transfer between bed and chair or wheelchair."The most recent Rehabilitation Screening Assessment dated 5/12/15, indicated Resident 1 required two-person assist with transfers.A review of Resident 1's care plan revised on 6/1/15, titled "The resident has self- care deficit" indicated one of the interventions was to provide a safe environment, but it did not include the use of two persons assist during transfers, in accordance with the assessment. A review of the facility's Interdisciplinary Team (IDT) Conference Record dated 8/2/15, indicated Resident 1 was a 98 year old female with hemiplegia (paralysis of one side of the body) and required total assistance with activities of daily living (ADL's). The IDT notes indicated Resident 1 fell on 7/30/15, when the certified nurse assistant (CNA1) transferred Resident 1 from a shower chair to bed using a Hoyer lift and sling. The notes indicated that during the transfer, Resident 1 shifted to one side and started to slip out of the sling. CNA 1 held on to Resident 1 and assisted her to the floor. Resident 1 sustained a laceration on the right lateral part (side) of the head. Resident 1 was transferred to the acute emergency hospital for evaluation and treatment.A review of the acute hospital notes dated 7/30/15, indicated Resident 1 sustained a laceration to the right parietal scalp. The notes indicated that the caretaker dropped the resident while transferring from shower chair to her bed. Resident 1 hit her head sustaining a laceration. The laceration was about 1 inch long, had a moderate amount of bleeding. The report also indicated Resident 1 was treated with wound repair with five staples to the head, and returned to the nursing home facility after treatment.During an interview on 8/13/15, at 7:30 a.m., Staff A stated that CNA 1 transferred Resident 1 from the shower chair to the bed without any assistance on 7/30/15. Staff A stated that CNA 1 had transferred Resident 1 without any assistance from the bed to the shower chair in the morning without any incident, and thought she could transfer the resident again from the shower chair to the bed without any assistance. Staff A stated CNA 1 used a Vander lift.A review of the manufacturer's Operating Manual for Vander-Lifts contained the following warnings:Before using the Vander Lift, residents must be assessed by the facility's professional nursing or professional rehabilitation staff to determine the number of staff members necessary to transfer each resident. Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. The above information must be recorded in the patient's record and must be communicated to the staff. On 8/13/15, at 8:30 a.m., during a concurrent observation and interview, CNA 2 and CNA 3 both stated "We always transfer Resident 1 with two persons". Both CNAs then demonstrated the use of the Vander Lift II (as would be performed in the transfer of a totally dependent resident). They stated this was the lift they always used for Resident 1. On 8/19/15, at 3:40 p.m., during a telephone interview, CNA 1 stated she used the lift to transfer Resident 1 from the shower chair to bed on 7/30/15. CNA 1 further stated that as she cranked the lift she noticed Resident 1 started to shift towards the right side. CNA 1 attempted to prevent the fall, but the resident's head hit the wheel of the lift that caused a cut and bleeding to the right side of Resident 1's head. CNA 1 stated she should have called for assistance to transfer the residentThese 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. |
| 950000022 |
COMMUNITY CARE CENTER |
950012240 |
A |
25-Jul-16 |
IPCW11 |
9826 |
F 323 free of accident hazards/ supervision/devices (adequate supervision) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On August 8, 2014, at 2 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident of a resident-to-resident altercation that resulted in a fall and injury to Resident 1. Based on observation, interviews and record reviews, the facility failed to provide a safe environment and adequate supervision to the residents. Specifically, the facility lacked consistent monitoring and supervision to residents, resulting in a resident to resident physical altercation. The facility failed to implement their policy and procedure on supervision by not providing adequate supervision. Resident 2 pushed Resident 1 causing Resident 1 to fall and strike the right side of his head on August 5, 2014. As a consequence of the fall, Resident 1 sustained a head trauma. He remained in the hospital for five days where he received conservative care (designed to avoid radical medical therapeutic measures (any treatment that does not involve surgery or operative procedures) which consisted of physical therapy, occupational therapy and pain management. According to , June 4, 2014 article, "When this type of injury occurs, loss of brain function can occur even without visible damage to the head. Force applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the brain tissue, or damage the nerve connections within the brain." Resident 1's medical record indicated the resident was re-admitted to the facility on July 1, 2008, with diagnoses that included paranoid schizophrenia [A type of schizophrenia in which the resident has depression and delusions (false beliefs) that a person or some individuals are plotting against him or her or family members]. According to the Minimum Data Set (MDS - a standardized comprehensive assessment tool) dated June 29, 2014, Resident 1 had the ability to understand others and make himself understood. The MDS also indicated that Resident 1 had received antipsychotic medication during the last seven days. Resident 2's medical record indicated that the resident was admitted to the facility on February 5, 2014, with diagnoses which included schizoaffective disorder (a type of mental disease), hypertension (high blood pressure) and insomnia (inability to sleep). The MDS assessment dated May 19, 2014, indicated Resident 2 was able to make himself understood and was able to understand others. The behavior assessment indicated Resident 2 had the potential indicator of psychosis that included hallucinations (seeing things that are not there) and psychosis (a condition that causes a person to lose his or her sense of reality). The MDS also indicated that Resident 2 had received antipsychotic medication during the last seven days. A review of the facility Interdisciplinary Notes written by Staff 6 indicated the following: On 08/05/14, at 3:55 pm, Staff 6 responded to code blue (medical emergency), ran to the scene and found Resident 1, in the hallway in front of the recreation room, in a prone position with the right side of his face on the floor. Staff 6 noticed a 2 cm cut on the right temporal area near the right eye with a small amount of bleeding. At 4 pm, Resident 1 regained consciousness; at 4:05 pm, Resident 1 started talking and attempted to get up. The paramedic (emergency) team arrived. A review of the facility Interdisciplinary Abuse Investigation indicated the following: Resident 2 pushed Resident 1 in the hallway in front of the recreation room, causing Resident 1 to fall and hit his head, cut his right eye and was unconscious. Code blue (a medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) was called, 911 (emergency service response) was also called. Resident 1 was transferred to an Acute Emergency Department for treatment. Resident 2 pushed Resident 1 thinking Resident 1 was the one who closed the door and hit his head on August 4, 2014 (the day before). But it was Staff 4 who accidentally hit Resident 2's head while opening the door on August 4, 2014. On August 8, 2014, at 3 p.m., during an interview, Staff 1 stated, Resident 2 believed that Resident 1 opened the door and hit him on the head on August 4, 2014. Staff 1 also stated that Resident 2's neurological (brain function) was monitored for 72 hours, and the resident was counseled and told that it was a counselor (Staff 4) who accidentally hit his head. On August 8, 2014, at 3:25 p.m., during an interview with Staff 1, he stated he saw Resident 1 lying on the floor in the hallway on August 5, 2014, at between 3:55 p.m. and 3:58 p.m. Staff 1 stated he was the first one to see Resident 1 lying on the ground when he happened to pass by. Staff 1 stated that his first reaction was that Resident 1 probably had a stroke or seizure activity so he called Code Blue, (A medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest, (A sudden loss of heart function) and eventually called 911. Staff 1 helped and assessed the resident but stated, "He did not seem right, so I called for Code Blue. "Staff 1 also stated there was no staff or residents in the hallway because the residents were either in the classroom or canteen break (where residents buy snacks or drinks). During an interview conducted with Staff 3 on August 8, 2014, at 3:40 p.m. Staff 3 stated the facility did further investigation because the facility wanted to rule out a resident to resident altercation. Staff 3 stated that when the video was reviewed, Staff 3 saw Resident 2 push Resident 1. Staff 3 also stated that during the initial interview with Resident 2, he denied pushing Resident 1. An interview with Resident 2 was attempted on August 8, 2014, at 3:50 p.m., Resident 2 did not want to converse or answer any of the surveyor's questions. Resident 2 was observed to be talkative, repeating the surveyor?s questions and at times was restless and fidgety (uneasy). On August 11, 2014, at 3:05 p.m., an interview was conducted with Staff 5. Staff 5 stated Resident 2 did not have any previous incidents with resident to resident altercation. Staff 5 also stated that Resident 2 had delusions (an unshakable belief in something untrue) but was never agitated or aggressive to anyone, staff or other patients. During an interview with Resident 3 on August 11, 2014, at 3:50 p.m., he stated that he was in the classroom with the door slightly open when he heard a loud noise coming from the hallway that "sounded like someone hit the wall." Resident 3 also stated he did not see Resident 1 fall to the floor. Resident 3 stated he just saw "part of Resident 1's head by the door." Resident 3 also stated he did not see anyone else outside the classroom. Another interview was conducted with Staff 3 on August 11, 2014, at 3:20 p.m., she acknowledged that there was no staff monitoring the hallways at the time of the incident and also stated the facility's Policy and Procedure indicated certified nursing assistants (CNAs) will monitor the hallways 24/7. A review of the Policy and Procedure titled "Hall Monitoring," dated August 12, 2014, indicated, "It is the policy of the facility that Certified Nurse Assistants (CNA) will monitor the hallways 24/7." The policy guidelines included, "CNAs will sit in the hallways at Station 1 and 2 to have sight of all 4 hallways to monitor the safety of all residents." A Neurology consultation dated August 5, 2014 (date of Resident 1?s admission to the hospital) indicated, ?CT (Computed Tomography scan is a non-invasive diagnostic imaging procedure that uses a combination of special x ray equipment and sophisticated computer technology to produce cross sectional images often called slices both horizontally and vertically of the body) scan demonstrates two very small hemorrhages in the left temporal lobe. The patient has a history of a fall prior to coming to the hospital.? On 8/6/2014 the neurology progress report indicated that the ?repeat CAT scan revealed a slight enlargement in the size of the blood.? [sic] The scan revealed: ?1) Two foci of possible hemorrhage in the left temporal lobe. There is a rounded shape of the lesion that raises the possibility of a solid lesion with hemorrhage.? On 8/7/32014 the Neurological examination from the Neurology Progress Note indicated: Mental Status: ?The patient is awake, alert, oriented to name. He cannot give me the name of the month or the year or his location.? A review of the acute hospital Neurology (specially trained in the diagnoses, treatment and management of diseases of the brain and central nervous system) Consultation Report dated August 8, 2014, indicated Resident 1 was admitted to the acute hospital due to syncope (fainting or passing out) on August 5, 2014. The report also stated the resident had small hemorrhages (bleeding) in the head and required further observation, evaluation, and critical care (life- threatening injuries and illnesses). The resident remained in the acute care hospital for five days, where he received conservative treatment (treatment option that does not involve surgery). This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 950000042 |
COUNTRY VILLA CLAREMONT HEALTHCARE CENTER |
950012558 |
B |
2-Sep-16 |
1QXO11 |
5455 |
F223 - 483.13(C) (1 ) (i ) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Based on observation, interview, and record review, the facility failed to ensure Resident 6 was free from verbal and mental abuse by Certified Nursing Assistant (CNA 2) and prevent CNA 2 from creating an environment of fear for Residents 6. Findings: Resident 6's was admitted to the facility on 1/04/16. The admission diagnoses included severe sepsis with septic shock (a serious condition that causes an infection to enter the blood stream and leads to serious medical complications), muscle weakness, difficulty in walking, chronic kidney disease, arthritis (inflammation of the joints), and osteoporosis (weakening of the bones that can increase the risk for a bone to break, commonly diagnosed in the elderly population). The admission Minimum Data Set Assessment on 1/11/16 (MDS), a comprehensive assessment of a resident's mental status, behaviors, likes and dislikes, activities of daily living and medical conditions) indicated, Resident 6 was cognitively intact, able to understand others and to make herself understood. Resident 6 had no signs or symptoms of delirium (confusion). She was incontinent of bladder and bowel (inability to hold urine or feces), and required assistance with personal care and hygiene needs. During a resident Quality of Life Interview on 7/31/16 at 8:15 AM., Resident 6 stated that two weeks ago (on 7/14/16), she had an episode of urinary incontinence. Resident 6 stated she waited 55 minutes for CNA 2 to answer the call light to come into her room to change her. Resident 6 stated CNA 2 yelled at her, ?at the top of his lungs? that she was not the only one he had to take care of, and that he had to change somebody. Resident 6 stated CNA 2 cleaned her using cold water. Resident 6 stated, "I was afraid, and thought he was going to hit me, I started to get upset and I vomited.? During the interview, Resident 6 began to cry and stated since that time, every time CNA2 worked, she tried to stay awake until CNA 2?s evening shift was over. She stated, ?I don't trust him and I am afraid he might come into my room.? Resident 6 stated on the same day, she told LVN 4 about CNA 2 yelling at her. Resident 6 stated that during the evening shift (3-11 pm) on 7/16/16, CNA 2 was involved in a verbal altercation with another staff member, in the hallway outside her room. They were very loud and yelling. Resident 6 stated that she was very scared. A Police Report dated 7/16/16 at 7 p.m., indicated the police responded to a call regarding an altercation between two male staff at the facility. According to the facility's schedule and time card records, CNA 2 continued to work the 3 PM to 11 PM shift on 7/15/16, 7/16/16, 7/17/16, 7/18/16, 7/21/16, 7/22/16, 7/27/16, 7/28/16, 7/29/16, and on 7/30/16. On 7/31/16, CNA 2 was not available for an interview. On 7/31/16 at 9:26 a.m., Resident 10 (Resident 6's roommate) was interviewed. Resident 10 stated CNA 2 came into the room two weeks ago and he was screaming at her roommate. The yelling lasted three (3) minutes. She stated that she felt bad, and was scared of CNA2 yelling at her roommate. Resident 10 further narrated that her roommate vomited after the incident. A review of Resident 10's clinical record indicated Resident 10 was originally admitted to the facility on 11/26/13 and was readmitted on 6/9/16. Resident 10's MDS dated 7/7/16 indicated Resident 10 was able to understand others and to make herself understood. During an interview with the Social Services Director (SSD) on 7/31/16 at 10:21 AM, the SSD found a grievance that was filed by Resident 6 stored within a binder in the social services office. The grievance filed on 7/15/16 was consistent with Resident 6?s description of the event that occurred on 7/14/16 involving her and CNA 2. The allegation on the grievance indicated that Resident 6 reported to LVN 4 that CNA 2 yelled at her. Resident 6 needed to be changed and was waiting for 55 min. The CNA yelled, ?you are not my only patient." During an interview with the Director of Staff Development (DSD) on 7/31/16 at 10:35 AM, she stated that she interviewed LVN 4 over the phone, but did not document the phone interview. The DSD stated the allegation filed in the grievance was verbal abuse. During an interview on 7/31/16 at 12:05 PM, Resident 7 was asked if he had any problems with any male staff members. Resident 7 stated he has had a previous negative encounter with CNA 2. Resident 7 stated CNA 2 had used foul language (curse words) with him in the past. He stated, ?me and him have had some words, he's got a bad temper, let's put it that way." Resident 7, who resided down the hall from Resident 6, was admitted on 1/5/15 and readmitted on 6/29/16. According to Resident 7's MDS dated 7/6/16, he was able to make himself understood and was able to understand others. The facility failed to ensure Resident 6?s was free from verbal and mental abuse by CNA 2 and failed to prevent CNA 2 from creating an environment of fear for Residents 6 and other residents in the facility. These above violation had a direct relationship to the health, safety or security of the resident. |
| 950000042 |
COUNTRY VILLA CLAREMONT HEALTHCARE CENTER |
950012560 |
B |
2-Sep-16 |
1QXO11 |
11650 |
F225 CFR 483.13 (c ) (1) (ii)-(iii) ?(c )(2) The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F226 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. Based on interviews and records review, the facility failed to implement its written policies and procedures that prohibit mistreatment and abuse of residents by failing to: 1. Immediately remove from the premises the staff member (CNA2) accused of verbal abuse. 2. Ensure the alleged verbal abuse by CNA 2 was immediately and thoroughly investigated. 3. Conduct investigations with information from individuals or residents under the care of CNA 2 who may have information relevant to the abuse allegation. 4. Report immediately the incident to the administrator and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action taken; and report to local law enforcement within 24 hours and a written report made to the local ombudsman and the California Department of Public Health. The deficient practices created an environment of fear for Resident 6 and possible continued abusive behavior by CNA2. Findings: Resident 6 was admitted to the facility on 1/04/16. The admission diagnoses included severe sepsis with septic shock (a serious condition that causes an infection to enter the blood stream and leads to serious medical complications), muscle weakness, difficulty in walking, chronic kidney disease, arthritis (inflammation of the joints), and osteoporosis (weakening of the bones that can increase the risk for a bone to break, commonly diagnosed in the elderly population). The admission Minimum Data Set Assessment on 1/11/16 (MDS), a comprehensive assessment of a resident's mental status, behaviors, likes and dislikes, activities of daily living and medical conditions indicated, Resident 6 was cognitively intact, able to understand others and to make herself understood. Resident 6 had no signs or symptoms of delirium (confusion). She was incontinent of bladder and bowel (inability to hold urine or feces), and required assistance with personal care and hygiene needs. During a resident Quality of Life Interview on 7/31/16 at 8:15 AM., Resident 6 stated that two weeks ago (on 7/14/16), she had an episode of urinary incontinence. Resident 6 stated she waited 55 minutes for CNA 2 to answer the call light to come into her room to change her. Resident 6 stated CNA 2 yelled at her, ?at the top of his lungs? that she was not the only one he had to take care of, and that he had to change somebody. Resident 6 stated CNA 2 cleaned her using cold water. Resident 6 stated, "I was afraid, and thought he was going to hit me, I started to get upset and I vomited.? During the interview, Resident 6 began to cry and stated since that time, every time CNA2 worked, she tried to stay awake until CNA 2?s evening shift was over. She stated, ?I don't trust him and I am afraid he might come into my room.? Resident 6 stated on the same day, she told LVN 4 about CNA 2 yelling at her. Resident 6 stated that during the evening shift (3-11 pm) on 7/16/16, CNA 2 was involved in a verbal altercation with another staff member, in the hallway outside her room. They were very loud and yelling. Resident 6 stated that she was very scared. A Police Report dated 7/16/16 at 7 p.m., indicated the police responded to a call regarding an altercation between two male staff at the facility. According to the facility's schedule and time card records, CNA 2 continued to work the 3 PM to 11 PM shift on 7/15/16, 7/16/16, 7/17/16, 7/18/16, 7/21/16, 7/22/16, 7/27/16, 7/28/16, 7/29/16, and on 7/30/16. On 7/31/16, CNA 2 was not available for an interview. On 7/31/16 at 9:26 a.m., Resident 10 (Resident 6's roommate) was interviewed. Resident 10 stated CNA 2 came into the room two weeks ago and he was screaming at her roommate. The yelling lasted three (3) minutes. She stated that she felt bad, and was scared of CNA2 yelling at her roommate. Resident 10 further narrated that her roommate vomited after the incident. A review of Resident 10's clinical record indicated Resident 10 was originally admitted to the facility on 11/26/13 and was readmitted on 6/9/16. Resident 10's MDS dated 7/7/16 indicated Resident 10 was able to understand others and to make herself understood. During an interview with the Director of Nursing (DON) on 7/31/16 at 9:38 AM, the DON stated there were no allegations of abuse reported to her during the month of July. During an interview with the Social Services Director (SSD) on 7/31/16 at 10:21 AM, the SSD found a grievance that was filed by Resident 6 stored within a binder in the social services office. The grievance filed on 7/15/16 was consistent with Resident 6?s description of the event that occurred on 7/14/16 involving her and CNA 2. The allegation on the grievance indicated that Resident 6 reported to LVN 4 that CNA 2 yelled at her. Resident 6 needed to be changed and was waiting for 55 min. The CNA yelled, ?you are not my only patient." The grievance report indicated that the Assistant Social Services Director interviewed Resident 6 on 7/15/16 regarding the abuse allegation. The grievance report also indicated on 7/22/16 (7 days later), CNA 2 was interviewed by the Director of Staff Development (DSD). CNA 2 indicated Resident 6 asked him why it took so long to get to her and that she had been waiting for over an hour to get help. CNA 2's response to the grievance was, "I'm sorry for the delay and offered her assistance she needed. I apply new diaper, call light in reach and make sure she is fine that evening." The grievance response signed by the Administrator and DSD on 7/22/16 and Social Services Director (SSD) signed on 7/28/16 indicated "CNA needed to be careful when speaking with the patient. Staff on the floor to answer the call light. Charge Nurse and Supervisor to monitor needs to be met.? During interviews on 7/31/16 at 10:21 AM, the DSD stated, she did not report the abuse allegation to the Department of Public Health, the local ombudsman, or the local authorities. The SSD indicated that if they were contacted, it would have been specified in the grievance report. There was no documentation that anyone had contacted any public agencies in the grievance report. During an interview on 7/31/16 at 10:35 AM, the DSD confirmed that she interviewed CNA 2 on 7/22/16 and confirmed that she did not report the allegation to any of the mandated public entities such as the Department of Public Health, the local ombudsman, and the local authorities. The DSD stated the allegation filed in the grievance was verbal abuse. During an interview the DON was asked if any allegations of abuse were reported by the facility to the mandated agencies. The DON stated "Not that I can recall. Any allegation of abuse will go through the Administrator and the DON and should be reported to the mandated agencies within 24 hours. " During an interview with the Administrator on 7/31/16 at 11:05 AM, the Administrator stated, no staff was suspended for an abuse allegation during the month of July. The Administrator stated CNA 2 did not have any disciplinary actions on file for the month of July. The Administrator confirmed that she signed the grievance form on 7/22/16 for Resident 6's abuse allegation and confirmed she did not report the abuse allegation to any of the mandated agencies A review of the facility's policy and procedure indicated: 1. A. When the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, or injuries of an unknown source, the Administrator or designee, will initiate an investigation immediately. The policy indicated under 1.A.ii., that the facility will not inhibit staff from their mandated reporter obligations. The policy indicates under 1.A.iv: If appropriate, call law enforcement. 2. A. Immediate Action: The Administrator or designee will provide for a safe environment for the resident as indicated by the situation. The policy indicates under 2.A.ii. That if the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation. 3. A. Interview: The administrator/designee conducting the investigation will interview individuals who may have information relevant to the allegation. The policy indicated under 4.A.i. that Individuals who may have information relevant to the incident are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc. The only interviews documented, in the grievance, were from CNA 2 and Resident 6. 5. A. Notification of Outside Agencies of Abuse when No Serious Bodily Injury: The facility failed to implement its written policies and procedures that prohibit mistreatment and abuse of residents by failing to: 1. Immediately remove from the premises the staff member (CNA2) accused of verbal abuse. 2. Ensure the alleged verbal abuse by CNA 2 was immediately and thoroughly investigated. 3. Conduct investigations with information from individuals or residents under the care of CNA 2 who may have information relevant to the abuse allegation. 4. Report immediately the incident to the administrator and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action taken; and report to local law enforcement within 24 hours and a written report made to the local ombudsman and the California Department of Public Health. The deficient practices created an environment of fear for Resident 6 and other residents and possible continued abusive behavior by CNA2. These violations had a direct relationship to the health, safety or security of residents at the facility. |
| 950000002 |
CLAREMONT CARE CENTER |
950012606 |
A |
30-Sep-16 |
V3H811 |
12087 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 08/16/2016 at 2:15 PM an unannounced visit was made to the facility to investigate a self- reported incident regarding a resident?s fall. Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was free from accidents by failing to: 1. Provide adequate assistance device or assistance with the help of two staff members to safely transfer Resident 1 from the bed to the shower chair. 2. Implement the facility's policy and procedure titled Falling Star Program indicating that high fall risk residents will have "Falling Stars" stickers placed near their nameplates and yellow band on their arms to identify them as high risk for falls. 3. Implement Resident 1?s ?Resident Care Guide? which indicated the use of Hoyer/Sara lift for mobility and transfers. These deficient practices resulted in Resident 1 falling and sustaining a right tibia fracture (a break in the continuity of the bone that forms the front part of the leg between the knee and the ankle). Resident 1 was sent to the hospital emergency room on 08/04/2016. A review of the clinical record indicated Resident 1 was admitted to the facility on 5/17/14, with diagnoses that included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients) without behavioral disturbance, diabetes mellitus (elevated blood sugar level) Type 2, without complications, essential hypertension (form of elevated blood pressure that has no identifiable cause) and blindness, one eye, unspecified eye. A review of the most recent Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 6/20/16, indicated Resident 1 had moderately impaired cognitive skills for daily decision making. Resident 1 also required extensive assistance with transfers with two or more person physical assist. The Fall Risk Evaluation, dated 5/18/14, indicated Resident 1 was at high risk for fall. Resident 1 had a balance problem while standing/walking and a change in gait pattern when walking was identified. The Balance and Functional Limitation in Range of Motion Assessment dated 8/27/14 and 11/26/14 both indicated that Resident 1 was not steady and was only able to stabilize while standing with staff assistance. On 8/03/2016, CNA 1 attempted to get Resident 1 up from her bed by himself, without the use of a Hoyer lift or the help of another staff member. Resident 1 fell and fractured her tibia. A review of the facility's policy and procedure titled Falling Star Program, revised on 01/2016 indicated high risk residents will have "Falling Stars" stickers placed near their name plates and yellow band on their arms to identify them as high risk for falls. LVN 1 and ADN both confirmed that per the facility's "Falling Star Policy", a sticker should be placed by the Resident1's name plate outside the door to identify that the resident is at risk for falls. An initial tour of the facility was conducted with the licensed vocational nurse (LVN1) on 8/17/16 at 2:35 p.m. It was observed that Resident 1 who was assessed for fall risk did not have a sticker placed by her name plate outside the door to identify that she was at risk for falls. LVN 1 stated there should have been a sticker placed by the Resident 1's name plate outside the door to indicate Resident 1 was a fall risk. LVN 1 further stated, Resident 1 was on the Falling Star Program after she fell on 8/3/16. On 8/17/16 at 2:40 p.m., an interview was conducted with the Acting Director of Nurses (ADN). The ADN confirmed Resident 1 did not have a sticker placed by her name plate outside the door to identify that she was at risk for falls. ADN stated Resident 1 should be in the Falling Star Program (a system used by the facility to identify residents at risk for falls) since Resident 1 had a recent fall on 8/3/16. A review of Resident 1's care plan for at risk for falls related to gait balance problem, initiated on 8/28/14 indicated Resident 1 would l be free of falls through the review date and would not sustain serious injury through the review date. Target date was 9/23/15. Interventions included placing the bed in the lowest position, floor mat, and to follow the facility?s fall protocol. On 8/17/16 at 2:50 p.m., an interview was conducted with LVN1 regarding Resident 1's fall incident on 8/3/16. LVN 1 stated the facility staff was using a Hoyer lift (assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, using hydraulic power) for all of Resident 1's transfers before she fell on 8/3/16. LVN 1 stated CNA 1 did not use a Hoyer lift to transfer Resident 1 resulting in a fall. On 8/17/16 at 3:00 p.m., an interview was conducted with the director of staff development (DSD). The DSD stated she heard someone asking for help in Resident 1's room on 8/3/16 while she was doing her rounds (the DSD did not recall exact time). The DSD immediately responded and found CNA 1 with Resident 1 on the floor in Resident 1's room. The DSD confirmed CNA 1 did not use a Hoyer lift to safely transfer Resident 1 nor did he ask for help from other staff to transfer Resident 1. The DSD stated she was the first person who saw the incident after the fall on 8/3/16. On 8/17/16 at 3:30 p.m., an interview was conducted with the physical therapist (PT 1) and the occupational therapist (OT 1). Both staff members confirmed Resident 1 needed a Hoyer lift to safely transfer the resident from the bed to the chair. They both stated there is a "Resident Care Guide" placed behind every resident's closet door to indicate what type of transfer a resident needed for every staff to use. On 8/17/16 at 3:45 p.m., an interview was conducted with LVN 2 who was the charge nurse of the unit when Resident 1 fell on 8/3/16. LVN 2 stated CNA 1 did not use the Hoyer lift to transfer Resident 1. LVN 2 stated the facility's protocol, in regard to transferring residents, is to use help or use a machine. LVN 2 stated CNA 1 did not use the Hoyer lift to safely transfer the resident and did not ask for help from any of the staff while transferring Resident 1 from the bed to the shower chair. On 8/17/16 at 4:10 p.m., an interview was conducted with DSD regarding the use of Resident Care Guide. DSD confirmed the facility used the Resident Care Guide to indicate what safety and positioning device the resident required. DSD stated the admitting nurse fills out the form and the form is placed behind every resident's closet door for the staff to use to meet the resident's needs. The DSD stated all residents should have a resident care guide in their room. A review of Resident 1's Resident Care Guide (undated) indicated the use of Hoyer/Sara lift for mobility and transfers. On 8/18/16 at 10:50 am, an interview was conducted with LVN 1 and Acting Director of nursing. Both staff stated, when a resident required extensive two person assist and was not able to use the lower extremities due to weakness, the facility staff should use a Hoyer lift to transfer the resident. LVN 1 and Acting Director of Nursing stated Resident 1 required a Hoyer lift for transfers. Both staff members stated the use of a Hoyer lift for transfers did not require a physician's order but rather it was being used as a nursing intervention to prevent falls. A review of the facility's policy and procedure titled " Quality of Care; Transfer of a Resident, Safely (using mechanical lift), revised 01/2016 indicated mechanical lift transfers are usually used for residents who are very large or extremely dependent. Safe and secure mechanical lift transfers may require the help of one, two or three caregivers depending of the resident's condition. A review of Resident 1's Care Plan for fall did not indicate specific use of a Hoyer lift for transfers. Acting Director of Nursing stated Resident 1's Care Plan should have been more individualized to reflect specific interventions on the use of the Hoyer lift to transfer the resident to prevent falls. On 8/18/16 at 11:30 a.m. an interview was conducted with the MDS coordinator. The MDS coordinator stated Resident 1's cognition was moderately impaired and stated Resident 1 required extensive assistance with transfers with two or more person physical assist. On 8/18/16 at 1:40 p.m., a telephone interview was conducted with CNA 1. CNA 1 confirmed he did not use a Hoyer lift to transfer Resident 1 from the bed to the shower chair. CNA 1 stated he thought he would be able to do the transfer by himself without the use of any assistive device. CNA 1 stated he did not know Resident 1 needed a Hoyer lift to transfer the resident and stated he looked around for help from other staff but did not see anyone available. CNA 1 stated he was only informed of the Resident Care Guide behind the resident's closet door after Resident 1 fell. He stated he did not get an orientation from the facility regarding the facility's policy and procedure and proper use of the Hoyer lift. CNA 1 stated he worked for a Registry company and he had worked at the facility in the past but it did not involve transferring Resident 1. On 8/18/16 at 2:10 p.m., an interview was conducted with the DSD and the facility administrator. The DSD stated she did not specifically orient CNA 1 on the use of the Resident Care Guide. The DSD stated the facility did not have a system in place to orient registry staff on the facility?s policy and procedure, prior to working at the facility. A review of Resident 1's radiology (X-ray) report done at the facility on 8/4/16 for right tibia (bone that forms the front part of the leg between the knee and the ankle) and fibula (outer and usually smaller of the two bones between the knee and the ankle) indicated posttraumatic linear lucencies (transparency) which appear to represent small fractures. A review of the physician order dated 8/4/16 at 5:06pm (one day after the fall) indicated to transfer the resident to the general acute care hospital for further evaluation. A review of Resident 1's History and Physical from the general acute care hospital, dated 8/4/16 indicated status post fall with right tibia transverse fracture (broken piece of bone is at a right angle to the bone's axis). Per the History by the emergency room physician dated 8/5/16, Resident 1 was initially hypotensive and lethargic and had a fever. Resident1?s x ray of the tibia showed severe osteoporosis (bone fragile) right proximal tibia transverse fracture and displaced and impacted. The orthopedist (medical specialty concerned with correction of deformities or functional impairments of the skeletal system) consult report dated 08/05/2016 indicated ?The fracture was non-operable. Review home medications, continue them as appropriate.? The facility failed to ensure that Resident 1 was free from accidents by failing to: 1. Provide adequate assistance device or assistance with the help of two staff members to safely transfer Resident 1 from the bed to the shower chair. 2. Implement the facility's policy and procedure titled Falling Star Program indicating that high fall risk residents will have "Falling Stars" stickers placed near their nameplates and yellow band on their arms to identify them as high risk for falls. 3. Implement Resident 1?s ?Resident Care Guide? which indicated the use of Hoyer/Sara lift for mobility and transfers. The violations resulted in Resident 1 to sustain a tibia fracture during the fall on 8/3/16. 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. |
| 950000052 |
CASA BONITA CONVALESCENT HOSPITAL |
950012799 |
A |
22-Dec-16 |
R0KX11 |
13677 |
483.25 ( c ) Treatment/Services To Prevent/Heal Pressure Sores. Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. On 9/27/2016 an unannounced recertification survey was conducted at the facility. Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent pressure sore (localized injury to the skin and or underlying tissue as a result of pressure or pressure in combination with shear and or/friction) development to Resident A by failing to: 1. Ensure the Resident A was not lying on her back directly on the pressure sore. 2. Revise Resident A?s plan of care to address the frequency in which the resident should be turned as well as the positioning of the resident. 3. Implement Resident A?s Care Plan to turn and reposition the resident every two hours while in bed. 4. Accurately assess Resident A?s skin condition of the sacral coccyx pressure sore ([sacral]- a triangular shaped bone at the bottom of the spine [coccyx] -tailbone ). 5. Relieve the pressure from Resident A?s heels when in bed. These failures resulted in Resident A developing an avoidable Stage III pressure sore (full thickness tissue loss, subcutaneous (innermost layer) fat may be visible but bone, tendon or muscle are not exposed) to the sacral coccyx with suspected deep tissue injury (DTI-purple or maroon localized are of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) to the periwound (tissue surrounding the wound itself). The resident also developed suspected deep tissue injury to her left heel. A review of the Admission Record (face sheet) indicated Resident A was readmitted on xxxxxxx, with diagnoses that included Alzheimer's disease (progressive memory loss), congestive heart failure (heart unable to pump out enough blood supply to body) and cerebral infarction (diminished blood flow to the brain) with right sided weakness. The Admission Assessment dated 7/3/16, indicated Resident A was readmitted to the facility without a pressure sore. The Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 7/10/16, indicated Resident A was assessed with short and long term memory recall problems, totally dependent in bed mobility (full staff performance every time during entire seven day period) and was incontinent of bowel (lack of voluntary control over defecation). The Wound Risk Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure sore) indicated a total score of 8 and above represented at high risk for developing pressure sore. Resident A scored 24 on 7/4/16, and 25 on 7/25/16 which indicated as high risk of developing pressure sore. During multiple observations on 9/20/16 at 7:52 a.m., 9:32 a.m.,10:00 a.m., 11:05 a.m., 12:00 p.m., 1:50 p.m., 2:55 p.m., 3:10 p.m., 4:00 p.m.; 9/21/16 at 7:14 a.m., 8:07 a.m., 9:14 a.m., 10:30 a.m., 11:20 a.m., 2:00 p.m., Resident A was observed lying on her back in bed. Her left heel had a dressing and was observed resting on the mattress on 9/20/16 at 3:10 p.m.; 9/21/16 at 9:14 a.m., 10:30 a.m. and 11:20 a.m. Resident A was non communicative. During an interview on 9/21/16 at 7:32 a.m., Treatment Nurse 1 (TN 1) stated she did the treatment to Resident A?s sacral coccyx and left heel pressure ulcers earlier at 6:30 a.m. because the dressing to sacral coccyx was soiled. TN 1 stated that on 9/21/16 at 6:30 a.m., the sacral coccyx pressure sore was UTD ([unstageable]-full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) 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 Stage III or IV). TN 1 also stated the left heel pressure sore was Stage I pressure sore (intact skin with non-blanchable redness of a localized area usually over a bony prominence). On 9/21/16 at 2:00 p.m., Resident A was observed lying on her back and was non-communicative. During the body check of Resident A conducted with TN 1, Certified Nursing Assistant (CNA 1) and Registered Nurse (RN 1), Resident A was observed with Stage III pressure sore to the sacral coccyx with deep tissue injury to the periwound that was purple and maroon in color. Resident A?s left heel was observed purple in color with fluid filled blister. TN 1 measured the pressure sores. The sacral coccyx pressure sore measured 8.5 centimeter (cm) in length (L) x 7 cm in width (W). The left heel pressure sore measured 1.5 cm (L) x 2 cm (W). TN 1 and CNA 1 both stated Resident A's sacral coccyx pressure sore looked the same when treatment was done on 9/21/16 at 6:30 a.m. TN 1 and CNA 1 both stated Resident A's left heel was red in color on 9/21/16 at 6:30 a.m. TN1 did not measure the sacral coccyx pressure sore for depth, undermining (destruction of tissue extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface), and tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) until requested. The depth was 2.5 cm. with undermining of 3.1 cm at 12:00 o'clock, 0.9 cm at 3:00 o'clock, 0.4 cm at 6:00 o'clock, and 1.5 cm at 9:00 o'clock. TN 1 cleansed Resident A?s the sacral coccyx pressure sore with normal saline (salt with water), applied Silvasorb gel (antibacterial wound gel), packed Alginate wound dressing (absorbent wound dressing) in the wound bed, applied Inzo cream (antifungal cream) around the periwound area and covered the pressure sore with dry dressing. The Resident A was quiet and did not show any signs and symptoms of pain while on the right side lying position for 30 minutes during body check and treatment of sacral coccyx pressure sore. During an interview on 9/21/16 at 2:50 p.m., CNA 1 stated she was the regular caregiver assigned to Resident A. CNA 1 was aware Resident A had pressure sores to her sacral coccyx and left heel. She stated several days (unable to remember specific dates) before her last day of work on 9/18/16, she observed during treatment Resident A's sacral coccyx pressure sore appeared bigger and deeper. She stated Resident A was turned and repositioned to her right side, left side and back every two hours when in bed. She stated the facility had repositioning schedule posted at the nurses' station. The "Repositioning Schedule" indicated to reposition the residents every two hours as follows: 8:00-window 10:00-door 12:00-back 2:00-window 4:00-door 6:00-back CNA 1 was asked why she repositioned Resident A on her back when she knew the resident had pressure sore to her sacral coccyx. CNA 1 stated she was not informed by any staff member that Resident A should not be turned and repositioned on her back while in bed and was just following the facility?s repositioning schedule. CNA 1 stated Resident A's left heel kept on going down to the mattress because the pillow under the left foot was thin. CNA 1 also stated the resident?s pressure sore to the coccyx was getting bigger from lying on her back. On 9/21/16 at 3:50 p.m., the medical record of Resident A was reviewed with TN 1. The Skin Progress Report indicated Resident A was assessed as follows: On 7/14/16, with Stage 1 pressure sore (reddened intact skin) to her sacral coccyx measured 3 cm (L) x 3cm (W). On 8/15/16 (one month later), the pressure sore was assessed as deep tissue injury (DTI) measured 2.6 cm (L) x 2.6 (W) described as intact skin and maroon in color. TN 1 stated DTI is a pressure sore caused by pressure to the skin tissue. On 8/19/16 (four days later), Resident A?s had a skin breakdown to her sacro-coccyx assessed as UTD (unstageable) measured 4 cm (L) x 4 cm (W) described as having thick yellow slough (dead tissue) covering the wound. The resident's sacral coccyx remained unstageable pressure sore as follows: On 8/26/16 = 4 cm x 4 cm, yellow slough 100% On 9/2/16 = 4 cm x 4 cm, yellow slough 100% On 9/9/16 = 4.5 cm x 4.5 cm, slough 50% gray and 50% yellow On 9/16/16 = 4.8 cm x 4.8 cm, slough 50% gray and 50% yellow The Skin Progress Report did not indicate Resident A's unstageable pressure sore to her sacral coccyx was assessed for depth, undermining and tunneling by TN 1 since 8/19/16. A review of the facility's undated policy and procedure for measuring pressure sore indicated, "All pressure sores shall be measured upon admission and on a weekly basis. The length, width, and depth of pressure sores are to be measured in centimeters (cm), undermining and tunneling shall also be gauged in cm." TN 1 stated she could not measure the resident's pressure sore for depth, undermining and tunneling due to presence of yellow and gray slough to sacral coccyx pressure sore. TN 1 was asked why she was able to measure Resident A's sacral coccyx pressure sore for depth and undermining when requested on 9/21/16 at 2:00 p.m., when the wound bed of the pressure sore was observed with yellow and gray slough. TN 1 stated, "I don't know." She stated the sacral coccyx pressure sore will not heal when Resident A was directly lying on the pressure sore. TN 1 stated CNA 1 was not made aware Resident A should not be repositioned on her back in bed. During an interview and record review of Resident A's medical record with Director of Nursing (DON) on 9/23/16 at 2:51 p.m., she stated Resident A was admitted under hospice (an approach to caring for the terminally ill individual that provides palliative [keeping the resident comfortable as possible while maintaining dignity and quality of life] care rather that that traditional medical care and curative treatment) care on 7/3/16, due to diagnosis of myeloplastic syndrome ([MDS] conditions that can occur when the blood forming cells in the bone marrow are damaged. MDS is considered a type of cancer). The initial care plan for pressure sore dated 4/11/15, indicated Resident A was at risk for developing pressure sore related to impaired bed mobility and incontinence. The care plan goal was to minimize the risk of skin breakdown, bruising and pressure sore by the next review on 10/9/16; the care plan interventions included turning and repositioning the resident whenever necessary when in bed. Resident A developed pressure sore to her sacral coccyx assessed as Stage 1 on 7/14/16, deep tissue injury on 8/15/16 and unstageable on 8/19/16. Resident A's care plan for sacral coccyx pressure sore dated 7/14/16, 8/15/16 and 8/19/16, indicated the resident was to be turned and repositioned every two hour or as often as necessary when in bed. The care plan interventions did not indicate which specific side the resident's body should be turned and repositioned every two hours in bed to prevent pressure sore development and to prevent worsening of the existing pressure sore. Resident A's care plan was not revised since 7/14/16, to prevent the resident from developing Stage III pressure sore to her sacral coccyx. The care plan for Stage 1 pressure sore to the left heel dated 9/20/16 did not indicate specific measures how the resident's left heel should be relieved from pressure when lying in bed to prevent skin breakdown. Resident A's Stage 1 pressure sore to her left heel had progressed to deep tissue injury on 9/21/16. The DON stated staff did not have a written or visual monitoring system to ensure a resident with a pressure sore was not turned and repositioned directly on a pressure sore while in bed. According to Medical Surgical Nursing Ninth Edition pages 186-187, "Prevention remains the best treatment for pressure sores. Reposition the patients frequently to prevent pressure sore at least every two hours and every hour when in chair. Never position the patient directly on the pressure sore." The facility failed to: 1. Ensure Resident A was not lying on her back directly on the pressure sores. 2. Revise Resident A?s plan of care to address the frequency in which the resident should be turned as well as the positioning of the resident. 3. Implement Resident A?s Care Plan to turn and reposition the resident every two hours while in bed. 4. Assess accurately Resident A?s skin condition of the sacral coccyx pressure sore ([sacral] ? a triangular shaped bone at the bottom of the spine [coccyx] ?tailbone. 5. Relieve the pressure from Resident A?s heels when in bed. These failure resulted in Resident A developing an avoidable Stage III pressure sore (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) her sacral coccyx with suspected deep tissue injury (DTI-purple or maroon localized are of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) to the periwound (tissue surrounding the wound itself). The resident also developed suspected deep tissue injury to her left heel. The above 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. |
| 950000047 |
COAST CARE CONVALESCENT CENTER |
950012821 |
B |
14-Dec-16 |
RR6711 |
7993 |
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). ? 483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. During a recertification survey on 9/13/16, it was found during record review that a resident to resident altercation had occurred between Resident 3 and Randomly Selected Resident 13 (RSR 13). Based on interview and record review, the facility failed to implement their abuse policies and procedures by failing to: 1. Thoroughly investigate a resident to resident altercation between Resident 3 and Randomly Selected Resident (RSR13). 2. Send a written notification of the incident to the DHS (Department of Health Services) (State survey and certification agency) agency within 24 hours of a resident to resident altercation between Resident 3 and Randomly Selected Resident (RSR 13). A review of the face sheet for Resident 3 indicated the resident was originally admitted to the facility on xxxxxxx and readmitted on xxxxxxx, with diagnoses that included: Dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) without behavioral disturbance, schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems) unspecified and unspecified psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 7/14/16 indicated Resident 3 is cognitively impaired. Resident 3 required limited assistance with activities of daily living and uses a walker and wheelchair for ambulation. A review of the face sheet for RSR 13 indicated the resident was admitted to the facility on 11/18/2015 with diagnoses that included: Unspecified dementia with behavioral disturbance and age related osteoporosis (decreased bone strength) without current pathologic fracture (bone fracture [break in the continuity of a bone] caused by disease that led to weakness of the bone structure). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/27/16 indicated RSR 13 is rarely understood with modified independence (some difficulty in new situations) for cognitive skills for daily decision making. RSR 13 required limited to extensive assistance with activities of daily living and uses a walker and wheelchair for ambulation. A review of the clinical record indicated Resident 3 had an altercation with RSR13 on 7/24/16 at 11:15 am. On 9/14/16 at 3:00 pm, an interview was conducted with the facility assistant activity director who stated she was at the activity room on 7/24/16 at around 11:15 am-11:30 am monitoring the residents waiting for lunch when RSR 13 came inside the room and bumped her wheelchair on Resident 3?s wheelchair. Resident 3 stood up right away and punched RSR 13 on the nose. Assistant activity director stated that it was the first time that Resident 3 got so upset and became violent. Assistant activity director stated she called for help and staff came right away to separate the two residents. On 9/14/16 at 3:15 pm, an interview was conducted with LVN 2. LVN 2 stated she was at the hallway close to the activity room on 7/24/16 at around lunch time when she heard RSR 13 yelling. LVN 2 stated she took RSR 13 right away to her room while another staff took Resident 3 to his room. LVN 2 stated she saw slight bleeding on RSR 13?s nose so she notified the registered nurse (RN) supervisor. RN supervisor applied ice pack to RSR 13?s nose to control bleeding and LVN 2 stayed with RSR 13 in her room for close monitoring. A review of the physician's order dated 7/24/16 at 11:30 am indicated nasal X-Ray to rule out fracture. A review of the facility nasal radiology report done on 7/26/16 indicated there was modest swelling of the forehead over the right frontal sinus; no foreign body was seen with a normal nasal bone. On 9/13/16 at 3:00 pm, an interview was conducted with the facility administrator who stated she was on vacation when the altercation happened between Resident 3 and RSR 13. The administrator stated that in her absence the facility president and the director of nursing (DON) are the abuse coordinators. On 9/13/16 at 3:05 pm, an interview was conducted with the facility president regarding the altercation between Resident 3 and RSR 13. The facility president stated he vaguely remembered the incident and referred the inquiry to the DON. On 9/13/16 at 3:10 pm, an interview was conducted with the DON regarding the altercation between Resident 3 and RSR 13. The DON stated he was notified by facility staff on 7/25/16 about the resident altercation and he did his initial investigation. The DON stated he did not complete the investigation. The DON stated he forgot to follow up the abuse incident and stated he should have reported the resident to resident altercation to the licensing agency (State survey and certification agency) immediately. On 9/13/16 at 4:00 pm, an interview was conducted with the facility administrator. The administrator stated the facility failed to notify the licensing agency within 24 hours of the incident per policy. The administrator further stated the facility also failed to fully investigate and notify the licensing agency of the final investigation of the abuse incident within 5 days per facility policy. A review of the facility?s policy and procedure titled Patient Abuse and Prevention (undated) indicated under abuse reporting: (a) The facility shall ensure thorough and extensive investigation of different types of incidents including but not limited to those that may constitute abuse. Facility administrator and/or abuse coordinator and/or designees shall be responsible for ensuring thorough investigations of alleged violations. (b) The facility shall report the incident by calling the DHS (Department of Health Services) (State survey and certification agency) within 24 hours of the knowledge of such incident, followed by a letter explaining the circumstances surrounding the incident. (c) The administrator and director of nurses, in the order written, shall report incidents of suspected abuse to the following agencies within 24 hours of occurrence: Department of Health-Licensing and Certification, LTC (Long-Term Care) Ombudsman or designee or Local enforcement agency or Police Department. (d) The facility administrator shall report findings of investigation to the department (State survey and certification agency) within 5 working days of the incident. On 9/14/16, the facility reported to the licensing and certification department the resident to resident altercation that occurred on 7/24/16. The report was made 51 days after the incident occurred. The facility failed to implement their abuse policies and procedures by failing to: 1. Thoroughly investigate a resident to resident altercation between Resident 3 and Randomly Selected Resident (RSR13). 2. Send a written notification of to the DHS (Department of Health Services) (State survey and certification agency) within 24 hours of an altercation between Resident 3 and Randomly Selected Resident (RSR13). The facility?s failure to implement their abuse policies and procedures, put Resident 3 and RSR 13 at risk for further potential abuse. These violations had a direct relationship to the health, safety, or security of the residents. |
| 970000163 |
CAMELLIA GARDENS CARE CENTER |
950012911 |
B |
26-Jan-17 |
L1RH11 |
4860 |
Abuse ? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). On 10/26/2016 at 2:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding an injury of unknown source. Based on interview and record review, the facility failed to: immediately report Resident 1?s injury of unknown source to the State survey and certification agency within 24 hours. Findings: A review of the admission face sheet indicated Resident 1 was admitted to facility on XXXXXXX with diagnoses that included, but not limited to, dysphagia (difficulty swallowing), chronic respiratory failure (impaired gas exchange in the lungs resulting in difficulty of breathing) and hypertension (high blood pressure). A review of document titled "History and Physical Examination" dated 6/17/2016 indicated Resident 1 does not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS), a comprehensive assessment tool, dated 9/30/2016 indicated that Resident 1 rarely/never understood self and others had severely impaired cognitive skills for daily decision making, required total dependence with one person assist with bed mobility, transfer, dressing, toilet use and bathing. During the tour on 10/26/2016 at 2:10 pm with the Director of Nursing (DON), Resident 1 was observed with greenish discoloration on the right hip area. A Review of document titled "Progress Notes" dated 10/15/2016 indicated that Certified Nursing Assistant (CNA) 1 noticed a discoloration and swelling on Resident 1's right groin and was reported to charge nurse; assessment was done and noted Resident 1 with bluish-purple discoloration and swelling to right groin area extending to buttocks; attending physician was notified. A review of document titled "Physician's Orders" dated 10/15/2016 indicated "Stat (immediately) X-Ray (imaging study) right hip, right pelvis (hip bone), and right thigh for swelling/discoloration. A review of document titled "Final X-ray Report" dated 10/16/2016 indicated "Findings are suspicious for a non-displaced fracture (broken bone) of the femoral neck (thigh bone). CT (computerized tomography-more detailed imaging study) recommended. During an interview with CNA 1 on 10/26/2016 at 3:35 pm, CNA 1 stated she noticed the purplish discoloration and swelling on Resident 1's right groin extending to the right hip. CNA 1 also stated she immediately reported it to charge nurse. During an interview with the DON on 10/26/2016 at 3:00 pm, the DON stated that she was informed by the charge nurse regarding Resident 1's bruise and swelling on right groin area extending to right hip. The DON also stated that an investigation was done to determine cause of the swelling and bruising. The DON further stated that the attending physician ordered Resident 1 transferred to general acute care hospital (GACH) after being informed of the results of the x-ray. A review of the GACH document titled progress record dated 10/16/2016 indicated an orthopedic (specialist in bone disorders) notes with impression of right hip strain/muscle tear. A review of the GACH document titled CT scan of the right pelvis dated 10/16/2016 indicated no acute osseous (bone) abnormalities. During another interview with the DON on 10/26/2016 at 4:10 pm, DON stated that she did not report incident to state licensing and certification agency because there was no fracture noted when CT scan was done in the acute hospital and that she discussed it with the administrator. DON further stated that facility should have reported the incident to state licensing and certification agency because it was an injury of unknown origin. A review of District office intake of entity reported incidents did not show any report made to the district office regarding Resident 1?s injury of unknown source. A review of an undated facility policy and procedure titled ?Preventing and Reporting Resident Abuse? indicated if the suspected abuse does not result in serious bodily injury, the incident must be reported within 24 hours to the local law enforcement agency and provide a written report to local ombudsman, the licensing and certification program and local law enforcement agency within 24 hours. Therefore, the facility failed to: immediately report (within 24 hours), Resident 1?s injury of unknown source to the State survey and certification agency. This violation had a direct relationship to the health, safety, or security of the resident. |
| 960001150 |
CAMELOT DIVISION |
960009794 |
B |
22-Mar-13 |
NJS611 |
6866 |
WIC 4502 (h) Class B CitationPersons 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 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 have rights including, but not limited to, the following:(h) a right to be free from harm, including unnecessary physical restraints, or isolation, abuse, or neglect. On October 17, 2012 at 6:30 a.m., an unannounced visit was made to the facility to conduct an Investigation of abuse. According to the facility's report the incidentoccurred October 1, 2012, and the assistant executive director Staff G was made aware of the incident October 9, 2012. Based on observation, interview, and record review the facility staff failed to: 1) Ensure Client 1 was not abused by the facility?s staff. Staff A and Staff B tied Client 1 to the chair in an effort to control his behavior.On October 17, 2012 at 7:30 a.m., a review of Client 1's health records, face sheet revealed, Client 1 was admitted to the facility with the diagnoses of Moderate mental retardation and psychosis. Client 1 was non-verbal but able to make his needs known through gestures and pointing. According to Client 1's most current Psychological Assessment dated September 16, 2012, Client 1 had no family involvement, and was described as generally compliant with staff requests, and exhibited no evidence of hallucinations or delusions. Client 1's Individual program plan (IPP) dated August 9, 2012, disclosed a behavior plan to manage Client 1's identified behaviors, which included rage tantrums, hitting and pulling hair, stealing food from his peers, removing personal items from his peer's room, and exposing his private parts in public.On October 17, 2012 at 6:40 a.m., during an interview with Staff C (the house leader) she stated, that on October 9, 2012 while making rounds at 4:40 p.m., she was immediately met at the door by Staff H attempting to explain the scratches on the program room's newly installed floor.Staff H disclosed, Staff A and Staff B tied Client 1 to the dining room chair, a week ago (October 1, 2012), when Staff A was not able to control Client 1's behaviors (roaming around the house and not wanting to go to sleep). Staff C stated, she immediately called the Licensee, and texted the Qualified Mental Retardation Professional (QMRP) informing them that it was reported to her by Staff H that Staff A and Staff B tied Client 1 to the dining room chairOn October 17, 2012 at 7:20 a.m., during an interview with the qualified mental retardation professional (QMRP) he stated, he was not made aware of the client being tied to the chair until after the house leader returned from her vacation October 9, 2012 around 5:00 p.m. The QMRP continued to give an account of the incident by saying: On October 1, 2012, shortly after midnight he called Staff D and directed him to attend to Client 1 who was as told to him by Staff A, having behaviors of running in the facility, attempting to steal food from the refrigerator, and entering the rooms of his peers. The QMRP further stated, Staff A told him she was unable to handle Client 1's behaviors but he was never told that she (Staff A) tied the client to the chair with a sheet. The QMRP then stated, he was not informed of the client being tied to the chair until October 9, 2012, when Staff C (the house leader) texted him and informed him that Staff A and Staff B tied Client 1 to the dining room chair with a sheet. The QMRP said Staff D did not tell him Staff A and B tied Client 1 to the dining room chair with sheets. On October 17, 2012 at 12:02 p.m., during an interview with Staff A she stated, she had been working in the facility since September 14, 2012 (16 days). Staff A said she was familiar with the company's policies and procedures regarding abuse and abuse reporting. Staff A said, she was having difficulty controlling Client 1's behaviors that night causing her to tie the client with sheets to a chair. Later that night, the night supervisor (Staff D) arrived to the facility, walked into the living room and immediately removed the sheets which were tied around the client and told them (Staff A and Staff B) that they should not have tied Client 1 to the chair and that they were wrong for abusing Client 1. When Staff A was asked if she was aware of the abuse policy and procedure, Staff A stated "she was aware of the facility's policy and procedure regarding abuse.?On October 17, 2012 at 2:11 p.m., during an interview with Staff D (the night shift supervisor) he stated, that during the night of October 1, 2012, between 3:15-3:25 a.m., he witnessed Client 1 seated in a dining room chair with a sheet tied around his waist, ankles and chin area. When asked about the demeanor of Client 1, he stated Client 1 was not happy and was very agitated. Staff D said, he immediately untied the client, and scolded both Staff A and B and informed them that restraining the client to the chair was inappropriate, unacceptable, and abusive. On October 5, 2012, Staff D stated he texted the QMRP and informed him that he needed to speak with him regarding the mishandling of Client 1 from Staff A and Staff B.On October 17, 2012 at 4:30 p.m., during an interview with Staff B she stated, on the early morning of October 1, 2012, Staff A was panicking and unable to manage Client 1's behaviors. Staff B said, later in the early morning she witnessed Client 1 already tied to the dining room chair. Staff B continued to firmly state, "I know that I am a mandated reporter and that I should have reported witnessing the client tied to the dining chair but, I did not, because I really felt so sorry for Staff A because she did not know how to manage Client 1's behavior."On October 17, 2012 according to the facility's policy and procedure (no date) and latest in-service training dated October 12, 2012, abuse is not tolerated and all staff are legally mandated to report abuse that is seen, heard of, or suspected within 24 hours of the time they are made aware of the incident.Based on observation, interview, and record review the facility staff failed to: 1) Ensure Client 1 was not abused by the facility?s staff. Staff A and Staff B tied Client 1 to the chair in an effort to control his behavior.The above violation cause or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the client. |
| 960001150 |
CAMELOT DIVISION |
960009795 |
B |
22-Mar-13 |
NJS611 |
7649 |
H & S Code 1418.91 (a) (b) 1418.01 Reports of incidents of alleged abuse or suspected abuse or 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. (b) A failure to comply with the requirements of this section shall be a Class ?B? violation. On October 17, 2012 at 6:30 a.m., an unannounced visit was made to the facility to conduct an investigation of an entity reported incident of abuse that occurred October 1, 2012. The Department was made aware of the incident October 10, 2012.Based on interview and record review, the facility?s staff failed to: 1. Report an allegation of suspected abuse to the Department within 24 hours when Client 1 was found tied to a dining chair by the night supervisor.On October 17, 2012 at 7:30 a.m., a review of Client 1's health records, face sheet revealed, Client 1 was admitted to the facility with the diagnoses of Moderate mental retardation and psychosis. Client 1 was non-verbal but able to make his needs known through gestures and pointing. According to Client 1's most current Psychological Assessment dated September 16, 2012, Client 1 had no family involvement, and was described as generally compliant with staff requests, and exhibited no evidence of hallucinations or delusions. Client 1's Individual program plan (IPP) dated August 9, 2012, disclosed a behavior plan to manage Client 1's identified behaviors, which included rage tantrums, hitting and pulling hair, stealing food from his peers, removing personal items from his peer's room, and exposing his private parts in public.On October 17, 2012 at 6:40 a.m., during an interview with Staff C (the house leader) she stated, on October 9, 2012 while making rounds at 4:40 p.m., Staff H informed her that on October 1, 2012, Staff A and Staff B tied Client 1 to the dining room chair when Staff A was not able to control Client 1?s behaviors (roaming around the house and not wanting to go to sleep). Staff C stated, she immediately called the Licensee, and texted the Qualified Mental Retardation Professional (QMRP) informing them of this incident.On October 17, 2012 at 7:20 a.m., during an interview with the qualified mental retardation professional (QMRP) he stated, he was made aware of the client being tied to the chair and the scratches on the floor (made by the client attempting to break free of being tied with sheets to the dining chair) after the house leader returned from her vacation October 9, 2012 at around 5:00 p.m.On October 17, 2012 at 7:30 a.m., during an interview with Staff F (the Registered Nurse) she stated, she was made aware of the incident on October 9, 2012, after the QMRP informed her. Staff F stated, she was told by the QMRP, Client 1 had been tied to the dining room chair and that her licensed nurse on duty that night (Staff E) was aware of the incident, but did not report the incident as she was mandated as a licensed nurse.On October 17, 2012 at 9:42 a.m., during an interview with Staff G (the Assistant Executive Director) she stated, she was made aware of the incident that occurred on October 1, 2012, on October 9, 2012, by the Licensee, the QMRP, and Staff C.Staff G stated, the night shift supervisor (Staff D) who was directly involved in the incident failed to report the abuse as mandated by the facility's policy and procedure. She stated, 5 people were aware of the abuse that occurred on October 1, 2012, and each of them failed to report the abuse as mandated.On October 17, 2012 at 12:02 p.m., during an interview with Staff A she stated, she reported to work on September 30, 2012, to work the night shift. She informed the evaluator that her work hours were from 11 p.m. until 6 a.m. and she had been working in the facility since September 14, 2012 (16 days). Staff A said she was familiar with the company's policies and procedures regarding abuse and abuse reporting.Staff A stated, she did not know how to manage Client 1's behaviors neither had she received training regarding the management of the client's behaviors.Staff A said, around 12:30 a.m., she called the licensed nurse (Staff E) to administer medication to Client 1 to calm the client down but the medication did not work. Staff A said, after a little while (does not know the amount of time) the client began to attempt to go outdoors, so she and Staff B retrieved a sheet from the cupboards and tied it around the waist, and legs of Client 1, and then attached the sheet to the dining room chair by tying a knot. Staff A said, the client was so angry and out of control that she and Staff B waited outside and left the client unattended in the living room. Staff A said, the night supervisor (Staff D) arrived at the facility, walked into the living room and immediately removed the sheets which were tied around the client and told her and Staff B that they should not have tied Client 1 to the chair and that they were wrong for abusing Client 1. Staff A said, she did not report the incident to the QMRP, either the executive officer or the CEO.On October 17, 2012 at 2:11 p.m., during an interview with Staff D (the night shift supervisor) he stated, during the early morning of October 1, 2012, when he arrived to the facility for the second time he met Staff A and Staff B standing outside of the facility's door and witnessed Client 1 seated in a dining room chair with a sheet tied around his waist, ankles and chin area.. Staff D said, he immediately untied the client, and informed them thatrestraining the client to the chair was inappropriate, unacceptable, and constituted abuse.Staff D said, he did not notify the QMRP of the abuse, that the client had been tied to the dining room chair on October 1, 2012, but that on October 5, 2012 he texted the QMRP and informed him that he needed to speak with him regarding the mishandling of Client 1 from Staff A and Staff B.Staff D further stated, he did not report the incident to the CEO, the Assistant CEO, neither did he record the incident in the end of shift report because he (Staff D), was tired and needed rest.On October 17, 2012 at 4:30 p.m., during an interview with Staff B she stated, on the early morning of October 1, 2012, she witnessed Client 1 already tied to the dining room chair. When asked if she reported seeing Client 1 tied to the chair she stated no. Staff B continued to firmly state, "I know that I am a mandated reporter and that I should have reported witnessing the client tied to the dining chair but, I did not, because I really felt so sorry for Staff A who did not know how to manage Client 1's behavior.? On October 17, 2012 according to the facility ' s policy and procedure (no date) and latest in-service training dated October 12, 2012 all staff are legally mandated to report abuse that is seen, heard of, or suspected within 24 hours of the time they are made aware of the incident. The ?Abuse Reporting? policy further stated, ?Suspected abuse should be reported immediately to the QMRP, executive director, vice-president, or CEO, licensing, Adult or Child Protective Services, Regional Center and the police. Staff are also mandated to report the incident to the ombudsmen. The facility?s staff failed to: 1. Report an allegation of suspected abuse to the Department within 24 hours when Client 1 was found by the night supervisor tied to a chair by Staff A, in an attempt to control his behavior. The failure had a direct relationship to the health, safety, and security of Client 1. |
| 960002901 |
CK II |
960010152 |
B |
18-Sep-13 |
9JIL11 |
7014 |
WELFARE AND INSTITUTIONS CODE SECTION 4500-4519.7 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:(a) A right to treatment and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports should foster the developmental potential of the person and be directed toward the achievement of the most independent, productive, and normal lives possible. Such services shall protect the personal liberty of the individual and shall be provided with the least restrictive conditions necessary to achieve the purposes of the treatment, services, or supports.(b) A right to dignity, privacy, and humane care. To the maximum extent possible, treatment, services, and supports shall be provided in natural community settings. On March 11, 2013 an unannounced visit was made to the facility to initiate a recertification survey. Based on observations, interview and record review, the facility staff failed to ensure Client 4 received humane care by failing to: 1. Ensure Client 4 was served meals consistent with his developmental level as the physician ordered and the speech consultant recommended. 2. Ensure Client 4 was allowed to eat and drink prior to giving gastrostomy tube (g-tube, surgical opening made through the skin of the belly and into the stomach that allows food and medicine to be given directly into the stomach instead of through the mouth) feedings.Failure to ensure the client received oral meals as prescribed by the physician resulted in the client not being allowed to differentiate food items and their individual taste.The clinical record for Client 4 was reviewed on March 13, 2013. The face sheet indicated the client was admitted to the facility on April 15, 2010, 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), Down's syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21), and Esotropia (in which one or both eyes turns inward, crossed eyed). Further review of the clinical record indicated the client now has hypothyroidism (thyroid that regulates the process the body gets energy from food is under active) and a gastrostomy tube (g-tube is placed through this opening that allows food and medicine to be given directly into the stomach instead of through the mouth). The client was non-verbal, walked independently and followed commands.During an observation on March 11, 2013, at 4:05 p.m., Staff B administered a can of Jevity 1.5 and 100 milliliters (ml) of water mixed together into Client 4's g-tube. The alert client was not given anything by mouth.During an observation on March 13, 2013, at 3:45 p.m., Staff A/B, Administered a can of Jevity 1.5 and 100 milliliters of water mixed together into Client 4's g-tube. The alert client was not given anything by mouth.During an interview at the client's day program on March 12, 2013 at 12:35 p.m., the day program licensed vocational nurse stated, Client 4 drinks (orally) his can of Gevity 1.5 daily and his g- tube was accessed solely for water flushes. During an interview with the registered nurse (RN)/ administrator, on March 13, 2013, at 5:25 p.m., she stated there was no swallow study for Client 4. She stated the speech therapist recommended the client be fed orally before he is given a g-tube feeding, she further stated, she told the staff not to give him oral gratification because he was sleepy. During an observation, on March 13, 2013, at 5:30 p.m., Client 4 was awake, up and walking about the facility without any assistance. During an interview with Staff A and B, on March 13, 2013, at 5:50 p.m., Staff B stated the client was fed orally about 1/2 a teaspoon of yogurt 3 times a week. Staff A concurred and stated the client was given a glass of water to drink orally before his 4 p.m. and 8 p.m. meal if he was not sleeping.During an interview with the RN/ administrator, on March 14, 2013, at 10:15 a.m., she stated the client was not fed by the staff because the client ate too fast, therefore, the staff had to spoon feed him. The clinical record for Client 4 was reviewed on March 13, 2013. The physician orders dated February 15, 2013 - April 15, 2013 indicated the client take puree fruits, juices, pudding, custards, 60 milliliters thin liquids with or without thickener for oral gratification with total supervision.A review of the client's quarterly individual service plan (IPP) dated January 11, 2013, indicated Client 4 must attempt oral intake first then give the remainder of the Gevity via g-tube. The client is to attempt to drink formula orally and given g-tube feeding only if he is unable to finish drinking. For oral gratification, the client is given puree fruits, juices, pudding, custards, and 60 cc thin liquids with staff supervision. This IPP meeting was attended solely by the administrator and the LVN. A review of the client's speech therapy assessment dated December 17, 2012, indicated the client "is able to swallow Jevity with no signs or symptoms of aspiration and penetration and should continue with speech and swallow therapy through his home caregiver provider. The assessment further recommended to maintain nutrition and hydration, the client was to receive medication via g-tube and oral intake of Jevity.A review of the client's comprehensive psychological evaluation and functional analysis dated October 5, 2005, indicated the client was able to feed himself using a lipped plate. A review of the Consumer Rights in Client 4's chart signed May 15, 2010, by the administrator and the client's family member, indicated the client has the right to be treated with consideration, respect and full recognition of the consumer's dignity and individuality, including privacy treatment and in care of the consumer's personal needs.The facility staff failed to ensure Client 4 received humane care by not serving meals consistent with his developmental level as the physician ordered and the speech consultant recommended and by not allowing Client 4 to eat and drink prior to giving g-tube feeding. These failures resulted in Client 4 not being able to differentiate food items and their individual taste.This violation had a direct relationship to the health, safety or security of Client 4. |
| 630014292 |
Cold Springs Home |
960013157 |
B |
3-May-17 |
LSZR11 |
3784 |
The criminal record clearance shall be completed prior to direct staff contact with residents/clients of the facility. A criminal record clearance shall be complete when the department has obtained the person?s criminal record information from the Department of Justice and has determined that he or she is not disqualified from engaging in the activity for which clearance is required.
1265.5(a) (2) (B)
On 9/18/15, at 5:30 a.m., an Annual Fundamental Recertification Survey was conducted.
The facility failed to ensure:
Criminal clearance from the Department of Justice (DOJ) was obtained for Staff B prior to him working in the facility. This failure placed all 6 clients at risk for potential harm.
On 9/18/15, at 5:45 a.m., during an observation, the facility's population consisted of 2 ambulatory clients and 4 wheelchair-bound clients who depend on staff for assistance in the basic activities of daily living.
On 9/21/15, at 2:40 p.m., a review of the facility's staff personnel files indicated Staff B's personnel file was missing.
On 9/21/15, at 4:00 p.m., during an interview with the facility's Registered Nurse (RN), she stated Staff B was no longer working at the facility. Staff B's personnel file was requested for review.
A review of Staff B's personnel file indicated he was hired on 4/8/15. Further review of Staff B's personnel file indicated there was a letter dated 6/25/15, titled "Notice of Mandatory Denial of Criminal Record Clearance" in the file. The letter indicated this denial of criminal record clearance precludes the individual from providing direct care and residing in Intermediate Care Facilities for the Developmentally Disabled, including habilitative and nursing facilities. The letter also indicated as the individual is not granted criminal record clearance, this person's continued employment, or residence on the facility's premises may result in a violation, pursuant to Health and Safety Code Section 1265 et seq.
On 9/22/15 at 9:20 a.m., during a telephone interview with the facility's Executive Director (ED), she stated the previous Human Resource?s (HR) staff failed to ensure Staff B was cleared with the DOJ for employment. The ED stated on 9/18/15, as the surveyor requested the staffs' personnel files, the current HR staff called the DOJ and found out that Staff B was not cleared for employment. The ED stated Staff B was suspended from employment effective 9/18/15. The ED stated Staff B was given 5 days to obtain the criminal clearance from the DOJ prior to returning to work. The ED further stated the original denial letter from the DOJ was mailed out to the wrong office.
A review of the transmittal application for criminal record clearance for Staff B indicated the address on the application was the same as the address on the denial letter.
A review of the facility's policy and procedure titled ?Prevention of Abuse, Neglect, and Mistreatment" indicated: In order to prohibit the employment of an individual with a conviction, all direct care staff are either cleared through the California Department of Public Health services centralized fingerprint database and telephone directory, or they submit a set of fingerprints to the facility Administrator or designee prior to working directly with individuals receiving services. Any individual with a conviction or prior employment history of child abuse, neglect, or mistreatment will be prohibited from employment.
The facility failed to ensure Staff B had been cleared by the DOJ for criminal clearance prior to him working in the facility. This failure placed all 6 clients at risk for harm.
The above violation had a direct relationship to the safety and security of the clients residing in the facility. |
| 980002279 |
CAREMERIDIAN, LLC |
980010431 |
B |
06-Feb-14 |
S7NG11 |
5676 |
Title 22 Section 72541-Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On January 7, 2014, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint regarding a fire resulting in injuries to patients and staff.Based on observation, interview, and record review the facility failed to report to the Department within 24 hours an unusual occurrence of a fire by failing to: Report that on January 4, 2014, at 7:28 a.m., the facility had a fired that affected one of the patient's rooms and resulted in evacuation of the total census of 10 patients and injuries to four patients and two staff members requiring transfer to General Acute Care Hospitals (GACHs).On January 7, 2014, the Department retrieved a telephone message from the Fire Department left on Saturday January 4, 2014, at 8:15 a.m., reporting a fire extinguished at the Congregate Living Health Facility (CLHF). According to the message, the fire originated in one of the patient?s rooms, was confined to that room and there were four patients and two employees injured that required transfer to GACHs. By January 7, 2014, the CLHF had not reported by telephone or in writing report the unusual occurrence. On January 7, 2014, at 11 a.m., an unannounced visit was conducted at the facility to investigate the reported fire incident. During the entrance conference, the Administrator/DPCS (Employee A) stated the room affected by the fire was a two-bed room shared by Patients 1 and 2. Employee A also indicated the room was undergoing repairs. At 11:30 a.m., during a tour of the facility, Patient 1?s bed was observed in the backyard of the facility. The bed had the end portion of the mattress burned and had black ashes. Patient 2's bed was also in the backyard with no evidence of burn from fire. At 11:45 a.m., Patients 1 and 2?s room was observed to have the walls newly painted with white color and the wood flooring had been removed exposing a hard cement surface. Upon asking Employee A for the incident investigation report, she provided a written report in a letter format addressed to the Department. The report dated January 4, 2014, indicated that on the same day (January 4, 2014), at 7:15 a.m., the facility's fire alarm went off. Employee B, who was in charge, found the room of Patients 1 and 2 on fire and Patient 1's corner of the bed with flames. Employee B called out "Code Red" and instructed three employees on duty (including Employees C and D) to remove the two patients from the room. 911 was called and all the patients, a total of 10, were evacuated. Paramedics, fire department and law enforcement arrived, the fire was extinguished. The fire affected only one room. Patients 1, 2, 3 and 4 along with Employees C and D were transferred to different GACHs for evaluation of smoke inhalation and/or minor burns. The report did not address notification of the fire to the Department.On January 7, 2014, at 12 p.m., during an interview, Employee A stated that on January 4, 2014, at 8:10 a.m., when she arrived to the facility, she was instructed by a corporate office staff member to call the Health Department using the telephone number located at the bottom part of the facility's license (which is not the 24-hours number to the Department) but it was just an answering machine. Employee A also stated she was not aware of the State Hotline telephone number and the number was not written in their Fire and Disaster Manual or posted on the walls of the facility. Employee A was not aware of the contact number or fax number of the Department District Office with jurisdiction over the CLHF and did not know the telephone or fax number of the Department of Public Health - Health Facilities Inspection Division headquarters.On January 7, 2014, a review of the facility?s Fire and Disaster Manual, Emergency Fire Procedures revised 08/2003, disclosed the manual did not contain the Department 24-hours telephone number.According to the facility's policy and procedure on Unusual Occurrences revised on January 1, 2011, the Administrator/Director of Nurses or designee with report any unusual occurrence in the facility to the regulatory agencies within 24 hours and/or per regulatory guidelines. The definition of unusual occurrences included fires and any occurrence which threatened the welfare, safety or health of the residents, staff, family or visitors. The facility failed to report to the Department within 24 hours an unusual occurrence of a fire by failing to: Report that on January 4, 2014, at 7:28 a.m., the facility had a fired that affected one of the patient's rooms and resulted in evacuation of the total census of 10 patients and injuries to four patients and two staff members requiring transfer to GACHs.The above violation had direct or immediate relationship to the health, safety, or security of the patients. |
| 630013062 |
CAPRI IN THE DESERT |
980010736 |
A |
29-May-14 |
U7OH11 |
12835 |
72311 (a)(1)(B). Nursing Service-General (a)Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. 723131(a)(2) Nursing Service-Administration of medications and treatments. (a) Medication and Treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. Based on observation, interview, and record review, the facility failed to: 1. Develop a plan of care to prevent/manage Patient 1?s pressure sore/ skin breakdown. 2. Ensure Patient 1?s wound on the sacrococcyx area was treated as ordered by the physician. The violations were determined on March 4, 2014 and March 10, 2014, when unannounced complaint visits were conducted at the facility for an allegation that the facility administration laid off six nursing assistants. According to the admission record, Patient 1 was admitted to the facility from an acute hospital on February 7, 2014 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), tracheostomy ventilation dependence (an opening cut into the trachea and a tube is inserted to let air in, which attached to a breathing machine), diabetes mellitus (metabolic diseases in which a person has high blood sugar), hypertension (high blood pressure), End Stage Renal Disease (ESRD), renal cell cancer with status post left nephrectomy, morbid obesity, and status post incision and drainage of right shoulder joint. A review of the physician?s initial history and physical dated February 10, 2014, indicated Patient 1 did not have the capacity to understand and make decisions. A review of the Comprehensive Resident Assessment dated February 7, 2014, indicated the patient was unresponsive and opened eyes without tracking. The patient was bed bound, weighed 420 pounds, and required total assistance with care. The patient had a tracheostomy, PEG (Percutaneous endoscopic gastrostomy), and indwelling catheter. He had a round quarter sized Stage II pressure ulcer on his sacrococcyx area. According to a Braden Scale (for predicting pressure sore risk) dated February 4, 2014, in the clinical record, the patient was scored 10. The form indicated the total score of 12 or less represented the patient was at a high risk for pressure sores. However, a review of the whole clinical record revealed there were no plan of care for the prevention and management of pressure sores. On March 4, 2014, at 9:30 a.m., there was a Licensed Vocational Nurse (LVN 1), a Respiratory therapist (RT 1), a care giver (CG 1), and housekeeper I working at the facility. The Director of Nursing (DON) arrived at the facility at 10:40 a.m. On March 4, 2014, at 9:50 a.m., Patient 1 was observed lying supine (lying with the face up) on a low air loss mattress with a tracheostomy tube connected to a ventilator. The patient?s eyes were open but not tracking, and patient was not responsive when his name was called. There were two pillows under the patient?s left side of the body, but the patient was still supine.On March 4, 2014, at 2:25 p.m., Patient 1 was observed still in the same position. At that time, the DON, RT 1, and CG 1 came and repositioned Patient 1 on his right side for a treatment on the sacrococcyx area. During an interview with CG 1 at the same time, he stated the patient had been having intermittent diarrhea approximately four times during his shift (9 a.m. to 5 p.m.) since shortly after the patient was admitted to the facility. Three to four persons were needed to clean the patient or to change position because the patient was so big. During the treatment observation of the treatment by the DON, the wound was observed black with no skin. The DON stated the wound was an erosion (slightly depressed areas of skin in which part of all of the epidermis had been lost) due to diarrhea. She stated it was black color because the excoriation was covered with scab. Upon the Evaluator?s request, the DON measured the size of the wound. It measured 16 centimeter (cm) by 13 cm. She stated the wound got better compared to before. However, when the DON was asked about the quarter sized Stage II pressure ulcer which the patient had on the sacrococcyx area upon admission, she did not answer but kept on saying the current wound was just skin erosion due to diarrhea, not pressure ulcer. A review of the ?Weekly Special Skin Report? dated February 7, 2014, indicated the patient had Stage II pressure ulcer on the sacrococcyx area that was 3centimeter (cm) diameter and with 0.2 cm depth. There was a physician?s order dated February 7, 2014 to cleanse the sacrococcyx ulcer with normal saline, pat to dry, apply Hydrogel dressing (used in a variety of wound types and they are designed to hold moisture at the wound surface, providing the ideal environment for wound cleansing and autolytic debridement) every other day. A review of the Nurses Note dated February11, 2014, from 6 p.m. to 1:30 a.m. shift indicated the patient had one loose bowel movement, and the patient was cleaned and dressing was changed from the sacrococcyx ulcer, which was ?actively bleeding and getting black?. A review of a ?Weekly Wound Report? dated February 12, 2014 in Patient 1?s record (without the patient?s name, and no signature on the record as to who measured the wound), indicated the sacrococcyx area measured 20 length and 20 width (there was no indication of unit). The color was black and no drainage was noted. There was no measurement of depth for the wound. The physician?s order dated February 12, 2014, indicated to discontinue previous treatment order of the sacrococcyx area and it was changed to cleanse the open wound with normal saline, pat dry, and apply Petroleum dressing to the wound bed, cover with ABD (Army Battle Dressing, used when high absorbency is required to handle heavy draining wounds or large wounds), secure with occlusive dressing every other day and as necessary if soiled and dislodged. The Nurses Note dated February 19, 2014, from 11 p.m. to 7 a.m. shift indicated the patient had two large diarrheas. The patient was cleaned and dressing was changed. The ?Weekly Wound Report? dated February 19, 2014 in Patient 1?s record indicated the sacrococcyx pressure sore measured 20 length and 20 width (there was no indication of unit). The color was black and there was a small amount of bright- red drainage. However, a review of the treatment record for the month of February 2014 indicated the physician?s order for the sacrococcyx pressure ulcer was transcribed as a prn (as needed) order, and not every other day and prn as ordered by the physician. There was no evidence wound treatment were done every other day as ordered by the physician. There was a nurse?s initial that it was done only on February 17, 2014. There were no other initials documented on the treatment record. On March 4, 2014, at 2 p.m. during an interview and record review, the DON was able to show nurses notes that treatments were done on February 13, 15, 19, 21, and 23. However, there was no evidence the wound treatment was done on the patient?s sacrococcyx wound on February 24, 25, 26, 27, and 28, 2014. On March 4, 2014 at 3:30 p.m., during a review of the patient?s clinical record with the DON, there was no care plan found in the clinical record for the pressure ulcer/skin breakdown prevention/management including how often the staff was going to relieve the pressure off from the pressure points, how many staffs needed for the position change, and what they were going to do for the patient?s wound treatment. During an interview at the same time, the DON stated there was none. When asked how the patient?s pressure ulcer/skin break down should be managed, the DON stated the interventions should include monitoring the patient?s skin daily, assessing the wound weekly, and turning the patient every 2 hours. When the DON was asked how she would ensure the patient had been actually repositioned every 2 hours, she stated it was the facility?s "protocol" and all of the staff should be aware of it. However, when asked to show evidence in the clinical record that Patient 1 was repositioned every 2 hours, there was no evidence that it was done on February 7, 8, 10, 11, 13, 14, and 24, 2014. On March 4, 2014, at 3:30 p.m., when the facility?s policy and procedure for the pressure ulcer/skin breakdown management was requested, the DON stated the policy and procedure book was at the corporate office which was approximately 15 minutes away from the facility. On March 10, 2014, at 12 p.m., another visit was made to the facility for further investigation. A review of the clinical record revealed there was a care plan dated March 4, 2014, for pressure ulcers which included repositioning every 2 hours, monitor for incontinence monitor lab values as ordered. At 12:15 p.m., Patient 1 was observed lying supine on the low air loss mattress (a pressure relieving mattress used in the prevention and treatment of pressure ulcers) with a tracheostomy tube connected to a ventilator. Patient 1 had two pillows under the left side of his body, but he was still on his back. During an interview with CG1 at the same time, he stated he had been only changing the patient?s position by putting the pillows under the patient?s side because the patient could not tolerate lateral position due to the tracheostomy tube connected to the ventilator. The DON stated the patient tolerated turning to side just 5 to 10 minutes, such as during cleaning or treatment. She further stated the patient turned blue when he was positioned to the side. However, the DON was not able to provide any documentation that the patient actually turned to be blue when he was positioned to the side, or the physician was notified. During an interview on March 10, 2014, at 12:20 p.m., with RT 1, she stated the patient had been placed on a lateral position when the staff cleaned the patient for five to ten minutes. RT 1 further stated that she did not think turning the patient to side would hurt the patient. On March 10, 2014 at 1:05 p.m., during a treatment observation, the DON measured Patient 1?s pressure ulcer on the sacrococcyx 15 and half cm by 15 cm with black color, and was observed bloody around the wound. Then the DON stated the wound on the patient?s sacrococcyx area was not only an erosion, but an unstageable pressure ulcer (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed). According to the National Pressure Ulcer Advisory Panel dated April 28, 2014, 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. (http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/) The DON stated the pressure ulcer had a tunneling (2 cm on 3 o?clock direction and 3-4 cm on 12 o?clock direction). RT 1, LVN 2, and CG 1 helped the DON position the patient, and holding the patient while the DON was doing treatment. The patient did not have any respiratory distress or turn blue. RT 1 stated the patient was doing okay. At 2 p.m., when the DON and the staffs were putting pillows under the patient?s left side again, the Evaluator pointed out the pillows were under the left side of the patient at 12 p.m. Then the DON put the pillows under the right side of the patient and stated she would use a turning schedule which was newly made, and would let the staff use it. A review of the facility?s policies and procedures obtained from the main office for ?Decubitus ulcers causes and prevention? indicated as follows: Preventive measures: (a) Turn the patient at 2 hour intervals and reposition to lateral, supine, or prone positions. (b) Make small changes in position to alter pressure points every 30 to 60 minutes.This was not followed.The facility failed staff failed to prevent the pressure sore from getting worse by failing to: 1. Develop a plan of care to prevent/manage Patient 1?s pressure sore/ skin breakdown. 2. Providing treatment to Patient 1?s wound on the sacrococcyx area as ordered by the physician. These violations either jointly, separately, or in any combination presented an imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result to Patient 1. |
| 630013062 |
CAPRI IN THE DESERT |
980010737 |
B |
29-May-14 |
None |
9335 |
72515(b) Accept and retain only those patients for whom it can provide adequate care. Based on observation, interview, and record review, the facility admitted Patient 1 to whom they cannot provide adequate care.The violation was determined during complaint investigations on March 4, 2014 and March 10, 2014 for an allegation that the facility administration laid off six nursing assistants. According to the admission record, Patient 1 was admitted to the facility from an acute hospital on February 7, 2014 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), tracheostomy ventilation dependence (an opening cut into the trachea and a tube is inserted to let air in, which attached to a breathing machine), diabetes mellitus (metabolic diseases in which a person has high blood sugar), hypertension (high blood pressure), End Stage Renal Disease (ESRD), renal cell cancer with status post left nephrectomy, morbid obesity, and status post incision and drainage of right shoulder joint. A review of the physician?s initial history and physical dated February 10, 2014, indicated Patient 1 did not have the capacity to understand and make decisions. The Comprehensive Resident Assessment dated February 6, 2014, indicated the resident was unresponsive, opened eyes without tracking. The patient was bed bound, weighed 420 pounds, and required total assistance with care. The patient had a tracheostomy, PEG (Percutaneous endoscopic gastrostomy), and indwelling catheter. Patient 1 had a round quarter sized Stage II pressure ulcer on his sacrococcyx area. A review of the whole clinical record revealed there was no plan of care for the prevention and management of pressure sores. There was a physician?s order dated February 7, 2014 for the Stage II sacrococcyx area, to cleanse with normal saline, pat dry and to apply Hydrogel dressing (used in a variety of wound types and they are designed to hold moisture at the wound surface, providing the ideal environment for wound cleansing and autolytic debridement) every other day and as necessary if soiled. The physician?s order dated February 12, 2014, indicated to discontinue previous treatment order and changed to cleanse the open wound with normal saline, pat dry, and apply Petroleum dressing to the wound bed, cover with ABD (Army Battle Dressing, used when high absorbency is required to handle heavy draining wounds or large wounds), secure with occlusive dressing every other day and as necessary if soiled and dislodged. However, a review of the treatment record of the month of February 2014 indicated the order was transcribed as prn (as needed), and not every other day and prn as ordered by the physician. There was no evidence in the treatment sheet wound treatment was done every other day as ordered by the physician. There was only a nurse?s initial that the treatment was done on February 17, 2014. There were no other initials documented on the treatment record. On March 4, 2014, at 2 p.m. during an interview, the DON provided the Nurse?s notes dated February 13, 15, 19, 21, 23, 2014, indicating the ?wound care was provided/done/changed?. However, she was not able to show any evidence that treatment was provided on February 24, 25, 26, 27, and 28, 2014. When asked how the patient?s pressure ulcer/skin break down should be managed, the DON stated the interventions should include monitoring the patient?s skin daily, assessing the wound weekly, and turning the patient every two hours. A review of the facility?s policies and procedures for ?Decubitus ulcers causes and prevention? obtained from the corporate office on March 4, 2014 at 4 p.m., indicated preventive measures as follows: (a) Turn the patient at 2 hour intervals and reposition to lateral, supine, or prone position. (b) Make small changes in position to alter pressure points every 30 to 60 minutes.However, when asked to show evidence in the clinical record that Patient 1 was repositioned, there was no evidence in the clinical record that this was done on February 7, 8, 10, 11, 13, 14, and 24, 2014. A review of the Patient 1?s wound assessments revealed the patient?s sacrococcyx pressure ulcer worsened as follows: The Weekly Wound Report dated February 12, 2014 in Patient 1?s record (without the patient?s name, and no signature on the record as to who measured the wound), indicated the sacrococcyx pressure ulcer measured 20 length and 20 width (there was no indication of unit). The color was black and no drainage was noted. There was no measurement of depth for the wound. The Weekly Wound Report dated February 19, 2014 in Patient 1?s record indicated the sacrococcyx pressure sore measured 20 length and 20 width (there was no indication of unit). Color was black and there was a small amount of bright- red drainage. On March 4, 2014, at 9:30 a.m., there were five patients in the facility including Patient 1. There was a Licensed Vocational Nurse (LVN 1), a Respiratory therapist (RT 1), a care giver (CG 1), and housekeeper I working at the facility. The Director of Nursing (DON) arrived at the facility at 10:40 a.m. There was also a certified nursing assistant 1 (CNA 1) at the facility next to Patient 1?s bed. At 9:50 a.m. during an interview with CNA 1 stated that she was working only for Patient 1. CNA 1 stated she was from a senior assistants agency. CNA1 further stated her working hours for Patient 1had been decreased. During an interview on March 4, 2014, at 9:35 a.m., CG1 stated he had been working from 9 a.m. to 5 p.m. as a service contractor for patients? feeding and showering since last month. During an interview with LVN 1 at the same time, she stated the facility laid off all the CNAs since middle of February 2014, and the facility hired/contracted caregivers for individual patients? bathing and feeding. LVN 1 stated it became much harder because one LVN and one RT had to work in the facility with five to six patients from 5 p.m. (after the care giver left) to 9 a.m. the next morning. On March 4, 2014, at 10:20 a.m. during an interview, RT 1 confirmed that one LVN and one RT would have to work by themselves after the caregiver left at 5 p.m. On March 4, 2014, at 10:25 a.m. during an interview with Patient 2 who was alert and oriented, she stated she had to wait in the bathroom for 20 to 30 minutes until she received help from the staff. Patient 2 further stated it happened several times during the last two or three weeks. On March 4, 2014, at 2:25 p.m., Patient 1 was observed lying supine on a low air loss mattress (a pressure relieving mattress used in the prevention and treatment of pressure ulcers) is back with a tracheostomy tube connected to a ventilator. The patient?s eyes were opened but not tracking, and Patient 1 was not responsive when his name was called. The DON, RT 1, and CG 1 came to reposition the patient onto his right side, in order for the DON to provide a wound treatment on the sacrococcyx area. During this procedure, CG 1 stated that ?three (with a male staff) to four (without a male staff) had to move the patient to clean or to change position because the patient was so large.? On March 4, 2014 at 2:25 p.m., the DON was observed providing the wound treatment. The wound was black with no skin, and measured 16 centimeter (cm) by 13 cm. On March 10, 2014, at 12 p.m., another visit was made to the facility for further investigation. At 12:15 p.m., Patient 1 was observed lying supine on the low air loss mattress with a tracheostomy tube connected to a ventilator. On March 10, 2014 at 1:05 p.m., the DON was observed doing the saccrococcyx wound treatment. The wound measured 15 and a half cm by 15 cm with black color, and was observed bloody around the wound. The DON stated the wound on the patient?s sacrococcyx area had a tunneling (undermining) of 2 cm at 3 o?clock direction and 3-4 cm at 12 o?clock direction. A review of the agency?s ?Client Billable Hours? indicated there was no documented evidence of any personnel from the another agency had worked from February 28, 2014, at 1:30 p.m. to March 2, 2014 at 8 a.m. (41 hours), and from March 3, 2014, at 12 a.m. to March 4, 2014, 8 a.m. (32 hours). A review of the schedule of the LVN, RT, and caregiver indicated only two personnel (one LVN and one RT) had worked on the above days after the care giver was off at 5 p.m. This indicated that only two persons were available to provide care for all of the patients including Patient 1. Since Patient 1 needed three to four people to reposition, there was not enough staff to reposition him. A review of the facility?s license indicated the facility had a Congregate Living Health Facility (CLHF) ?A? license. CLHF A is defined as providing services for persons who are mentally alert, physically handicapped, who may be ventilator dependent. However, Patient 1 was not alert to be able to make his needs known. On March 10, 2014, at 2:30 p.m., during an interview with the DON, she stated the facility had decided to transfer the patient to a higher level of care. The facility failed to accept and retain only those patients for whom it can provide adequate care. The violation had a direct relationship to the health, safety, or security of Patient 1. |
| 630013243 |
Corbin Congregate Home, Inc. |
980011733 |
A |
30-Sep-15 |
56DW11 |
15680 |
Title 22 72315 (f) (1) Each patient shall be given care to prevent formation and progression of pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure applied to the area and decreasing circulation), contractures and deformities. Such care shall include: Changing the position of bedfast and chair fast patients with preventive skin care in accordance with the needs of the patient. Title 22 72313 (f) (7) Each patient shall be given care to prevent formation and progression of pressure ulcers, contractures and deformities. Such care shall include: Carrying out physician?s orders for treatment of pressure ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311 (b). Based on record review and interview, the facility failed to: 1. Ensure wound care treatments were done as ordered. 2. Ensure pressure ulcer treatments were carrying out as ordered to prevent progression of the pressure ulcer. The violations were determined on 6/10/15 at 1:25 p.m., when an unannounced complaint visit was made to the facility to investigate an allegation that the facility neglected Patient 1?s wound care. A review of Patient 1?s Acute Hospital Referral for Continuity of Patient Care indicated Patient 1 was transferred to the facility on 4/9/15, with diagnoses including congestive heart failure (heart inadequately pumps oxygen rich blood to the body, eventually leading to organ failure and the accumulation of fluids in the body), end stage renal failure (kidney unable remove waste and water from the body), diabetes (chronic condition associated with abnormally high blood sugar), peripheral vascular disease (any disease or disorder of the circulatory system outside of the brain and heart), and multiple pressure ulcers. Patient 1 was unable to bathe, dress, eat, perform personal hygiene, or walk by herself. Patient 1 had scheduled dialysis (machine does the work of the kidneys and removes the waste from the blood) treatments and had a Vancomycin (antibiotic) resistant Enterococcus (type of bacteria) infection. A review of the Acute Hospital, wound assessments and wound photographs of Patient 1 dated 4/9/15, included the following wounds: Wound 1: Sacral (area at the base of the spine) stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer, 8.5 centimeters (cm) in length, 9.5 cm in width, and 3.5 cm in depth, with a moderate amount of serosanguinous (slightly bloody) drainage. Wound 2: Left lower leg diabetic ulcer (long-term effects of diabetes, caused by a decrease in blood flow, which leads to break down of the skin) unstageable (full-thickness tissue loss in which the base of the ulcers covered in eschar (dry-hard dead tissue) making the wound bed not viewable), 21.5 cm, by 2.5 cm, by 1 cm, with tendon (fibrous tissue that attaches muscle to bone) exposed, with a small amount of serosanguinous fluid. Wound 3: Right lower leg diabetic ulcer, unstageable, tendon exposed, 7.5 cm by 4 cm by 0.4 cm, with a small amount of yellow color drainage. Wound 4: Left heel unstageable ulcer, covered with eschar, 9 cm by 5 cm. Wound 5: Right heel unstageable ulcer, covered with eschar, 5 cm by 6 cm. Wound 6: Left great toe diabetic ulcer, unstageable, covered with eschar, 1.8 cm by 2 cm. Wound 7: Left hip, pressure ulcer, unstageable, eschar present, 1.8 cm by 2.0 cm by 1.0 cm. A review of the wound treatment orders from the Acute Hospital included daily wound treatments as follows: Wound 1: Sacral wound-cleanse wound with 1/4 strength Dakin's solution (antibacterial cleanser), pat dry, apply silver alginate (absorbs wound drainage and antimicrobial) to the wound bed and paint the wound edges with Calmoseptine (moisture barrier ointment), cover with gauze and Tegaderm (transparent dressing). Wound 2 and 3: Left and Right lower leg wounds-cleanse with normal saline pat dry, apply Santyl (removes dead wound tissue) to necrotic tissue, then Alginate (absorbs wound drainage), cover with gauze. Wounds 4, 5, and 6: Left and Right heel wounds and eschar on feet-cleanse wound with mild soap, pat dry, apply Betadine solution (antibacterial solution), leave open to air.Wound 7: Left hip-cleanse with normal saline, pat dry, apply Santyl ointment, cover with Alginate dressing, cover with dry dressing. A review of the facility Treatment Record for Patient 1 included the following treatments:1. Intact eschar on heels or toes: cleanse with mild soap and water, dry, and apply Betadine solution. 2. Pressure ulcers to both calves (fleshy part of the leg below the knee): cleanse with normal saline, pat dry, apply Santyl to necrotic tissue, then Alginate dressing for large wounds with moderate to heavy drainage. Cover with dry dressing. 3. Sacral wound (Wound 1): cleanse wound with 1/4 strength Dakin's solution, pat dry, apply Silver Alginate to wound bed. Apply Calmoseptine to wound edges cover with Kerlix, secure with Tegaderm daily. The left hip pressure ulcer (Wound 7) was not included on the Treatment Record.A review of the Treatment Record indicated no documentation that any treatments were done to any of the wounds until 4/11/15.A review of the Clinical Notes dated 4/10/15, on the 7:00 p.m. to 7:00 a.m. shift, indicated licensed vocational nurse (LVN) 5 documented treating the sacral wound with DuoDerm dressing (provides a moist wound healing environment). There was no physician?s order for the application of the DuoDerm to the sacral wound.a. On 4/11/15, the facility staff documented treatments were started to both heels and toes. However, there was no documentation of any treatments done to the heels and toes on 4/15, 4/18, 4/22, and 4/24/15. There was no documentation as to the reason the treatment to heels and toes were not done on those days. From 4/10/15 to 4/24/15, the facility staff performed wound care to Patient 1?s heels and toe as ordered only eleven times in sixteen days.b. On 4/12/15, LVN 3 documented wound care supplies were not available to perform the bilateral lower legs (calves) and sacral treatments.A review of Patient 1's Supplementary Physician's Orders indicated the supplies were not ordered until 4/12/15 (three days after admission) for the following supplies: Normal Saline, Alginate Dressing, Tegaderm, Santyl Ointment, Adaptic, Hydrogel, Calmoseptine, and Betadine Solution. On 4/13, 4/14, and 4/15/15, there was no documentation that any wound care was done to the calves. On 4/16/15, LVN 3 again indicated that the wound care supplies for the lower leg treatments (calves) were not available. On 4/18, 4/20, and 4/22/15, there was no evidence wound care treatments to the calves were done. There was no documentation for the reason the treatments were not done.From 4/10/15 to 4/24/15, the facility staff performed wound care to the calves as ordered only five times in fourteen days. c. On 4/12/15, 4/16, and 4/17, LVN 2 documented in the treatment record that wound care supplies were not available to perform the sacral wound treatments.A review of LVN 3's Clinical Note dated 4/12/15, indicated, "assessment done on wound area (sacral area). LVN 3 described the wound as ?necrotic skin, cleansed with normal saline. It had a bad odor, so dressed with wet to dry dressing. LVN 3 documented ?both lower legs not done, supply not available."LVN 3 indicated on 4/14/15, she treated Patient 1?s sacral wound with a wet to dry dressing change, not in accordance with the physician?s order. A review of Patient 1's clinical record, no documentation was found that LVN 3 had contacted the physician and an order was obtained for the wet to dry dressing for the sacral area. On 4/18/15, there was no documentation found that the wound care to the sacral area was done.From 4/10/15 to 4/25/15, the facility staff performed sacral wound care as ordered only eight times in sixteen days, instead of daily as ordered.d. A review of Patient 1?s Clinical Notes dated 4/19/15, LVN 3 indicated treatment was done to the left hip. It was the only time that treatment was documented to have been done to the left hip.A review of Patient 1?s clinical nursing notes indicated the following regarding the repositioning of Patient 1 to prevent the formation and progression of pressure ulcers. On 4/10/15, on the 7 a.m. to 7 p.m. shift, Patient 1 was transferred to an ?Invacare bed? (low air loss overlay mattress, support surface that provides a flow of air to assist in managing the heat and humidity of the skin) at 4:00 p.m.A review of Patient 1?s clinical nursing notes indicated, once Patient 1 was placed on the Invacare bed (air flow mattress), there was no evidence the staff turned/repositioned Patient 1 every two hours.The clinical notes dated 4/11/15, 4/13 to 4/19/15, and 4/22 to 4/25/15, indicated there was no evidence the patient was turned/repositioned every two hours. Staff just documented that the ?patient was repositioned via airflow mattress?, Invacare bed, alternating pressure mattress, or pressure airflow mattress.A review of the facility Prevention and Care of Pressure Sores (not dated), indicated: All bedridden patients and all patients with a propensity to develop pressure ulcers are placed on a turning and repositioning schedule. Each patient who is not mobile is repositioned or turned, depending on his/her condition, at least once every two hours by the nurse assistant who is responsible for his/her direct care.A review of ?Chapter 12 Pressure Ulcers: A Patient Safety Issue? by Courtney H. Lyder and Elizabeth A. Ayelio, at http://www.ncbi.nih.gov/books/NBK2650/, page 9, indicated, ?CMS (Centers for Medicare and Medicaid Services) has divided support surfaces into three categories for reimbursement purposes. Group 2 devices are powered by electricity or pump and are considered dynamic in nature. These devices include alternating and low-air-loss mattresses. These mattresses are good for patients who are at moderate to high risk for pressure ulcers or have full-thickness pressure ulcers. However, being on a pressure-redistributing mattress or cushion does not negate the need for turning or repositioning.? The clinical notes dated 4/25/15, indicated the patient was picked up for dialysis.On 6/10/15 at 2:20 p.m., the Director of Nurses (DON) stated while at dialysis (removal of waste from the blood for patients with kidney failure) therapy, Patient 1 was transferred back to the Acute Hospital for evaluation. A review of the Acute Hospital wound photographs dated 4/25/15, indicated Patient 1?s wound status on readmission were as follows: 1. Sacrococcyx-stage IV, pressure ulcer, 12 cm by 14 cm, tunneling (is a tract or channel extending into the underlying tissues) at 8 o'clock (as in the face of a clock, 12 o'clock toward the head of the patient) of 3 cm.2. Left posterior leg-stage 4, venous ulcer (wounds that occur due to the veins not returning the blood back toward the heart), no measurements documented.3. Posterior right leg-stage 4, pressure ulcer, no measurements documented, bone exposed. 4. Left heel-diabetic ulcer, no measurements documented, eschar. 5. Right heel-diabetic ulcer, no measurements documented.6. Left toe, diabetic ulcer, no measurements documented. 7. Left hip-Stage 3, pressure ulcer, 2.5 cm by 2.0 cm.All the wounds except the left great toe had deteriorated, since 4/9/15.8. The left buttock, Stage 3, 3.0 cm by 3.0 cm, no depth measurement documented. This is a new pressure ulcer found on readmission to the Acute Hospital. A review of the Acute Hospital and the Acute Hospital wound specialist assessment notes dated 4/27/15, indicated Patient 1?s wound status on readmission to the hospital were as follows: 1. Sacrococcyx-stage 4, pressure ulcer, 14 cm by 19 cm by 3.7 cm, the wound extends to the left and right buttock, undermining (the presence of a cavity under the perimeter of the wound tissue) at the 12 o'clock (as in the face of a clock, top of the wound) of 2 cm, 9 o'clock (right side of the wound) of 3.5 cm, 3 o'clock (left side of the wound) 1.5 cm, 6 o'clock (bottom of the wound) of 2.3 cm.2. Left lateral lower leg-stage 4, approximately 28 cm by 5.2 cm by 1 cm, with large amount of serosanguinous drainage, with mild odor. Wound has undermining around the clock of approximately 2 cm. 3. Right lateral lower leg-unstageable, approximately 23.5 cm by 6.5 cm.4. Left heel-unstageable, with black eschar approximately 8 cm by 7.7 cm, unable to determine depth.5. Right heel-with dry black eschar 6 cm by 7 cm, unable to determine depth.6. Left great toe, 1.2 cm by 1.5 cm, unable to determine depth.7. Left hip not assessed. All the wounds except the left great toe had deteriorated, since 4/9/15.8. Left buttock, unstageable, 3.0 cm by 3.5 cm by 1.5 cm, undermining at 12 o'clock, 2.2 cm, and 3 o'clock 2.0 cm. This is a new pressure ulcer found on readmission to the Acute Hospital. On 6/25/15, at 1:00 p.m., an interview was conducted with the DON. The DON stated she was not able to be at the facility from 4/10/15 to 4/13/15, and was not at the facility when Patient 1 was admitted on the night of 4/9/15. The DON stated she did not do the initial comprehensive nursing assessment. The DON reviewed Patient 1?s clinical record and stated the staff ordered Patient 1?s medications but did not order the wound care supplies until 4/12/15. The DON stated the facility supplier was slow in delivering the wound care supplies. She stated she did not have any documentation when the supplies were delivered but it appeared the supplies were not delivered until 4/17/15, eight days after admission. The DON was not able to provide any documentation the physician was notified of the staff?s inability to provide treatments as ordered for Patient 1?s sacral and calves wound due to lack of supplies.The DON stated she was not able to find any physician?s orders for wet to dry dressing for Patient 1?s sacral area. The DON stated she did not know what treatments they did when the ordered wound care supplies still had not arrived. The DON stated the nurses needed to get physician orders prior to performing a different wound treatment.The DON stated that the low air loss mattress does not replace the need for turning the patient. The DON stated the staff should have repositioned Patient 1 at least every two hours. The DON asked LVN 2, who gave the facility staff an in-service in the low-air-loss mattresses, if she had instructed the staff that they still need to turn the patient when the mattress was used. LVN 2 did not respond.On 6/25/15, at 2:00 p.m., an interview was conducted with LVN 2. LVN 2 stated she had completed the Treatment Record for Patient 1. LVN 2 reviewed the treatment record and stated she must have forgotten to put left hip on the treatment record. Therefore, the facility failed to: 1. Ensure wound care treatments were done as ordered. 2. Ensure pressure ulcer treatments were carried out as ordered to prevent the progression of the pressure ulcer. The facility failure contributed to Patient 1?s wounds and pressure ulcers condition deteriorating. These violations had either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would be result or a substantial probability that death or serious physical harm would result. |
| 630013062 |
CAPRI IN THE DESERT |
980012542 |
AA |
10-Nov-16 |
4J3J11 |
18645 |
T22 DIV CH3 ART-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. T22 DIV 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. T22 DIV ART-72515(b) Admission of Patients The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care. On 5/9/16 at 12:20 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s transfer to the facility, where she died the next day. Based on record review and interview, the facility failed to ensure that Patient 1, was provided interventions in accordance with the patient?s care plans for respiratory distress, oxygen use and cardiac (heart) distress; failed to ensure the facility?s policies and procedures regarding cardiopulmonary resuscitation (CPR) and ambu bag (a hand held device used to provide positive pressure ventilation to patients who are not breathing) were implemented for Patient 1; failed to ensure the facility accepted a patient for whom it can provide care. These failures were a proximate cause of Patient 1?s death. Based on record review, Patient 1 had diagnoses that included respiratory failure (inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide or both could not be kept at normal levels) and a tracheostomy (surgical opening through the neck into the airway to relieve obstruction to breathing). The facility?s failures included the following, which were a proximate cause of Patient 1?s death: 1. Failure to evaluate the patient?s breathing pattern and observe for signs and symptoms of respiratory distress. 2. Failure to observe the patient for consistency of sputum (secretions). 3. Failure to auscultate (listen to) Patient 1's breath sounds and report diminished or absent breath sounds or audible crackles and rhonchi (coarse rattling respiratory sounds caused by secretions in bronchial airways) to the physician. 4. Failure to obtain orders for oxygen therapy, suctioning and breathing treatments from the attending physician. 5. Failure to ensure Patient 1, who had no pulse and was not breathing, was suctioned from her tracheostomy tube to clear any possible blockage prior to initiating cardiopulmonary resuscitation (CPR). 6. Failure to ensure Patient 1 was positioned on a hard surface when chest compressions were performed. 7. Failure to ensure CPR was discontinued only by a physician's order and/or the arrival of rescue personnel who take over CPR efforts. Patient 1?s respiratory status was not monitored and evaluated between 10:30 p.m. on 4/29/16 and 7:00 a.m. on 4/30/16. Patient 1 was found unresponsive with no pulse, no blood pressure, and no respirations on the morning of 4/30/16. Licensed Vocational Nurse (LVN) 1 failed to suction Patient 1?s tracheostomy and failed to place Patient 1 on a hard surface to ensure the effectiveness of chest compressions when she initiated cardio-pulmonary resuscitation. Patient 1 was pronounced dead by paramedics at 8:42 a.m. on 4/30/16. The Death Certificate indicated Patient 1?s immediate cause of death was respiratory failure, with bacterial pneumonia (infection of one or both lungs) as the underlying cause. A review of the Admission and Discharge Summary and Admission Plan of Care on 5/9/16 indicated Patient 1 was admitted to the facility at 9:30 p.m. on 4/29/16. The patient arrived via critical care transport, accompanied by a registered nurse and had diagnoses which included respiratory failure, gastric feeding tube, tracheostomy, Noonan Syndrome (genetic disorder that prevents normal development in various parts of the body), and Turner Syndrome (rare chromosomal disorder). The Admission and Discharge Summary indicated Patient 1 was admitted from a general acute care hospital (GACH 1). The History and Physical Record dated 4/1/16 indicated Patient 1 was ambulatory and able to feed and clothe herself. Patient 1 was well until 3/31/16 when she became lethargic and did not go to work. Patient 1 was admitted to GACH 1 on 4/1/16 with diagnoses that included respiratory failure, hypoxemia (low level of oxygen in the blood), and hypercapnia (increased level of carbon dioxide-the waste product of breathing-in the blood) with pneumonitis (inflamed lung tissue usually caused by a virus). The Discharge Summary from GACH 1 dated 4/29/16 indicated Patient 1 was admitted to the medical intensive care unit on 4/1/16 with acute respiratory failure. Patient 1 underwent a percutaneous tracheostomy (a less invasive procedure to create a hole in the patient?s airway to help her breathe) on 4/12/16. Patient 1 also underwent a PEG tube (a feeding tube placed through the abdominal wall into the stomach) placement on 4/21/16 for inability to swallow safely. The discharge diagnoses included acute pneumonia-resolved, acute-on-chronic respiratory failure-improved (minor but multiple incidents cause acute deterioration), and upper airway obstruction, status post tracheostomy. The discharge instructions indicated to continue routine tracheostomy tube care and suction and to continue supplemental oxygen by her tracheostomy tube as needed. A review of the Daily Skilled Nurse's Note, dated 4/29/16 at 9:30 p.m., indicated LVN 1 received Patient 1 via critical care transport, the patient was alert, and connected to oxygen via trach mask at 5 liters per minute, and breathing was even and non-labored. The patient was transferred to bed, vital signs were within normal limits, connected the patient to the cool mist FiO2 (a fraction or percentage of oxygen a patient is inhaling produced by an oxygen device such as a nasal cannula or mask) at 30%, and no shortness of breath (SOB)was noted. There were no physician?s orders regarding oxygen treatment/settings, and no respiratory therapist was present to perform an admission assessment and set-up the patient?s oxygen/suctioning equipment. A review of the resident short term care plan titled, ?Respiratory Problems, related to shortness of breath and pneumonia? dated 4/29/16, completed by Registered Nurse (RN) 1, indicated Patient 1 was at risk for respiratory distress related to shortness of breath and pneumonia. The goal in the plan of care was for the patient to remain free from respiratory distress as evidenced by no shortness of breath and clear breath sounds. The care plan interventions included assess/document baseline of breathing pattern of Patient 1, provide oxygen per physician?s order, observe/report for signs and symptoms of respiratory distress including nasal flaring, increased congestion, productive coughing, neck distention and use of abdominal muscles for breathing, observe/report for consistency of sputum such as color, consistency, odor, amount if present, breathing treatment as ordered and monitor/report adverse reactions to the physician. The plan of care did not address suctioning secretions from the patient's tracheostomy. A review of the resident short term care plan titled, ?Oxygen Use,? dated 4/29/16, completed by RN 1, indicated Patient 1 required special care related to oxygen use and was at risk for potential complications such as oxygen toxicity (a condition of oxygen overdose which can result in pathological tissue changes and can also decrease drive to breathe). Interventions included initiate and maintain oxygen flow rate and concentration with humidification as ordered, auscultate breath sounds and report diminished or absent breath sounds or audible crackles and rhonchi to physician. The plan of care interventions did not address suctioning secretions from the patient's tracheostomy. There was no documentation in the clinical record regarding care of Patient 1?s tracheostomy and suctioning. The medication orders in the plan of care did not include any orders for oxygen use or breathing treatments. There was no documentation in the clinical record of a physician's orders for Patient 1's oxygen use or the amount of oxygen Patient 1 should receive and when. The Medication Administration Records for April 2016 included no documentation to indicate oxygen was being administered to Patient 1. A review of a care plan titled , ? 22 Cardiac/Circulatory Diseases? dated 4/29/16, completed by RN 1, indicated the patient was at risk for cardiac distress. Interventions included oxygen inhalation at five (5) liters per minute as ordered and monitor oxygen saturation as needed/as ordered. Although LVN 1?s documentation indicated Patient 1 was on oxygen at the time of arrival, there were no physician?s orders to indicate the amount of oxygen Patient 1 should receive, how oxygen should be delivered, and the frequency of the oxygen therapy. Patient 1?s Daily Skilled Nurse's Note, (Side Two) indicated the following information between 10:30 p.m. on 4/29/16 and 7:00 a.m. on 4/30/16: At 10:30 p.m., insulin medication was not given to the patient due to the blood sugar level of 65, the tube feeding of Jevity 1.2 formula at 45 milliliters (ml) per hour and tolerated well. At 11p.m., the patient?s blood pressure was 115/62, pulse was 85 beats per minute, temperature was 97.9 degrees Fahrenheit, respirations were 14 per minute and oxygen saturation was 97 percent. The CNA reported to LVN 1 that Patient 1?s skin color was pale. The patient was covered with a blanket for the low temperature. At 11:30 p.m., the patient?s temperature was 98.5 degree Fahrenheit. There was no documentation to indicate any follow-up observation of Patient 1?s pale skin color. At 12 a.m., the patient?s blood sugar level was 111 and no shortness of breath. However, the patient?s breathing pattern was not evaluated. At 2 a.m., the patient was awake, was noted with a Stage II skin breakdown, and wound care was provided. At 4:15 a.m., the patient was pointing to her abdomen at the feeding tube site. The patient pointed to her wheelchair and a staff member informed the patient that she could not get out of bed as it was not time. At 5 a.m., the patient complained of stomach pain by pointing toward her abdomen and with facial grimacing. The patient was given Norco (narcotic pain reliever), pain level was six (6) out of 10 with 10 being the worst pain. At 6 a.m., the patient?s pain level decreased to two (2) out of 10 with 10 being the worst pain and no shortness of breath. However, the patient?s breathing pattern was not evaluated. Patient 1?s oxygen saturation was not checked. There was no documentation between 10:30 p.m. on 4/29/16 and 7:00 a.m. on April 30, 2016, to indicate the respiratory status of Patient 1 was monitored and evaluated in accordance with the care plans. There was no documentation the patient was receiving oxygen, the amount of oxygen Patient 1 was receiving, how oxygen was delivered and the frequency of the oxygen therapy. There was no documentation that Patient 1 was assessed for breathing pattern (labored or shallow as indicated in the Daily Skilled Nurse?s Note, side one), observed for signs and symptoms of respiratory distress such as nasal flaring, increased congestion, neck distention and use of abdominal muscles for breathing, observed for consistency of sputum such as color, consistency, odor and amount if present. There was no documentation the licensed nurse auscultated the patient?s lungs to listen for crackles, rhonchi and diminished or absent breath sounds. There was no documentation that secretions were suctioned from the patient's tracheostomy. According to a written statement by CNA 2, undated and provided by the facility, during her initial rounds, CNA 2 noticed Patient 1 was very pale looking and her respirations were slow. CNA 2 reported to the licensed nurse Patient 1 was very pale looking, but Patient 1?s breathing pattern was not evaluated and her oxygen saturation was not checked. An interview was conducted with Registered Nurse 1 on September 22, 2016 at 10:20 a.m. Registered Nurse 1 stated there were no physician?s orders for oxygen therapy when Patient 1 was admitted to the facility on April 29, 2016. She stated the respiratory therapist was responsible for getting the respiratory therapy orders from the physician and the respiratory therapist did not come to see the patient on April 29, 2016. She stated that maybe she should have contacted the physician for further orders that included oxygen therapy for Patient 1. The Daily Skilled Nurse's Note, dated 4/29/16 to 4/30/16, at 8:08 a.m., by LVN 1, indicated the Certified Nursing Assistant (CNA) notified LVN 1 that Patient 1?s oxygen saturation was 83 percent. LVN 1 went to the patient?s room and observed the patient was unresponsive and had no pulse. There was no documentation the patient was receiving oxygen at this time. An interview was conducted with CNA 1 on 5/9/16 at 12:20 p.m. CNA 1 stated she went to Patient 1?s room to take her vital signs in the morning of 4/30/16 at 8:08 a.m. CNA 1 stated Patient 1 did not respond. CNA 1 placed a pulse oximeter (a small device that clips on the patient?s finger ?values under 90 percent are considered low) and the oxygen saturation reading showed 83 percent. CNA 1 reported to LVN 1. The Daily Skilled Nurse's Note, dated 4/29/16 to 4/30/16, by LVN 1, indicated at 8:08 a.m., LVN 1 entered Patient 1's room and found the patient unresponsive, with no pulse. LVN 1 informed LVN 2 and began chest compressions on the patient. The Daily Skilled Nurse's Note indicated 911 (medical emergency telephone number) was called at 8:11 a.m., and LVN 1 "continued bagging patient via ambu bag." At 8:14 a.m., "...connected patient to O2 (oxygen) via trach mask upon emergency paramedic arrival." At 8:15 a.m., "...emergency paramedics arrived. CPR given." At 8:42 a.m., Patient 1 was pronounced dead by the paramedic staff. A review of the Daily Skilled Nurse?s Note dated 4/30/16 by LVN 2, indicated at 8:10 a.m., the CNA reported Patient 1?s oxygen saturation was 83% and she could not get the patient?s blood pressure. LVN 1 went to Patient 1?s room and reported the patient was not breathing. LVN 1 started CPR, LVN 2 called 911, called the supervisor, and started the paperwork. There was no documentation that LVN 2 assisted LVN 1 with CPR efforts. The Daily Skilled Nurse?s Note indicated when the paramedics pulled up in front of the facility, CPR was stopped and the patient was placed on oxygen via trach mask at 5 liters. The paramedics came in, placed the patient on the floor, and resumed CPR. Patient 1 was pronounced dead by paramedics, at 8:42 a.m. on 4/30/16. During an interview with LVN 1, on 6/13/16, at 10:05 a.m., she stated she did not suction Patient 1 at any time since her arrival. There was no documentation regarding tracheal suctioning in evidence in the clinical record. LVN 1 stated she was finishing up Patient 1's admission paperwork on 4/30/16, at 8 a.m., when CNA 1 came to her and reported Patient 1's oxygen saturation was 83% and her blood pressure was not registering. LVN 1 stated she went to the patient's room and found the patient unresponsive with no pulse. LVN 1 stated she connected oxygen to the ambu bag, started to bag and do chest compressions, while the other nurse called 911. LVN 1 stated she continued compressions and bagging the patient until the paramedics pulled up out front. At that time, she stopped CPR and connected the patient to oxygen via trach mask at five liters per minute. LVN 1 further stated she performed chest compressions with Patient 1 in her bed and there was no backboard available. LVN 1 stated she did not suction the patient at any time and when asked why LVN 2 did not assist her with CPR, LVN 1 stated she just did not think to ask her to assist, but stated it would have been better to do two person CPR. The facility's policy and procedure titled, "Emergency Procedures: Ambu Bag," revised 12/2012, indicated before using the manual resuscitation bag, check the patient's upper airway for the presence of foreign objects. If present, remove them. The policy indicated if the patient had a tracheostomy in place, suction the tube. The facility's policy and procedure titled, "Emergency Procedures: Cardiopulmonary Resuscitation (CPR)," revised 12/2012, indicated once CPR was initiated, it would be discontinued only by a physician's order and/or the arrival of rescue personnel who take over CPR efforts and/or transport the resident. The policy indicated to position the patient providing a hard surface to perform chest compressions. A review of the Death Certificate indicated Patient 1 died on 4/30/16, and the immediate cause of death was respiratory failure with Bacterial Pneumonia as underlying cause. The facility failed to ensure that Patient 1, who had diagnoses that included respiratory failure and tracheostomy, was provided interventions in accordance with the patient?s care plans for oxygen use, and respiratory/cardiac distress; failed to ensure the facility?s policies and procedures regarding CPR and ambu bag were implemented for Patient 1; failed to ensure the facility only accepted patients for whom it could provide care. The failures included the following, which led to Patient 1?s death: 1. Failure to evaluate the patient?s breathing pattern and observe for signs and symptoms of respiratory distress. 2. Failure to observe the patient for consistency of sputum. 3. Failure to auscultate Patient 1's breath sounds and report diminished or absent breath sounds or audible crackles and rhonchi to the physician. 4. Failure to obtain orders for oxygen therapy, suctioning and breathing treatments from the attending physician. 5. Failure to ensure Patient 1, who had no pulse and was not breathing, was suctioned from her tracheostomy tube to clear any possible blockage. 6. Failure to ensure Patient 1 was positioned on a hard surface when chest compressions were performed. 7. Failure to ensure CPR was discontinued only by a physician's order and/or the arrival of rescue personnel who take over CPR efforts. The above violations presented an imminent danger or substantial probability that death or serious physical harm would result and was a direct proximate cause of Patient 1?s death. |
| 630014924 |
CareMeridian - Texhoma |
980012547 |
A |
8-Sep-16 |
MQMQ11 |
8859 |
T22 DIV5CH3 ART3 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. On 6/30/16, at 1 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Patient 1's fall and sustained a fracture of the right hand. Based on observation, interview and record review, the facility failed to ensure the Interdisciplinary team (IDT) evaluated a patient's care plan as necessary and updated a patient's care plan accordingly for one of one sampled patient (Patient 1). Patient 1, who was at high risk for falls and had four (4) incidents of falls, was not evaluated by the IDT to prevent further falls and injuries, and the care plan for potential for injury was not updated accordingly. This deficient practice resulted in Patient 1 having another fall incident and sustaining a fracture of the right metacarpal (tubular bones that comprise most of the space in the palm). Patient 1 complained of right wrist pain and was medicated with Dilaudid pain medication. Patient 1 required to be transferred to a general acute care hospital where she received a cast and sling on her right arm. On 6/30/16 at 1:05 p.m., Patient 1 was observed sitting in her wheel chair in her room wearing a splint on her right hand and wrist, and Family Member 1 was sitting next to the patient. Patient 1 was alert and oriented and was able to communicate. During a concurrent interview, Patient 1 stated she fell on the floor when she tried to move from a commode to her bed. During an interview with Family Member 1 at the same time, he stated the patient had four falls at the facility and the recent fall had happened approximately two and half weeks ago while he was not in the patient?s room. A review of the Patient 1's clinical record indicated the patient was admitted to the congregate living health facility on 2/5/16, with diagnoses including chronic low back pain, diabetes mellitus (chronic metabolic disease in which there is high blood sugar levels), and compression fracture (collapse of several spinal bones usually due to trauma) on lumbar number 3 (spinal bone). A review of the physician's "History and Physical" dictated 2/8/16, indicated the patient has had progressive back and leg pain to the point where the patient was no longer able to ambulate. The physician?s impressions included status post back surgery, persistent pain, left leg and compression fracture. A review of the Fall Risk assessment dated 5/16/16, indicated Patient 1 scored 17, and a total score of 10 or above represents high risk for potential falls. The Fall Risk assessment forms also indicated Patient 1?s fall risk was reassessed between 2/16/16 and 6/16/16 indicated Patient 1?s scores ranged from 12 to 18, which indicated the patient was a high risk for falls. A review of the clinical record and facility?s investigation reports indicated Patient 1 had fall incidents on the following days: 1. The facility's investigation report dated 2/25/16, indicated the patient called to use a commode and complained of pain. Licensed Vocational Nurse 1 (LVN 1) administered Dilaudid (medication use to relieve moderate to severe pain), and while the patient was on commode, LVN 1 left the room for privacy with call light in reach. Thirty-five minutes later, the patient called for help and the patient was found on the floor with no injury. 2. The "Shift Note" dated 3/3/16, indicated the patient was found on the floor on the left side of the bed, on her knee with no injury. 3. The "Shift Note" dated 4/7/16 indicated Family Member 1 assisted the patient from the commode to the bed without assistance from the staff. The patient slipped off the bed to floor mat. The patient was found on both knees with no injury. 4. The facility's investigation report dated 5/15/16, indicated Family Member 1 was helping the patient to transfer from the commode to her bed. During the transfer, the patient lost her balance and dropped to her knees onto the floor with no injury. 5. The facility's investigation report dated 6/21/16, by Registered Nurse 1 (RN 1) indicated the incident/accident occurred on 6/15/16, despite numerous requests for Family member 1 not to transfer Patient 1 back to bed and to call staff instead, Family Member 1 attempted to transfer the patient from the commode to the bed. Family Member 1 was unable to take the patient's weight and the patient slid down onto the floor in a sitting position. Patient 1 was noted with swelling to her right wrist on night shift of 6/16/16. The X- ray result indicated the patient had oblique fracture of the 5th metacarpal. A review of the Shift Note Summary Report dated 6/15/2016, indicated at 11:40 p.m., Family Member 1 attempted to transfer the patient from the commode to bed. Family Member 1 could not support the patient's weight and the patient slid down to a sitting position on the floor in front of the commode. Family Member 1 stated he attempted to pick up the patient but the patient refused to let Family Member 1 try. The Daily Nurses Notes dated 6/17/2016, at 9 p.m., indicated the patient complained of pain in the right wrist and the hand was a little swollen with bluish color. Dilaudid pain medication, three milligrams was given to the patient and her pain level was nine out of 10 with 10 being the worst pain. At 10 p.m., Patient 1?s pain level decreased to two out of 10 with 10 being the worst pain. An x ray was ordered by the physician and taken at 12 a.m. A review of the X- ray result dated 6/17/16 indicated the patient had acute 5th metacarpal fracture. The Shift Note Summary Report dated 6/20/16, at 5:05 p.m., indicated the facility received the radiology report indicating the patient had acute 5th metacarpal fracture. The physician was notified and the physician ordered to transfer the patient to the acute hospital for evaluation. On 6/20/16 at 11:05 p.m., the patient returned back to the facility with a cast and sling on her right arm. A plan of care developed on 2/25/16, for the potential of injury related to impaired safety awareness and pain medication effects. Interventions included providing assistance of 1 person for transfer and ambulation activities and educating the family member not to lift the patient by himself and to ask for assistance. However, there was no documented evidence the care plan developed on 2/25/16, was updated to prevent future falls and injuries when Patient 1 had incidents of falls on 3/3/16, 4/7/16, 5/15/16, and 6/15/16. There were IDT notes dated 2/5/16, and 2/19/16. However, there was no documented evidence the IDT meetings were held (including the family member) to evaluate the effectiveness of the care plan interventions when the patient had fall incidents on 2/25/16, 3/3/16, 4/7/16, 5/15/16, and 6/15/16, and to update the care plan as necessary to prevent future falls and injuries. On 6/30/16 at 3:30 p.m., during an interview, RN 2 stated he was not able to provide the documented evidence the care plan was updated when the patient had falls on 3/3/16, 4/7/16, 5/15/16, 6/15/16, and the IDT was held (including the family member) to prevent future falls on 2/25/16, 3/3/16, 4/7/16, 5/15/16, and 6/15/16. RN 2 was not able to provide the investigation reports for the fall incident happened on 3/3/16 and 4/7/16, and stated the facility did not have a policy regarding the frequency of the IDT meeting. A review of the facility's policies and procedures on "Fall Risk" indicated effectiveness of the fall reduction interventions (as stated in the care plan) shall be reassessed as often as needed, and/or quarterly, at a minimum using the fall risk assessment form. Subsequently, care plans will be revised as necessary. The facility failed to ensure the IDT evaluated Patient 1's care plan for potential for injury as necessary and update a patient's care plan for Patient 1. Patient 1, who was at high risk for falls and had four incidents of falls, was not evaluated by the IDT to prevent further falls and injuries. As a result, Patient 1 had another fall incident and sustained a fracture of the right metacarpal. Patient 1 required to be transferred to a general acute care hospital where she received a cast and sling on her right arm. 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 Patient 1. |
| 630014038 |
CROFT LIVING HOME INC. |
980012767 |
B |
21-Nov-16 |
IW9M11 |
8951 |
? 72527. Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 8/31/16, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient Abuse. The facility had not reported to the Department the incident of abuse alleged by the complainant. Based on observation, interview, and record review, the facility failed to ensure its patients have the right to be free from physical and mental abuse and failed to ensure established written policies and procedures on patients? rights were implemented, including: 1. Failure to ensure Patient 1 was not mentally and physically abused by Patient 3, who first threatened Patient 1to hit him and later hit Patient 1 with a baseball bat on the left shin (the front of the leg below the knee) while Patient 1 was lying in bed. Patient 3 also threw a bottle to Patient 1 but the bottle did no hit him. 2. Failure to ensure Patient 2 was not mentally and physically abused by Patient 3, who threatened to hit her with a baseball bat and then threw a bottle of water to her. The bottle and water landed on her right arm and wet her shirt. 3. Failure to implement its policies on Patient Abuse by allowing Patient 3 to mentally and physically abuse Patients 1 and 2 and by not reporting the abuse to the Department within 24 hours. As a result, Patient 3 mentally and physically abused Patents 1 and 2 without staff implementing interventions to prevent abuse, protect patients from abuse, and without reporting the abuse to the Department. Patient 1 had pain to the left lower leg and both Patients 1 and 2 were afraid of further abuse from Patient 3. A review of the clinical record indicated Patient 1 was admitted to the facility on 8/4/16, with diagnoses including quadriplegia (paralysis - the loss of the ability to move and sometimes to feel in part or most of the body, both the arms and legs) and tracheostomy (an opening surgically created through the neck into the windpipe to improve breathing). A review of the Staff Assessment Of Daily Activity Preferences sheet, dated 8/15/16, indicated Patient 1 was alert and oriented, verbally responsive and able to make his needs known. Patient 1 was unable to walk and unable to move, feel and use his arms requiring assistance from the staff for all activities of daily living (ADLs ? including bathing, dressing, oral hygiene, toileting, and eating). During an interview with licensed vocational nurse 1 (LVN 1), on 8/31/16, at 9:15 a.m., she stated, "I was told by the night nurse (LVN 2) that Patient 3 hit Patient 1 with a bat. On 8/31/16, at 9:30 p.m., during an interview, Patient 1 stated on 8/29/16, around 4:15 p.m., while lying in his bed, Patient 3 came in his room and hit him in the left shin with a bat causing him pain. Patient 1 stated he started yelling for the nurse. When LVN 2 came to the room, he asked her to call the police but LVN 2 did not want to do it. Patient 1 called the police who came and took a report. Patient 1 said Patient 3, earlier the same day, had come to his room and threatened to hit him with a bat if he continued to call the nurses to the facility?s telephone. Patient 1 asked the Evaluator, ?How do you let a patient walk around and enter another patient's room with a bat and hit people?? Patient 1 stated he was afraid Patient 3 would again hit him. Patient 1 stated Patient 3 came back to his room later in the day and threw a bottle with water but missed him. On 8/31/16, at 10:07 a.m., Patient 3 was observed riding on his motorized wheelchair cursing and yelling. Staff was observed asking Patient 3 to go back to his room so the wound care nurse could provide care to his wound. Patient 3 yelled and cursed at staff, refused to go back to his room and left the facility. A review of the clinical record indicated Patient 2 was admitted to the facility on 2/3/15, with diagnoses including spinal cord injury with paralysis on most of the body, tracheostomy, and ventilator (equipment to move air in and out of the lungs) dependent due chronic obstructive airway. Patient 2 was alert, oriented, and able to make her needs known, was unable to walk and move, feel or use her arms, and was totally dependent with all ADLs. On 8/31/16, at 11:18 a.m., during an interview, Patient 2 stated, Patient 3 messes with everybody. She stated that on 8/29/16, Patient 3 threw a water bottle at her while she was in her motorized wheelchair. The water bottle hit her right arm and sprayed her shirt with water. Patient 3 threatened to hit her with his baseball bat. Patient 2 stated she saw Patient 3 going in and out of Patient 1's room because Patient 1 kept calling the nurses from his cellular telephone. Patient 3 went into Patient 1's room and yelled at him to stop calling the nursing station. Patient 2 stated Patient 3 keeps a baseball bat in his room. Patient 2 stated she was afraid Patient 3 would harm her. A review of the clinical record indicated Patient 3 was admitted to the facility on 5/20/16, with diagnoses including quadriplegia. Patient 3 was alert, oriented, and able to make his needs known, was unable to walk, was able to use his arms, and was dependent on staff for ADLs. According to the clinical record the patient had substance abuse and behavioral problems. A review of the policy and procedure titled, "Patient Care - Abuse -Elder/Dependent Adult, Abuse/Identification and Reporting," dated 1/1/13, defined mental abuse as humiliation, failure to provide privacy, harassment, threats, punishment, or deprivation; dependent adult was defined as 18 to 64 years of age who has physical or mental limitations, which restrict his or her ability to carry out normal activities or to protect his or her rights included but not limited to persons who have physical or developmental disabilities or whose physical and mental abilities diminished because of age. Any abuse will be investigated immediately by the supervisor and the administrator. The administrator/designee will report details of the incident to the local health office and the Department of Public Health by telephone and confirm in writing immediately (within 24 hours). On 8/31/16 at 12:07 p.m., during an interview, the director of nursing (DON) stated LVN 2 called her on 8/29/16 and notified her about Patient 3 hitting Patient 1and the police was called. The DON was unable to provide evidence of a plan to prevent Patient 3 from abusing Patients 1 and 2, and other patients. There was no evidence of measures to protect from abuse patients unable to defend themselves. The DON had no documented investigation of the incident of abuse. On 8/31/16, at 12:20 p.m., during an interview, the administrator stated she was notified Patient 3 hit Patient 1 with a bat and the police was called. The administrator further stated she was aware of Patient 3's behavior. When asked if the incident was reported to the Department she stated, "I was not aware the Department needed to be notified." The facility failed to ensure its patients have the right to be free from physical and mental abuse and failed to ensure established written policies and procedures on patients? rights were implemented, including: 1. Failure to ensure Patient 1 was not mentally and physically abused by Patient 3, who first threatened Patient 1to hit him and later hit Patient 1 with a baseball bat on the left shin (the front of the leg below the knee) while Patient 1 was lying in bed. Patient 3 also threw a bottle to Patient 1 but the bottle did no hit him. 2. Failure to ensure Patient 2 was not mentally and physically abused by Patient 3, who threatened to hit her with a baseball bat and then threw a bottle of water to her. The bottle and water landed on her right arm and wet her shirt. 3. Failure to implement its policies on Patient Abuse by allowing Patient 3 to mentally and physically abuse Patients 1 and 2 and by not reporting the abuse to the Department within 24 hours. As a result, Patient 3 mentally and physically abused Patents 1 and 2 without staff implementing interventions to prevent abuse, protect patients from abuse, and without reporting the abuse to the Department. Patient 1 had pain to the left lower leg and both Patients 1 and 2 were afraid of further abuse from Patient 3. The above violation had direct or immediate relationship to the health, safety, or security of Patients 1 and 2 and all patients in the facility. |
| 910000028 |
COUNTRY VILLA WESTWOOD CONVALESCENT CENTER |
910013523 |
B |
29-Sep-17 |
2DPB11 |
10257 |
F223
? 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(a) The facility must-
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
On 6/1/17 an unannounced visit was made to the facility to investigate an entity reported incident which indicated on several occasions for a period of six months, Resident 1 verbally bullied and threatened Residents 2, 3, 4,and 5.
The facility failed to ensure Residents 2, 3, 4 and 5 were free Resident 1?s abuse by:
1. Failure to follow its policy and procedure regarding abuse prevention.
2. Failure to adhere and implement Resident 1?s plan of care to prevent abusive behaviors.
3. Failure to follow the physician?s orders to monitor and document Resident 1?s abusive behavior.
These deficient practices of not monitoring Resident 1 of verbal abuse including: bullying and threatening Residents 2, 3, 4, 5 and other residents who resided in the facility, resulted in the residents crying, verbalizing fear, anxiety, mental anguish and had limited freedom of movement and participate in activities in the facility for at least six months.
a. A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on 7/28/16, and re-admitted on 3/10/17. Resident 1 diagnoses included, but not limited to, hypertension (high blood pressure), diabetes mellitus (high blood sugar), cognitive (mental) communication deficits, and anxiety disorder (a reaction to stress characterized by symptoms of worriedness and panic).
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/27/17, indicated Resident 1's cognition was fully intact and was independent in activities of daily living, such as bed mobility, transferring, walking, eating, and personal hygiene.
A review of Resident 1's plan of care, dated 12/28/16, titled, "Resident with identified Needs and Behaviors which may lead to Increase Risk for Conflict with Other Peers/Residents/Staff," related to Resident 1 entering other resident's rooms and accusing other residents of touching or invading his personal belongings. The staff?s listed interventions included identifying the resident?s increasing or escalating behaviors that required re-evaluation. The plan of care also indicated the staff would monitor the resident?s behaviors daily, investigate and report any identified behavior noted.
A review of another plan of care for Resident 1, dated 3/3/17, titled, "Problem Behavior related to Socially Inappropriate/Disruptive Behavior,? indicated the resident?s behaviors included screaming, yelling, and bullying other residents. The staff's interventions included to attempt to point out the inappropriate behaviors; refocus the attention to something positive to avoid further escalations and report to the physician accordingly.
A review of Resident 1's physician's orders, dated 3/3/17, indicated for the staff to monitor the resident's behavior for screaming and yelling at other residents and staff every shift. There was no record of monitoring for resident's behavior by the staff.
A review of a nurse' note, dated 5/25/17 and timed at 10:56 p.m., indicated Resident 1 had an argument with Resident 2.
A review of the facility's investigative report, dated 5/26/17, indicated at approximately 4:30 p.m., a resident (Resident 2) reported to the Administrator that he and some other residents were being threatened by Resident 1. The report indicated Resident 2 stated Resident 1 was being very aggressive, banging tables, screaming at the visitors, and other residents. The investigative report indicated after an in depth investigation including interviews with the facility's staff, residents and family members, the investigation concluded Resident 1's aggressive behavior resulted in other residents feeling afraid and threatened. The investigative report indicated the police had to be called on several occasions due to Resident 1's behavior towards other residents and that Resident 1 was transferred to an assisted living facility on 6/1/17.
A review of Resident 2?s Admission Face Sheet indicated the resident was admitted to the facility on 5/28/15 with diagnoses of acute kidney failure (the kidneys inability to filter blood) and atrial fibrillation (abnormal heart beat).
A review of Resident 2's MDS, dated 5/1/17, indicated the resident?s cognition was intact and had no memory problems.
On 6/1/17 at 1:10 p.m., during an interview, the Administrator stated that many of the residents stopped attending activities due to Resident 1's behavior. The Administrator stated he, some residents and family members all feared for their lives, due to Resident 1 behavior.
At 2:05 p.m., on 6/1/17, during an interview, Resident 1 stated on 5/31/17, the facility?s staff told him to leave and called the police on him, because he was accused of threatening to murder someone.
b. On 6/1/17 at 2:50 p.m., Resident 3 stated, ?The resident (Resident 1) was a loud mouth, who takes other resident's food and/or belongings.? Resident 3 stated a few days prior, while in the dining room, Resident 1 entered the dining room and began knocking over the residents' food trays.
A review of Resident 3's Admission Face Sheet indicated the resident was readmitted to the facility on 4/5/17, with diagnoses that included muscle weakness, end stage renal disease ([ESRD] kidneys not functioning well to remove toxins from the body), and required dialysis treatments (procedure to clean the blood).
A review of Resident 3's MDS, dated 5/1/17, indicated the resident?s cognition was intact and had no memory problems.
On 6/1/17 at 3 p.m., during an interview, Resident 3's family member (FM 1) stated Resident 1 had stolen food from Resident 3's refrigerator before and would yell loudly, and used bad language toward other residents.
c. At 3:50 p.m., on 6/1/17, Resident 4 stated two weeks prior, he was sitting in the patio and Resident 1 came into the patio area and stated, "Go." Resident 4 stated it made him upset and afraid to be spoken to like that and it made him cry. Resident 4 stated the Administrator was made aware but nothing was done, because the following day Resident 1 repeated the same behaviors toward him. There was no documented evidence of this incident.
A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on 8/27/14, with diagnoses that included muscle weakness and dysphagia (difficulty swallowing).
A review of Resident 4's MDS, dated 3/1/17, indicated the resident?s cognition and memory were intact.
d. During an interview on 6/1/17 at 4:05 p.m., Resident 5 stated there have been several incidents involving Resident 1. Resident 5 stated Resident 1 would walk back and forth in front of the television (TV) in the dining room and no one wanted to argue with him. Resident 5 stated once an older resident asked Resident 1 to move from in front of the TV and Resident 1 flipped his middle finger at her. Resident 5 stated during an activity outing Resident 1 stood up and began swearing/cursing at another resident, which made her feel embarrassed. Resident 5 stated Resident 1 would sit by her room and watch her, which made her afraid. Resident 5 stated the Administrator was made aware on several occasions of Resident 1's inappropriate behavior, but nothing was ever done.
A review of Resident 5's Admission Face Sheet indicated the resident was last readmitted to the facility on 3/28/17, with diagnoses that included muscle weakness and lumbago sciatica (pain radiating from the sciatica nerve [a nerve located in the lower back to the hips and buttocks and down each leg]).
A review of Resident 5's MDS, dated 4/26/17, indicated the resident?s cognition and memory were intact.
During an interview on 6/1/17 at 4:13 p.m., the Activities Director (AD) stated she was aware of Resident 1's abusive behavior towards other residents. The AD stated approximately the third week of May 2017, Resident 1 was arguing with another resident and gestured as if he wanted to hit the other resident.
During a concurrent interview and record review on 6/1/17 at 4:45 p.m., the Registered Nurse Supervisor (RNS 1) stated there was no documented evidence that the staff monitored Resident 1's behavior for screaming, yelling and bullying other residents, staff and family members, as per physician orders. RNS1 further stated that there was no documented evidence of the incidents involving Residents 1 and 3.
A review of the facility's policy titled "Abuse-Prevention Program," with a revised date of November 2016, indicated the facility?s purpose was to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy also stipulated that the facility would not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The policy indicated that the administrator, who was the abuse prevention coordinator, was responsible for the coordination and implementation of the facility's abuse prevention policies and training.
The facility failed to ensure Residents 2, 3, 4 and 5 were free Resident 1?s abuse by:
1. Failure to follow its policy and procedure regarding abuse prevention.
2. Failure to adhere and implement Resident 1?s plan of care to prevent abusive behaviors.
3. Failure to follow the physician?s orders to monitor and document Resident 1?s abusive behavior
The above violations had a direct or immediate relationship to the health, safety, or security of patients, caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.? |
| 030001817 |
Cottonwood Health Care Center |
030013560 |
B |
20-Oct-17 |
HNBB11 |
4396 |
California Health & Safety code 1418.91
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) Failure to comply with the requirements of this section shall be a Class B Citation.
The following citation is written as a result of complaint #CA00526036. Un-announced visits were made to the facility on 3/24/17 and 4/6/17 to investigate a complaint received on 3/10/17 regarding an incident of alleged abuse sometime in February 2017.
It was determined that the facility failed to report the alleged incident of abuse that occurred when Patient 1 reported to the facility sometime in February 2017.
Patient 1 was a long term resident of the facility with multiple diagnoses including depression and cerebral palsy (neurological condition that involves poor coordination and muscle weakness). According to the most recent quarterly Minimum Data Set (MDS, an assessment tool) dated 2/23/17, Patient 1 scored 15 out of 15 in a Brief Interview for Mental Status indicating she was cognitively intact.
During an interview on 3/24/17 at 11:20 a.m., Patient 1 verbalized Certified Nurse Assistant 1 (CNA 1) was "scrubbing hard" on her groin area while cleaning her up after an incontinent episode. Patient 1 stated that after the cleaning it was painful when she urinated. Patient 1 was also tearful and stated she asked CNA 1 to stop but CNA 1 did not stop. Patient 1 also stated she overheard CNA 1 telling other staff about her care in a sarcastic way. Patient 1 further stated she reported the incident to management in early February. Patient 1 confirmed CNA 1 was still assigned to her.
During a concurrent interview and record review on 3/24/17 at 2:35 p.m., the Social Services Assistant (SSA) stated she heard a grievance from Patient 1 getting bad treatment from CNA 1. The SSA further stated the Social Services Director was aware. There was no documented evidence of the report and investigation of the alleged abuse.
During an interview on 3/24/17 at 2:40 p.m., the Staffing Coordinator stated CNAs were assigned to the same residents even if there was a resident complaint regarding the CNA. She further stated, "I can't do anything about it." She verified CNA 1 was still assigned to Patient 1 as of 3/24/17.
Review of the CNA assignment sheets for February and March revealed CNA 1 was still assigned to Patient 1 as of 3/29/17.
During an interview on 3/24/17 at 2:55 p.m., the Administrator indicated he was aware of the incident. The Administrator further stated the allegation should have been investigated and reported to the Department.
During an interview on 4/6/17 at 10:20 a.m., CNA 1 stated Patient 1 "did not like the way I take care of her." She stated it started between October and November of 2016. CNA 1 further stated she reported the incident to management and was told she would be reassigned to a different resident but was still assigned to Resident 1 until a few days ago.
A review of the facility's policy titled, "Elder/Dependent Adult Abuse" revised 06/21/2013, indicated, "...The facility will fully protect the rights of each resident... any form of mistreatment, or any other treatment that would result in physical harm, pain or mental suffering... The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any individual... each employee is a mandated reporter... to immediately report any actual/known, alleged, suspected incident of... abuse... immediately or as soon as possible but not to exceed 24 hours after the discovery of the incident..."
During an interview on 4/6/17 at 10 a.m., the Director of Nursing (DON) stated she had spoken to Patient 1 and CNA 1 regarding the allegation about a month ago. The DON validated there was no documented evidence of the investigation. She stated, "We should have reported it" to the Department. The DON further stated CNA 1 was still assigned to Patient 1 until after the department came and investigated the incident.
It was determined that the facility failed to report the alleged incident of abuse that occurred when Patient 1 reported to the facility sometime in February 2017.
The above violations had a direct relationship to the health, safety, or security of patients. |
| 940000004 |
COUNTRY VILLA BAY VISTA HEALTHCARE CENTER |
940013658 |
B |
1-Dec-17 |
9J5Y11 |
7527 |
F223
?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(a) The facility must-
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Based on observation, interview, and record review, the facility failed to:
1. Ensure Resident 1 was free from verbal abusive behavior by CNA 1.
2. Follow and adhere to its policy regarding abuse and reporting CNAs to the Certification Branch after an abuse incident.
These failures resulted in Resident 1 being verbally abused in a confrontational manner by Certified Nursing Assistant 1 (CNA 1), and the resident felt afraid and unsafe, and had the potential for emotional distress.
On 7/12/17 at 1:21 p.m., an unannounced entity reported incident (ERI) investigation was conducted regarding Resident 1 being verbally abused and confronted by CNA 1.
A review of Resident 1's Admission Face Sheet indicated the resident was an 82 year-old female who was initially admitted to the facility on 7/30/10, and readmitted on 3/14/17. Resident 1's diagnoses included paranoid schizophrenia (a mental disorder in which people interpret reality abnormally), anxiety disorder (a mental disorder characterized by feelings of worry, anxiety, or fear), and unspecified disorder of bone density (amount of bone mineral in a particular bone) and structure.
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/12/17, indicated Resident 1's cognition (thought process) was intact and had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 9-15 = interviewable). The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent with transfers in and out of bed. According to the MDS, Resident 1 was incontinent (inability to control voluntary urination or bowel) of bowel and bladder, and unable to walk.
On 7/12/17 at 1:40 p.m., during an interview, Resident 1 stated (CNA 1) came into her room, the morning of 7/7/17, while she was eating breakfast and pulled open the curtain. Resident 1 stated CNA 1 had a "do-rag (hat used to cover one's head) on her hair, tied to the front like Tupac (rapper/musician who often wore the style)." Resident 1 stated CNA 1 told her that another CNA (CNA 2) told her Resident 1 said "something nasty about her." Resident 1 stated CNA 1 was confronting her and she felt scared, threatened, and uncomfortable. Resident 1 stated she did not want CNA 1 or 2 to take care of her anymore. Resident 1 stated she was afraid CNA 1 would do something to her while she was asleep.
On 7/12/17 at 2:09 p.m., during an interview, CNA 3 stated she was in Resident 1's room feeding another resident, on 7/7/17, when the incident occurred. CNA 3 stated she overheard CNA 1 asked Resident 1, in a threatening manner, if she was speaking badly about her. CNA 3 stated, ?I did not know if CNA 1 wanted to fight Resident 1, but she was confronting her about something that was said by another girl (CNA 2) who works here."
On 7/12/17 at 2:48 p.m., during an interview, the Director of Staff Development (DSD) stated, "I interviewed the resident (Resident 1), CNA 1 and CNA 3, when I compared the stories CNA 1's version was different. I wrote an incident report about the incident."
A review of a hand written note, written by Registered Nurse 1 (RN 1) on 7/7/17, indicated at 7:45 a.m., Resident 1 called the nurses station and stated that CNA 1 confronted her during breakfast. According to the note, Resident 1 stated, "I thought she (CNA 1) was ready to get down with an old lady." The note indicated Resident 1 stated, CNA 1 told the resident she was talking about her.
On 7/17/17 at 3:24 p.m., during an interview, the DSD stated, "The CNA (CNA 1) did not pass the ninety-day probation period, and was suspended the day of the incident (7/7/17), and then terminated."
On 7/17/17 at 3:36 p.m., during an interview, the Assistant Administrator (AA) stated he did not report CNA 1 to the professional certification branch for misconduct in regards to the abuse allegation. The AA stated, "No, I did not report this because, I did not think it was necessary because it was verbal abuse. I am strict with customer service and this CNA (CNA 1) did not meet the expectations of our customer service."
On 7/26/17 at 12:03 p.m., during a telephone interview, RN 1 stated Resident 1 told her she felt scared and threatened because CNA 1 was confronting her about something said between her and another CNA. RN 1 stated CNA 1 was sent home immediately, so that Resident 1 would feel safe.
On 7/28/17 at 9:23 a.m., during an interview, the Social Services Director (SSD) stated, she interviewed various residents about the care they received from CNA 1, and overall, the residents stated, CNA 1 was pleasant and helpful. The SSD stated this situation should not have occurred, because "the CNA works in a clinical capacity and their job is to take care of the residents, not confront them (residents)."
A review of the facility's internal investigation conclusion, dated 7/11/17, indicated CNA 1 was suspended immediately after the incident (7/7/17), and upon conclusion of the investigation CNA 1 was terminated on 7/11/17."
A review of the facility's employee handbook, dated January 2017, under Section 3 titled, "Employee Relations," indicated that while it was not possible to provide an exhaustive list of all types of conduct that are unacceptable in the workplace, the following was an example of conduct that was prohibited and will not be tolerated, "...any employee/ resident abuse."
A review of CNA 1's personnel file indicated CNA 1 was hired on 5/5/17, and received abuse training on 5/5/17. The file indicated CNA 1 acknowledged receipt of the training and education by signing a copy of the facility's abuse policy, along with an illustration of various types of abuse on 5/5/17.
A review of the facility's policy titled, "Abuse, Reporting, and Investigations," dated November 2016, indicated if the suspected perpetrator was an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facility's policies. The policy also indicated if the investigation confirmed that the alleged incident, corrective action will be taken immediately under the supervision of the Administrator. According to the policy, notification would be made to the appropriate licensing agency, which included the professional branch for CNAs, if the incident involved a nursing assistant. Inquiries concerning abuse reporting and investigations should be referred to the Administrator or the director of nursing.
Based on observation, interview, and record review, the facility failed to:
1. Ensure Resident 1 was free from verbal abusive behavior by CNA 1.
2. Follow and adhere to its policy regarding abuse and reporting CNAs to the Certification Branch after an abuse incident.
The above violation had a direct relationship to the health, safety, or security of the residents in the facility. |
| 940000053 |
COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER |
910013685 |
A |
18-Dec-17 |
U12G11 |
8360 |
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 facility failed to ensure the residents' environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure to follow its policy/procedure regarding unwitnessed falls.
2. Failure to follow Resident 1's plan of care regarding the need for supervision and assistance with toileting.
These deficient practices resulted in Resident 1 being left unsupervised in the bathroom and led to the resident falling, sustaining a right hip fracture (broken bone), undergoing surgical repair and being admitted to the general acute care hospital (GACH) for seven (7) days.
On 9/11/17 at 6:41 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that residents who are at risk for falls should have floor mats, beds in the lowest position, use of a fall arm band, and have their curtains pulled back (open) for visual assessment.
At 7:26 p.m. on 9/11/17, during an interview, the facility's Administrator stated floor mats on each side of the bed, bed alarms, and a fall risk picture should be on the resident's foot board, for residents who are at risk for falls.
On 9/11/17 at 7:39 p.m., during an observation and interview, Resident 1 was observed in the bed and when asked about her fall, the resident stated a staff member left her in the bathroom alone. Resident 1 stated she felt terrible about the fall because the facility's Restorative Nurse Assistant 1 (RNA 1) stated she had to go to the bathroom as well. According to Resident 1, RNA 1 asked her to call for help when she finished using the toilet. Resident 1 stated that she was screaming for help, but no one responded. The resident further stated that she tried to get up from the toilet seat, felt dizzy, and fell to the floor. According to Resident 1, she continued to scream for another 10 minutes in the bathroom, after the fall, before staff came and helped her up from the bathroom floor.
On 9/11/17 at 7:55 p.m., during an interview and concurrent observation of Resident 1's bedside with LVN 3, LVN 3 stated that Resident 1 had a high risk for falls with a history of falls. LVN 3 stated Resident 1 did not have floor mats, but should have had them. LVN 3 also stated Resident 1's bed was elevated, but should have been in the lowest position.
On 9/11/17 at 8:04 p.m., during a concurrent observation and interview, Registered Nurse 1 (RN 1) stated Resident 1 did not have a floor mat, a yellow armband, or a fall risk picture on the footboard indicating that the resident was at risk for falls.
On 9/11/17 at 9:05 p.m., during an interview, the Director of Nurses (DON) stated on 7/28/17, RNA 1 left Resident 1 in the restroom unattended and the resident fell.
On 9/12/17 at 2 p.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated on 7/28/17 at 1:30 p.m., she was assisting another resident when Resident 1 had called for help. According to CNA 4, RNA 1 stated she would take Resident 1 to the bathroom and told her to assist the resident back to bed. CNA 4 stated that she told RNA 1 she was not able to assist Resident 1 at the time because she had to take care of another resident. CNA 4 stated she thought RNA 1, was going to stay in the bathroom with Resident 1. She found out later that RNA 1 left the resident in the toilet and Resident 1 had fallen.
According to Resident 1's Admission Face sheet Record, the resident was a 74 year-old female who was initially admitted to the facility on 10/31/16, and readmitted on 8/4/17 post surgery. Resident 1's diagnoses included muscle weakness, heart failure (heart does not pump effectively), and diabetes (high blood sugar).
A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 11/11/16, indicated Resident 1 could understand and be understood by others and had a Brief Intervention of Mental Status (BIMS) score of 15 (8-15= interviewable). According to the MDS, Resident 1 was totally dependent on the staff moving from a seat (toilet) to a standing position, moving from one unit to another, using the toilet and dressing. Resident 1 used a wheelchair and walker for mobility.
A review of Resident 1's occupational therapy (OT) and physical therapy (PT) care plan, dated 5/16/17, indicated the resident had an extensive deficit with self-care, dressing, bathing, toileting and transferring. The care plan indicated Resident 1 had an impairment of both balance and gait (walking). The staff's intervention included for Resident 1 to be assisted with transfers and to use a front wheel walker ([FWW] a device made of lightweight metal used to provide support during walking).
A review of Resident 1's care plan, dated 7/28/17, indicated the resident was at risk for falls.
A review of Resident 1's Fall Risk Assessment, dated 8/5/17, indicated the resident had a high risk for falls. According to the assessment, Resident 1 had a history of falls and was in need of frequent toileting due to receiving diuretics (medication used to flush excess water and salt by way of urination). Under transfer score, the assessment indicated Resident 1 required "major help" in transferring.
A review of Resident 1's History and Physical (H/P) indicated the resident had generalized joint pain especially with ambulation, claudication (pain and cramping in the lower leg due to inadequate blood circulation to the muscles) and neuropathy (weakness, numbness and pain in the hands and feet).
A review of Resident 1's Physician's Orders, dated 7/12/17, indicated for the resident to have daily RNA for ambulation with a FWW.
A review of Resident 1's X-ray and Computerized Tomography ([CT] a series of images of the body) of the right hip and pelvis results, dated 7/28/17, indicated the resident had a right hip (femoral neck) fracture (broken bone) with angulation (twisting).
A review of Resident 1's Physician's Order, dated 7/28/17, indicated to transfer the resident to the GACH via ambulance.
A review of the GACH Emergency Room (ER) note, dated 7/28/17, indicated Resident 1 was getting up from a sitting position, felt dizzy and fell. According the ER note, Resident 1 complained of pain 8 out of 10 (10 being the worse pain) to the head, right hip, wrist, and shoulder.
A review of Resident 1's GACH Operative/Procedure Report, dated 7/29/17, indicated the resident sustained a mechanical fall, developed acute (sudden) right hip pain and was brought into the emergency department. Resident 1 underwent a right hip repair with screws (hip pinning). The post-operative plan included weight bearing as tolerated and administration of Lovenox (blood thinner) in two weeks for staple removal.
A review of Resident 1's GACH "Discharge Summary," dated 8/4/17, indicated the resident had sustained a right hip fracture following a fall. The resident underwent right hip surgery under general anesthesia (total or partial loss of sensation to touch or pain) on 7/29/17.
A review of the facility's "Fall Management Program" policy, dated 11/7/16, indicated the Administrator would notify the appropriate local agencies and law enforcement, according to the state and federal regulation when a fall was not witnessed. It also indicated a high fall risk resident would be identified by a special logo to alert staff of the resident's risk activity.
The facility failed to ensure the residents' environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure to follow its policy/procedure regarding unwitnessed falls.
2. Failure to follow Resident 1's plan of care regarding the need for supervision and assistance with toileting.
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. |
| 250000619 |
CHERRY VALLEY HEALTHCARE |
250013612 |
B |
14-Nov-17 |
QG3211 |
5817 |
F-226 Failure to report allegation of abuse
?483.12 (a)(3)(4)(c)(1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.?
On December 13, 2016, at 9:50 a.m., an unannounced visit was made to the facility to investigate an allegation of sexual abuse made by Patient 1.
The facility failed to report an allegation of sexual abuse for one of three sampled patients (Patient 1) to the California Department of Public Health (CDPH) within 24 hours of becoming aware of the alleged abuse. This failure had the potential to place Patient 1, and other patients of the facility, at risk of possible abuse not being reported timely to the state agency so that necessary corrective actions could be taken depending on the results of the investigation.
A review of the facility's "Summary of Event," dated December 12, 2016, addressed to CDPH, indicated Patient 1 made an allegation to facility staff on December 9, 2016, at approximately 5:45 p.m., that she was raped by a male staff member. The report indicated Patient 1 stated the rape occurred on December 4, 2016 (no time specified). However, Patient 1 did not report her allegation to anyone until December 9, 2016.
An updated report dated December 20, 2016, addressed to the CDPH, indicated the facility staff investigated Patient 1's allegation of sexual abuse and was not able to substantiate it based on their investigation. The report further indicated, "Video review (from surveillance camera) revealed no conclusive info as to who entered [Patient 1's room] on certain times since [Patient 1?s room] door is located at the blind area of the camera."
An interview was conducted with the Administrator on December 13, 2016, at 9:50 a.m. The Administrator stated he was notified on December 9, 2016, at 5:45 p.m., of Patient 1's allegation of sexual abuse. The Administrator stated Patient 1 gave a lot of detail about the alleged sexual abuse. However, Patient 1 was confused sometimes and the Administrator did not think it happened. The Administrator stated during his initial interview with Patient 1, she first alleged the rape occurred at 3 a.m. (the morning of on December 5, 2016). The Administrator stated during other interviews with Patient 1, Patient 1 stated the rape occurred on December 4, 2016, around 10:30 p.m. The Administrator stated he notified CDPH on December 12, 2016. The Administrator stated he did not know why he did not notify CDPH sooner, and stated he should have notified CDPH within 24 hours of becoming aware of Patient 1's allegation of sexual abuse.
An interview was conducted with the Social Services Director (SSD) on December 13, 2016, at 9:50 a.m. The SSD stated a police officer came to the facility on December 9, 2016, to speak with Patient 1. The SSD stated the police officer was told by Patient 1 that the rape did not occur at the facility, and the rape occurred at a park.
An interview was conducted with Patient 1 on December 13, 2016, at 10:30 a.m. Patient 1 was alert and able to answer simple questions. Patient 1 was not able to clearly articulate conversations. Patient 1 was able to describe a sexual event but was not able to give an exact description or name of the alleged perpetrator.
Patient 1's record was reviewed. Patient 1 was admitted to the facility on May 16, 2016, and readmitted on September 25, 2016. Patient 1 had diagnoses including weakness, diabetes, and seizures (abnormal electrical activity in the brain).
Review of the nursing progress note dated December 9, 2016, at 5:45 p.m., by Licensed Vocational Nurse (LVN 1) indicated, "...Resident (Patient 1) verbalized allegations that someone sexually assaulted her while changing her a few nights ago..."
A nursing progress note dated December 10, 2016, at 3:04 p.m., by the Social Services Designee indicated, "...Ombudsman notified...and Administrator aware..." There was no documented evidence that the facility notified CDPH within 24 hours of the allegation.
During observation of the facility's video surveillance camera recording dated December 4, 2016, between the hours of 10:15 p.m. to 11 p.m., the video tape did not clearly show Patient 1's bedroom door, and did not show staff going in and out of the room due to the position of the camera. Staff were viewed going down the hallway away from Patient 1's door, but there was no clear visual picture of staff entering and exiting the patient's bedroom.
The facility's undated policy titled, "Abuse Prohibition Program," indicated, "...Reporting...The agency mandated by your state (CDPH) must be notified within 24 hours of suspected abuse..."
The facility's undated policy titled, "Resident (Patient) Abuse, Neglect, or Mistreatment," indicated "...Procedure...3. The Administrator or designee will notify the resident's representative, and any State (CDPH) or Federal agencies of allegation within 24 hours..."
Therefore, the facility failed to ensure Patient 1?s allegation of abuse was reported to CDPH with 24 hours. The above violation had a direct or immediate relationship to the health, safety, and security of the patients. |
| 070000031 |
Camden PostAcute Care, Inc. |
070013681 |
B |
11-Dec-17 |
E7PC11 |
7237 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to ensure the fall care plans were updated after fall incidents for Resident 1. This resulted in Resident 1's unwitnessed three falls with injuries occurring on 5/15/17 (separated right shoulder) , 8/30/17 (bump on the head), and 10/26/17 with loss of consciousness.
A review of Resident 1's medical record indicated he was admitted on 2/26/15 with diagnoses including muscle weakness, history of falling, abnormal posture, altered mental status, abnormalities of gait and mobility, and Parkinson's disease (a progressive disorder that affects movement impairing posture and balance). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/3/17, indicated the resident required staff assistance for mobility and that his balance during transitions and walking was "not steady, only able to stabilize with staff assistance".
A review of the medical record, "IDT POST-EVENT NOTE" for 5/15/17 at 8:10 p.m., indicated, "The nurse doing rounds saw the resident on the floor on the prone position. Resident was moaning and groaning. Assisted him back to wheelchair and ask what happened. Resident stated was reaching out for his TV lost balance and fell."
A review of the medical record, "THERAPY POST-FALL SCREEN" for 5/15/17 completed by the IDT, indicated the root cause of the fall was determined to be related to "behavioral symptoms" and "non-compliant with safety precautions". A recommendation was made for a "physical therapy eval(uation)".
A review of the medical record, "IDT POST-EVENT NOTE" for 8/30/17 at 11:00 a.m., indicated "Resident seen laying on the floor by his bedside incurring a head lump/bump... measuring 3.5 cm (length) x 3 cm (width)... When asked what happened, resident said that he bend over to reach this false teeth that fell on the floor in between his bed and his side table which caused him to fall and hit his frontal side of his head on the wall."
A review of the medical record, "THERAPY POST-FALL SCREEN" for 8/30/17, completed by the IDT, indicated the root cause of the fall was determined to be related to "behavioral symptoms" and "poor safety awareness". A recommendation was made for "frequent monitoring" and "chair alarm-pressure".
A review of the medical record, "IDT POST-EVENT NOTE" for 10/26/17 at 8:45 a.m., indicated, "CNA (1) went inside the room and found resident's wheelchair which was flipped to the side and found his head up to his shoulder was inside the trash bin. Per CNA, she removed the head out of the trash bin by herself and called for help. Staff came and found resident unresponsive, no pulse, no breathing... CPR initiated... called 911."
A review of the medical record indicated a "THERAPY POST-FALL SCREEN" had not been completed for 10/26/17.
A review of the medical record "COMPREHENSIVE PLAN OF CARE" update dated 5/19/17, indicated "refused bed and tab alarm to alert staff." Update dated 5/21/17 indicated "be sure call light is within resident's reach." Update dated 8/29/17 indicated "adaptive devices as recommended by therapy or MD... Monitor/document to ensure appropriate use of safety/assistive devices."
A review of the facility policy, "FALLS-RISK ASSESSMENT, IDENTIFICATION & REDUCTION" dated April 2005, indicated "Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on their individual risk factors... The IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or related incident."
A review of the facility policy, "COMPREHENSIVE PLAN OF CARE" dated April 2005, indicated "the comprehensive plan of care must include interventions to attempt to manage risk behaviors... re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment."
In an interview on 11/13/17 at 3:00 p.m., the director of nurses (DON) stated the care plan should have been updated after the falls. When asked what interventions were implemented for Resident 1 addressing falls related to reaching for objects, the DON stated, "We put an alarm. He really doesn't want anything done... We provided him a reacher." The DON said the interventions were documented in the short-term care plan. When asked if they should be documented in the long-term care plan, the DON stated, "It should be in the long-term care plan." When asked how Resident 1 is supervised, the DON stated, "We monitor him. We don't have a specific time that we monitor. Not in place that we document every hour. Mostly it's the huddle we do every morning."
In an interview on 11/13/17 at 8:46 a.m., certified nursing assistant 1 (CNA 1) stated on 10/26/17 at 8:45 a.m., "I walked near his bed and saw his wheelchair flat on its side. Then I saw his body... I saw his face in the trash can... it was to his shoulder. It had a liner...the plastic bag. I removed the wheelchair and removed the trash can and removed the liner."
In an interview on 11/13/17 at 9:30 a.m., licensed vocational nurse 1 (LVN 1) stated, "He is told not to transfer himself but he does it anyway".
In an interview on 11/13/17 at 9:41 a.m., registered nurse 1 (RN 1) stated, "We remind him of the call light. We tell him not to transfer alone. He says he can do it."
In an interview on 11/13/17 at 10:00 a.m., restorative nurse assistant 1 (RNA 1) stated, "We know he is a fall risk".
In an interview on 11/21/17 at 1:10 p.m., RNA 1 was asked if Resident 1 used his call bell. RNA 1 stated, "Most of the time he does not use that one." When asked about the grabber, RNA 1 stated, "I never saw him with the grabber... I did not know about that one." RNA 1 identified the "grabber" and the "reacher" as the same object.
In an interview on 11/21/17 at 1:20 p.m., CNA 1 stated the grabber was not on the bedside table when she found Resident 1 on the floor on 10/26/17.
The facility failed to ensure the fall care plans were updated after fall incidents for Resident 1. This resulted in Resident 1's unwitnessed three falls with injuries occurring on 5/15/17 (separated right shoulder) , 8/30/17 (bump on the head), and 10/26/17 with loss of consciousness.
This had a direct relationship to the health, safety, or security of residents. |
| 250000079 |
Centinela Grand, Inc. |
250013679 |
B |
13-Dec-17 |
6M7Q11 |
7269 |
HSC 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.
HSC 1418.91 (b) A failure to comply with the requirements of this section shall be a class "B" violation.
On September 21, 2017, at 11 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to an allegation of abuse.
It was determined the facility failed to report to the California Department of Public Health (CDPH)immediately, or within 24 hours, an incident of an allegation of abuse for one patient (Patient A). Failure to notify CDPH had the potential to place all the patients in the facility at risk for harm from physical abuse.
On September 21, 2017, at 11:50 a.m., Patient A was interviewed. He stated he was hit on the head by three different patients (Patient B, C, and D) on different occasions. Patient A stated on one occasion the police came in to investigate. He stated the incident happened again, and he told the Social Worker (SW). Patient A stated the staff were supposed to make sure the three patients would not be able to go inside his room. He stated the staff allowed the female patient (Patient B) to use his bathroom. Patient A stated the female patient would sit on top of him and hit him.
On September 21, 2017, at 12:16 p.m., the SW assistant was interviewed. She stated Patient A had verbalized incidents of being beaten up by two patients (1 female and 1 male) usually during night shift. The SW assistant stated Patient A verbalized the same issue of being hit by the same patients a few days ago (she said Tuesday, September 19, 2017). She stated yesterday (September 20, 2017), Patient A approached her and requested for her to remind the nursing staff to monitor and ensure the patients would not go into his (Patient A) room. The SW assistant stated Patient B needed redirection related to using different bathroom. She stated she caught Patient B several times going in and coming out from another patient's bathroom.
On September 21, 2017, Patient A's record was reviewed. Patient A was admitted to the facility on May 22, 2017, with diagnoses which included schizophrenia (severe brain disorder in which people interpret reality abnormally). Patient A's licensed personnel progress notes dated August 30, 2017, indicated, "Resident (Patient A) has verbalization again that he's being beat up every day by other people, resident (Patient A) has previous history of verbalization of being beat up...ombudsman was made aware by DON (Director of Nursing), communicated to IDT (interdisciplinary team) & (and) administrator."
There was no documentation related to Patient A's verbalization of being hit by other patients on September 19, 2017 (Tuesday date).
There was no documented evidence of Patient A's allegation of physical abuse as reported to the SW assistant on September 19, 2017, had been investigated and reported to the administrator.
On September 21, 2017, at 1:42 p.m., the RN (Registered Nurse) Supervisor was interviewed. She stated the incident related to Patient A's allegation of being hit by other patients on August 30, 2017, was investigated, and the copy of the investigation was provided to the DON. The RN Supervisor was not aware of the same incidents involving Patient A and other patients after August 30, 2017. She stated if there was a report of another allegation, the incident would have been investigated and the interventions reevaluated.
On September 26, 2017, at 3:21 p.m., the Administrator was interviewed. He stated the first incident of Patient A's allegation of physical abuse against the two patients was not reported to the Department because according to the DON, the incident was related to Patient A's behavior of hearing voices. The Administrator stated Patient A had the same behavior prior to this incident. He stated the incident (allegation of being hit by two patients) which was mentioned by the SW assistant on September 21, 2017, (happened September 19, 2017) was never reported to him, and no investigation was submitted to him related to the incident. The administrator agreed the regulation indicated for the facility to report all allegations of physical abuse and to provide results of the investigation to the state agency.
On September 27, 2017, at 4:26 p.m., the Administrator was asked to verify missing components from the facility abuse policy and procedures. He stated the investigation should be provided to the administrator within 24 hours of reported abuse. The Administrator stated he designated the SW Director last Thursday (September 21, 2017) to investigate the second allegation which was reported by Patient A to the SW assistant on September 19, 2017. He stated he had not received the complete investigation.
On September 28, 2017 (10 days after Resident A's allegation of physical abuse was reported to SW assistant), the SOC 341 (form used to report abuse) documentation related to Patient A's allegation of physical abuse was faxed to the Department by the facility.
The facility policy and procedure was reviewed. The policy titled, "Reporting Abuse to Facility Management," revised April 2010, indicated, "...It is the responsibility of our employees, facility consultant, Attending Physicians, family members, visitors...to promptly report any incident or suspected incident of neglect or resident abuse...to facility management...The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse...A completed copy of documentation forms and written statements from witnesses, if any must be provided to the Administrator within 24 hours of the occurrence of an incident of suspected abuse. An immediate investigation will be made and a copy of findings of such investigation will be provided to the Administrator within 3 working days of the occurrence of such intent..."
The policy titled "Abuse Investigation," revised April 2010, indicated," ...The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman and others as may required by the state or local laws, within five (5) working days of the reported incident..."
According to Code of Federal Regulations 483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
Therefore, it was determined the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an allegation of abuse by Patient A.
The failure of the facility to report an allegation of abuse placed all patient's health, safety, and security in potential danger. |
| 250000026 |
Corona Post Acute Center |
250013521 |
B |
3-Oct-17 |
S1QE11 |
17007 |
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
On May 31, 2017, at 10:10 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care issue.
During the investigation, it was determined Resident A had fallen out his wheelchair on May 9, 2017, and complained of severe and unresolved left hip pain for seven days before the resident was transferred to an acute care hospital. Resident A was diagnosed with a left hip fracture, had to undergo surgery to repair the fracture, and required hospitalization for four days after surgery.
On May 31, 2017, Resident A's record was reviewed. Resident A, a 73 year old male, was admitted to the facility on May 3, 2017, with diagnoses that included stroke with left sided weakness and generalized muscle weakness.
Resident A's physician admission orders, written on May 3, 2017, were to "...Monitor Level of Pain Q (every) Shift (Scale 0-10): (0 = No pain, 1-3 = Mild pain, 4-5 = Moderate Pain, 6-9 = Severe pain, 10 = Excruciating Pain). The orders included acetaminophen (Tylenol) Tablet 325 MG (milligrams) two tablets by mouth every 4 hours as needed for mild pain 1-3/10 and Norco tablets 5-325 mg (hydrocodone-acetaminophen) one tablet by mouth every six hours for moderate pain of 7-10/10.
A review of Resident A's facility record titled "HISTORY AND PHYSICAL," dated May 6, 2017, indicated Resident A had the capacity to understand and make decisions.
Resident A's facility record titled "PHYSICIAN'S PROGRESS NOTES," dated May 9, 2017, indicated, "Called by nursing staff about the patient's fall on his R (right) hip. Patient complained of increased pain that has not been relieved by current meds (medications). X-ray was ordered & pain medications were adjusted. The patient was noted not to have fracture after all. Will continue to monitor patient & enforce fall precautions."
Resident A had a care plan developed and titled, "actual fall on 05/09/2017 getting up unassisted, poor safety awareness forgetting to lock wheelchair." The care plan was initiated on May 9, 2017, and indicated that facility staff was to monitor for signs and symptoms of pain and discomfort and to call the doctor.
Further review of Resident A's facility record titled "Nurses Progress Notes," and dated May 10, 2017, revealed the following entries written by licensed nurses (LN):
5/10/2017 06:47 (6:47 a.m.)...?Pt (patient) has been medicated for pain on PM shift per MD (medical doctor) orders and Pt states it is not effective. Pt later was heard to be calling out for help and than (sic) started dry heaving. NP (nurse practitioner) was at the facility and saw pt, it was stated to me Pt is "detoxing" from Drug use. PT has no tremors, no hyperthermia (high body temperature) or constant N/V (nausea/vomiting). Pt is alert and orientated (sic) and able to make needs known at this time Pt has been placed in high fowlers (sitting upright in bed) at this time with no N/V and at this time he is laying (sic) in bed with eyes closed supine (lying on the back). Pt was later heard vomiting. Pt was attended to and had vomited aprox (approximately) 200 cc (cubic centimeters ? about seven ounces) green bile-like vomitus; MD notified, new orders received and carried out for Zofran (medication for nausea and vomiting) 4 mg IM (intra-muscular injection) given and tolerated well and effective. Pt has been yelling out all night continuously gagging. Pt has been given an order of one time Haldol (medication used for sedation associated with behavioral problems) 5 mg/ml IM per MD orders and tolerated well, effectiveness shown after 2 hours for Haldol...?
The acute care hospital?s record titled ?History and Physical,? dated April 27, 2017, indicated a medical history of intravenous drug abuse in the past.
On May 9, 2017 (day of Resident A?s fall), Norco 10-325 mg (1 tablet) was ordered one time only and given. No other pain medications were ordered nor given.
5/10/17, at 1:14 a.m., indicated, Topic: fall Assessed resident.
5/10/2017 13:22 (1:22 p.m.)...IDT (interdisciplinary team) met to discuss 05/09/2017 s/p (status post ? after) fall. Resident attempted to transfer by himself but forgot to lock wheelchair...monitor for s/s (signs and symptoms) of pain and discomfort..."
At 1545 (3:45 p.m.) the LN documented, "resident was alert, pupil responsive to light, able to move right and left arm, right leg, but pain to move left leg/hip."
1815 (6:15 p.m.) the LN documented, "x-ray tech came and performed x-ray."
1830 (6:30 p.m.) the LN documented, "PRN pain medication gave (sic)."
At 1930 (7:30 p.m.) The NP assessed resident and ordered a one time dose of Norco 10/325 (mg) and Xanax 0.5 mg to be given for pain and anxiety.
2015 (8:15 p.m.) the LN documented, "able to move right and left arm, right leg, but in pain to move left leg/hip."
2030 (8:30 p.m.) the x-ray results were back and a copy was sent to the NP
2215 (10:15 p.m.) The LN documented, "able to move right and left arm, right leg, but in pain to move left leg/hip."
5/11/2017 05:29 (5:29 a.m.)...COC (change of condition) for unauthorized MED (medication) being monitored d/t (due to) narcotics being found in pt belongings. Pt has only asked for pain MED x (times) 1 on shift...
5/13/2017 23:24 (11:24 p.m.)...resident complained that the Norco 5/325 mg PRN Q 6 h (as needed every 6 hours) wasn't effective and needed a more frequent time. NP (nurse practitioner's name) was notified and order for Norco 10/325 mg PRN q4h (every 4 hours) was made. Hes (sic) in bed at this time at the lowest position with call light within reach...
5/15/2017 11:32 (11:32 a.m.)...IDT Progress Notes...IDT met to discuss resident noted to have home medication at bedside that appears to be pain medications, Resident stated that it was left from his jacket upon admission but was not declared during inventory. Resident with history of pain seeking and drug abuse. MD and family notified...?
On May 15, 2017, a care plan titled "Intractable pain on lower back, left hip and left thigh was developed due to Resident A's comminuted (bone broken into pieces) left intertrochanteric (area between upper and lower thigh bone) femoral neck fracture with mild displacement and mild degenerative changes. The care plan indicated that, "Resident is at risk for further spontaneous fracture d/t (due/to) degenerative changes with osteopenia (a decrease in the amount of bone mineral density,)" The plan indicated facility staff was to monitor for signs and symptoms of pain and efficacy of treatment and to notify the doctor if pain was unrelieved.
Late entry 05/16/2017...IDT met regarding resident results of x-ray done 05/15/2017 Has acute comminuted left intertrochanteric femoral neck fracture and mild displacement with mild degenerative changes with osteopenia. Resident with recent fall on 05/09/2017 with x-ray done showing no fracture post (after) fall ....osteopenia, which will be risk factors for further falls with injury and spontaneous fracture. Resident on 05/15/2017 noted to have decline while in rehab d/t to excessive pain, affected area was immobilized until further evaluation and pain assessment and management initiated...Resident was transferred to hospital for further treatment per MD order..."
Resident A's facility record titled "MEDICATION ADMINISTRATION RECORD" for May 2017, was reviewed and indicated the following severe pain levels (0=no pain, 10=severe pain), from the day of Resident A's fall on May 9, 2017, until May 15, 2017, when the resident was transferred to the acute hospital six days later:
-May 9, 2017 (3-11 pm shift) 8/10, (11-7 am shift) 7/10
-May 10, 2017 (3-11 pm shift) 5/10, (11-7 am shift) 10/10
-May 11, 2017 (3-11 pm shift) 5/10, (11-7 am shift) 7/10
-May 12, 2017 (3-11 pm shift) 5/10, (11-7 am shift) 8/10
-May 13, 2017 (3-11 pm shift) 8/10, (11-7 am shift) 7/10
-May 14, 2017 (3-11 pm shift) 8/10, (11-7 am shift) 7/10
-May 15, 2017 (3-11 pm shift) 9/10
Resident A?s ?MEDICATION ADMINISTRATION RECORD,? indicated Resident A?s baseline pain level prior to the fall was decreased prior to the fall. From May 5, 2017, until May 8, 2017, the Resident?s pain level was 0/10 during the night shifts. From May 4, 2017, until May 8, 2017, during the day shifts, the Resident?s pain level was 0/10, except for May 7, 2017, which was 5/10.
The back of Resident A?s "MEDICATION ADMINISTRATION RECORD," was reviewed which called for a numeric pain scale. There was no documented numeric pain scale evidence regarding the effectiveness of the Norco given to the resident. The record indicated the pain medication was "helpful" in multiple entries on the record, but ?helpful? was not defined with a number.
On May 31, 2017, at 2:52 p.m., the Director of Nursing (DON) was interviewed. The DON stated when residents were in pain, the nurses would try non-pharmacological interventions first. She said the nurses should check for pain effectiveness using a numeric pain scale. If the pain levels were consistently 6-10, severe pain levels, then the nurses should call the doctor.
The DON stated Resident A was negative for hip fracture during the fall of May 9, 2017. He continued to experience pain, and another x-ray was ordered on May 15, 2017. The results showed a left hip fracture. The DON stated the nurses should document and assess Resident A's pain using the pain scale. She further said the doctor would order pain medications one time only. The DON stated Resident A had a history of narcotic dependence.
On June 8, 2017, the acute hospital records were reviewed. The acute care hospital records titled "ED (Emergency Department) Physician Record" and dated May 16, 2017, indicated:
"The patient presents with left hip pain. The onset was 1 weeks (sic) ago. The course/duration of symptoms is constant. Type of injury: fall. Location: Left hip. The character of symptoms is pain...male was brought in by ambulance from a convalescent home and presents to the ED complaining of left hip pain, onset 1 week ago after he missed his wheelchair and fell. Pt has been lying in bed since his fall and had an x-ray today which showed an upper femoral head (hip) fracture. Left hip pain is rated 10/10 in severity. Pt denies new trauma since his fall ...Pt was given 15 of morphine (morphine sulfate extended release) 15 mg from the facility's medications and 2 mg of Vicodin (Norco tablet 10-325 mg) en route by (EMS Emergency Medical Services)..."
A review of Resident A's acute hospital record titled "Operative Reports," dated May 17, 2017, indicated a surgical procedure was performed. The surgical procedure indicated "Hip Trochanteric Fixation Nail, LEFT INTRAMEDULLARY NAILING, Left LONG ."
On June 28, 2017, at 1:23 p.m., Resident A's family member (FM) was interviewed. The FM said Resident A was paralyzed on one side, and fell while attempting to get into his wheelchair. The FM said Resident A's wheelchair was not locked so he fell and hurt his hip. The FM stated Resident A ?was yelling for a nurse? after the fall. The FM said facility did an x-ray that day and it was negative for a fracture, but he complained of severe pain for one week. The FM stated the nurses thought he was ?only drug-seeking? but he was in ?severe pain? and needed pain medications.
The FM further stated Resident A was ?screaming in pain? because of a possible fracture the next day after the fall. The FM talked to a nurse that night and the nurse ?only gave him a sedative (Haldol was ordered one time only on May 9, 2017).? The FM stated Resident A really needed pain medication for the fracture. The FM stated one week later, she showed the nurses Resident A's ?one leg was more swollen than the other? and his knee was very swollen. That was when the facility decided to order another x-ray. The FM stated Resident A was transferred to the hospital after one week of severe pain.
On July 18, 2017, at 9:52 a.m., Resident A was interviewed by phone as he was at home. Resident A stated he had a stroke and was admitted to the facility to get rehabilitated. He said shortly after his stay began at the facility, he fell and broke his hip. Resident A stated the facility ?was not handling his severe pain.? Resident A stated ?the nurses looked at him and laughed when he was screaming? in pain the day following the fall. Resident A further stated the nurses said he was negative for a hip fracture and they were giving him Norco for pain. Resident A stated Norco was "doing no good" for his severe pain. Resident A stated he ?could not stand the pain? and the doctor was not answering the nurses' page.
Resident A stated the nurse practitioner did not come to evaluate his continued and consistent pain after the fall.
Resident A stated one nurse ?just laughed at me? and stated they "already took an X-ray so stop it. You are lying. Nothing is wrong with you." Resident A stated the first x-ray did not show a fracture. Then seven days later, the facility agreed to do another x-ray. Resident A stated he was screaming in pain and ?really wanted to be transferred to a hospital? for an immediate evaluation after the fall.
On July 18, 2017, at 11:29 a.m., the Nurse Practitioner (NP) was interviewed. The NP stated Resident A's ?case was an unusual one? because he had a history of drug and heroin abuse. The NP stated, ?The nurses made their own judgements and tended to ignore his pain during that time.? The NP stated Resident A ?was very upset? and the nurses should have addressed his severe and consistent pain levels.
The NP stated he ?was on call 24 hours a day,? and if Resident A was complaining of pain levels of ?5-10 consistently for seven days,? then Resident A should have been evaluated sooner and transferred to an acute care hospital. The NP further stated, ?The nurses should not wait until Resident A's pain level was 10/10.?
The NP stated, ?The facility should make the resident as pain free as much as possible.? The NP stated the facility tried to medicate him only once at a time because they did not want to overdose him. The NP stated the nurse "disregarded his pain because of a negative X-ray." The NP stated he ?would take this complaint up to Administration? at the facility.
On May 31, 2017, the facility's policy titled "Pain Assessment and Management," revised March 2015, had been reviewed. The policy indicated:
"The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain...
General Guidelines...
"Pain management" is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals...
Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in level of chronic pain...
Monitoring and Modifying Approaches...
Monitor the following factors to determine if the resident's pain is being adequately controlled...
The resident's response to interventions and level of comfort over time...
The status of the underlying cause(s) of pain...
Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g., approved pain scales, etc.) and relevant criteria for measuring pain management (e.g., target signs and symptoms)...
Reporting...
Report the following information to the physician or practitioner...
Significant changes in the level of the resident's pain...
Prolonged, unrelieved pain despite care plan interventions..."
Therefore, Resident A?s fall from his wheelchair on May 9, 2017, resulted in severe and unresolved left hip pain before the resident was transferred to an acute care hospital one week later where he was diagnosed with a left hip fracture, had to undergo surgery to repair the fracture, and had continued hospitalization for four days after surgery.
The facility?s failure to ensure Resident A?s unresolved and severe pain was addressed had direct or immediate relationship to the health, safety, or security of patients. |
| 060001652 |
CASA DE YORBA LINDA |
060013489 |
B |
13-Sep-17 |
CDGI11 |
7037 |
W331 - The facility must provide clients with nursing services in accordance with their needs.
Review of the facility's undated Policy and Procedure (P&P) titled Job Description for Registered Nurse showed the Registered Nurse Consultant (RNC's) responsibilities included:
- Provide a minimum of one hour of nursing service per client, per week to the facility.
- Assess the client health needs and coordinate community medical resources to obtain services needed.
- Supervise training to direct care staff in the areas of medication, observation, reporting, infection control, and certify the proficiency of staff to administer drugs.
- Notify the attending physician immediately of any sudden and or marked adverse change in signs, symptoms, or behavior exhibited by a client.
- Complete documentation as required for all nursing services provided each client, including the admission and discharge information.
Review of the facility's undated P&P titled Availability of Nursing Services in accordance to the Client's Needs showed the RNC will provide the following:
- "Direct physical examination as needed"
- "Review of client's health status for those clients' protective and preventive health measure..."
Clinical record review for Client 3 was initiated on 8/2/17.
Client 3 was admitted to the facility on 8/6/99, with diagnoses including severe intellectual disability (an individual with an Intelligence Quotient of 25 to 40) and seizure (a medical condition associated with a sudden surge in electrical activities of the brain affecting how a person appears or acts for a short time).
Review of Client 3's Special Incident Report dated 5/9/17, showed:
- Direct Care Staff (DCS) 3 "performed body check and noticed a cut on [the client's] right foot toe" on 5/9/17 at around 0100 hours.
- The client stated to DCS 3 he got a cut because "he fell."
Review of Hospital 1's Patient Education and Visit Summary record dated 5/9/17, showed Client 3:
- arrived at the hospital on 5/9/17 at 1924 hours (18 hours after the fall), with a complaint of "right toe injury, unknown cause, caregiver reports bruising/swelling worsened remarkably since this morning."
- symptoms of toe fracture included "bruising, stiffness, numbness...or blood beneath the toenail."
Review of the client's x-ray result dated 5/9/17, showed "moderately displaced fourth proximal (close to the center) phalanx (toe bone) fracture."
Review of the client's Doctor's Visit Documentation dated 5/11/17, showed:
- "Reason for visit: ...closed fracture of proximal phalanx of toe of right foot, contusion (bruise) of right foot, laceration (a break in the skin because of an injury) of fourth toe of right foot..."
- "Impression: [fracture] of right toe and abrasion (skin scrape) on right second toe."
On 8/2/17 at 1200 hours, during an interview, the Administrative Assistant (AA) stated the Facility Manager (FM) reported to her the client had a fall incident on 5/9/17 around 0100 hours, and the client had a cut to his right toe. The AA stated she reported the incident to the RNC that morning, but the RNC did not come to assess the client's condition that morning before the client went to the Day Program. The AA stated when the client returned from the Day Program around 1630 hours (approximately 15 hours after the fall incident had occurred), DCS 1 noted the client's right toe was swollen and bruised. DCS 1 reported this to the AA. The AA stated she then took the client to Hospital 1's Emergency Room (ER) per the physician's order at around 1900 hours.
On 8/2/17 at 1300 hours, during a telephone interview, DCS 3 stated on 5/9/17 around 0100 hours, he was in another client's room when he heard a noise coming from Client 3's room. He went to Client 3's room and found the client lying on the floor; the client was unconscious, wet, and having a seizure. DCS 3 stated the client regained consciousness when DCS 3 started turning the client on his side. DCS 3 stated he noted there was blood on the floor; he then checked the client for injuries and noted a "little deep cut" on his right toe. DCS 3 stated he reported the fall incident to the FM and AA at 0700 hours (six hours after the incident had occurred). DCS 3 stated he did not report the client's condition and injury to the RNC on 5/9/17.
Review of Client 3's Nursing Care Plan titled Fall Risk dated 6/20/17, showed one of the interventions was for the staff to "report any falls to Registered Nurse (RN) or Qualified Intellectual Disability Professional (QIDP)."
Review of the client's Nursing Care Plan titled Potential for injury related to history of seizure episodes dated 8/17, showed:
- An objective included the client would "remain free of injury."
- Staff was to "notify nurse immediately."
- Staff was to "document seizure episode as instructed."
During an interview on 8/2/17 at 1420 hours, the RNC stated she received a report from the AA regarding Client 3's fall incident in the morning of 5/9/17. The RNC stated she did not come to assess the client and his injury on 5/9/17. The RNC stated when the AA informed her about the swelling and bruising on the toe after the client returned from the Day Program, the AA had already arranged to take the client to Hospital 1's ER.
On 8/2/17 at 1430 hours, a clinical record review and concurrent interview was conducted with the RNC. Review of Client 3's Nursing Assessment record dated 5/17 (no day specified), showed "toe laceration from hitting bed frame..." When asked what the exact date this nursing assessment was conducted, the RNC stated she came to see the client and conducted her nursing assessment on 5/11/17 (two days after the incident had occurred).
On 8/2/17 at 1515 hours, clinical record review and concurrent interview was conducted with the AA. Review of the client's Nurse's Notes, Nursing Assessments, and Nursing Care Plans failed to show the nursing assessment was conducted by the RNC to address Client 3's health condition after the fall incident on 5/9/17, and after his injury had become worse and the nursing interventions, treatments, and preventative measures were provided to the client to ensure his condition had not worsened.
The facility failed to ensure the DCS had informed the RNC immediately on Client 3's fall incident on 5/9/17 at 0100 hours. The RNC failed to promptly assessed Client 3 when she was informed Client 3 was found on the floor unconscious on 5/9/17, with a laceration on his toe and transferred to the acute care hospital on 5/9/17 at 1924 hours, due to bruising and swelling of his toe. The RNC conducted the nursing assessment on 5/11/17, two days after the incident had occurred. These failures resulted in Client 3 not having diagnostic tests of the injury and did not receive treatment for the injury for 18 hours.
The above violations, either jointly, separately, or any combination had a direct or immediate relation to patient health, safety, or security. |
| 250000553 |
CONNER RESIDENCE |
250013542 |
B |
19-Oct-17 |
50N911 |
4558 |
W 331- 483.460 (c) Nursing Service provided according to needs.
The facility must provide clients with nursing services in accordance with their needs.
Based on observation, interview and record review, the facility failed to provide Client 12 with nursing assessment and health care when:
1. Client 12 had inadequate or lack of meal intake from August 1 through 13, 2015;
2. The client had a severe weight loss of 16.8 pounds, 11.6 % of her body weight from June 20 to August 8, 2015; and
3. There was no nursing assessment of the client's nutritional status, nursing interventions to slow or stop the weight loss, or training for direct care staff (DCS) on documenting the client's nutritional intake.
On August 13, 2015, at 12:20 p.m., an onsite visit was made to the facility to investigate a report of an episode of self-injurious behavior (SIB) by Client 12.
Client 12 was admitted to the facility on March 19, 2014, with diagnoses of mild intellectual disability, autism (a neurological and developmental disorder that affects how a person acts and interacts with others), and bipolar disorder (mood swings).
On August 13, 2015, at 1:30 p.m., a record review and concurrent interview was conducted with Direct Care Staff (DCS) 3, regarding Client 12's behaviors and food intake. DCS 3 stated that since August 10, 2015, Client 12 had been ?sleeping all the time.? She stated Client 12 had refused to eat all day that day (August 10, 2015). DCS 3 stated, ?She was given Ensure,? (a liquid nutritional supplement). DCS 3 stated that, from August 7 through August 10, 2015, the client would ?sleep all the time,? except in the evening when the client would ?sit on the dining room floor for two to three hours."
The August 2015 facility document titled, "Eating % (percent) Food Eaten," was reviewed. The form indicated Client 12 refused all her meals on August 1, 8,10,11,12, and 13, 2015. She ate only a portion of one meal daily on August 2, 3, 6, 7, and 9, 2015.
The Medication Administration Record (MAR) indicated Client 12 received nutritional supplement once daily on August 2, 4, 6, and 7, 2015; twice daily on August 3, 11, 12, and 13, 2015; and three times daily on August 8, 9, and 10, 2015.
The MAR did not include the time and amount of the supplements given to Client 12. The MAR did not indicate the amount of the supplement the client actually consumed.
The facility form titled, "Monitoring: Client 12's whereabouts every 15 minutes," was reviewed specifically regarding Client 12's nutritional intake. The "MAR" and the "Monitoring? information differed from each other, whereby the information did not match up.
The Facility Manager (FM) and DCS 3 were unable to explain or verify the actual amounts of food and fluid intake Client 12 consumed over the previous two weeks. The FM and DCS 3 further stated Client 12 sometimes had a snack, but there was no indication if snack was given, what the snack was, or if the client consumed the snack.
On August 13, 2015, and September 10, 2015, the facility, "Monthly Weights and Vital Signs,? form for Client 12 was reviewed and indicated the following:
June 20, 2015: 144.8 pounds
July 18, 2016: 136.4 pounds (a weight loss of 8.4 pounds or 5.8% in one month, a severe weight loss).
August 1, 2015: 129.2 pounds (a weight loss of 7.2 pounds, or 5.3% in two weeks).
August 8, 2015): 128 pounds (a 1.2 pound weight loss in seven days).
Client 12 had a severe weight loss of 16.8 pounds (11.6%) in one and a half months.
On August 13, 2015, at 2:25 p.m., an interview was conducted with the facility Registered Nurse (RN), regarding the nursing assessment and plan of care for Client 12's rapid weight loss and food intake documentation. The RN stated, "I last saw her (Client 12) on Tuesday, August 11th (2015). No one's told me since about her not eating."
The RN failed to implement a nursing care plan to assess, monitor, and attempt to reverse Client 12's continued weight loss. In addition, the RN did not provide training to the DCS for accurately recording the specific foods provided to and consumed by Client 12. The DCS was not provided with guidance on when to notify the RN of weight losses. As a result, Client 12 experienced severe weight loss totaling 16.8 pounds or 11.6 % in approximately six weeks without any interventions to slow or stop the weight loss.
This violation of the regulations had a direct or immediate relationship to the health, safety, or security of the patient. |
| 630010977 |
CIRCLE OF CARE ICF/DD-N |
070013622 |
B |
27-Nov-17 |
DJ2N11 |
3434 |
W104 GOVERNING BODY
CFR(s): 483.410(a)(1)
The governing body must exercise general policy, budget, and operating direction over the facility.
The facility failed to follow their policy and procedures on accident/incident for Client 6 when Client 6 had an accident with injury. On 7/24/17 during a van transit, Client 6's wheelchair tilted to the right side and caused him to hit his head and body on the wall of the van, and sustained an injury on his right earlobe, right elbow, and a bump on the right side of his head. He was transferred to an acute care hospital and required sutures of his right earlobe injury. This failure compromised Client 6's health and safety.
Client 6's comprehensive functional assessment (CFA, an assessment tool) dated 12/10/16 indicated he was admitted with diagnoses including mild intellectual disability and muscle weakness. He responded appropriately to questions and conversations. He required assistance with activities of daily living.
During record review on 11/7/17, a special incident report dated 7/25/17 indicated while the van driver was making a right turn onto a street, Client 6's wheelchair tilted to the right side and caused the client to hit his head and elbow on the wall of the van. Client 6 sustained a right earlobe injury, abrasion to his right elbow, and a bump on the right temporal area (a part of the head). Client 6 was transferred to an acute care hospital.
The nurse's notes dated 7/24/17 indicated the registered nurse (RN) received a call from the day program (DP, a program that provides social interaction, engagement, learning objectives, and medical supervision) staff that Client 6 had an accident during a van transit on the way to the DP. Client 6 sustained an injury on his right earlobe, a bump on the right side of his head, and abrasion on the right elbow. Sutures were required for his right earlobe injury.
During an interview and record review on 11/8/17 at 4:00 p.m., the RN stated on 7/24/17 the DP staff called her regarding Client 6's accident during a van transit and the client was transferred to an acute care hospital for suturing of his right earlobe cut. The RN stated she did not go to the DP to conduct a thorough investigation of the accident. The RN stated she did not conduct a thorough investigation of the accident upon Client 6's return to the facility. The RN confirmed she did not assess Client 6 and no care plan was developed for the incident and injuries. Furthermore, there was no evidence of 72 hour follow-up notes after the accident was done.
The facility's undated policy and procedure, "Accident or Incidents" indicated, Accidents involving clients shall be charted in detail on the client's chart including disposition and follow-up care. Fill out an incident report form and submit to the administrator for review. Upon an injury to the clients, the licensed nurse or direct care staff should make an assessment/observation of the incident.
The facility's policy and procedures, "Unusual Occurrence Accident/Incidents" indicated, the licensed nurse should perform an assessment for a minimum of 72 hours and continue as necessary.
The facility failed to implement the above policy and procedures to investigate Client 6's accident, follow-up the incident, and develop an appropriate plan of care.
The above violation had a direct relationship to the health, safety, or security of clients. |
| 630013691 |
Chateau Residential Care |
960013139 |
B |
24-Apr-17 |
5VIL11 |
3531 |
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 1/20/17, an unannounced visit was made to the facility to conduct an initial certification survey.
Based on interview and record review, the facility?s administrative staff failed to:
Ensure the criminal 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 2 clients (Clients 1 and 2), who reside in the facility. This failure had the potential for not ensuring the safety and well-being for the clients.
A review of Client 1's clinical record, indicated the client was admitted to the facility on 7/12/16 with diagnoses that included moderate intellectual disability (noticeable developmental delays), anxiety (a feeling of worry, nervousness or unease) and paranoid schizophrenia (delusions/false beliefs that a person or some individuals are plotting against them or members of their family).
A review of Client 2's clinical record, indicated the client was admitted to the facility on 10/5/16 with diagnoses that included severe intellectual disabilities (considerable delays in development) and schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions).
Further review of the Clients? medical records, indicated both Client 1 and 2 were dependent on staff for all activity of daily living including walking, transferring, eating and toileting.
On 1/24/17, at 10:30 a.m., a review of new employee files indicated Staff A was hired as a direct care staff (DCS, non-license care giver) on 12/31/16 and Staff B was hired as a DCS on 2/19/16.
Further review of the new employee files, indicated there was no documented evidence that the facility had submitted fingerprints to the DOJ for the purpose of obtaining a criminal record clearance for Staff A and B.
On 1/24/17, at 11:00 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 fingerprint cards were not on record (not submitted).
On 1/24/17, at 12:35 a.m., during an interview with the facility?s Administrator/Qualified Intellectual Disabilities Professional (ADM/QIDP) regarding Staff A?s and Staff B?s fingerprint cards, she stated she was not aware that the fingerprints for criminal background check for Staff A and Staff B have not been submitted to the DOJ.
A review of the facility?s undated policies and procedures titled ?Fingerprints/Live Scan,? indicated upon being hired, all employees that work directly with the clients must complete their live scan (electronic fingerprints) for ?obligation clearance?.
The facility?s administrative staff failed to ensure the criminal clearance for Staff A and Staff B were submitted to the DOJ prior to providing care for Clients 1 and 2, who reside in the facility. This failure had the potential for not ensuring the safety and well-being for the clients.
The above violation had a direct relationship to the health, safety and security of clients. |
| 630013691 |
Chateau Residential Care |
960013147 |
B |
24-Apr-17 |
5VIL11 |
3346 |
Title 22: 76931 (a) (1)
76931. Safeguards for Client?s Monies and Valuable
(a) Each facility to which a client?s money or valuables have been entrusted shall comply with the following:
(1) No licensee shall mingle clients?? monies or valuables with that of the licensee or the facility. Clients? monies and valuables shall be maintained separately and intact and free from any liability that the licensee incurs in the use of the licensee?s or the facility?s funds and valuables. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of clients? monies or valuables as theft, as defined by Section 484 of the Penal Code.
On 1/20/17, an unannounced visit was made to the facility to conduct an initial certification survey.
Based on interview and record review, the facility's administrative staff failed to:
Ensure Client 1?s and 2?s personal funds/monies were maintained separately from the licensee?s funds. The facility's licensee/administrator (ADM) kept the clients? personal funds in the facility's business account. This deficient practice placed the clients at risk for financial abuse.
A review of Client 1's clinical record, indicated the client was admitted to the facility on 7/12/16 with diagnoses that included moderate intellectual disability (noticeable developmental delays), anxiety (a feeling of worry, nervousness or unease) and paranoid schizophrenia (delusions/false beliefs that a person or some individuals are plotting against them or members of their family).
A review of Client 2's clinical record, indicated the client was admitted to the facility on 10/5/16 with diagnoses that included severe intellectual disabilities (considerable delays in development) and schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions).
Further review of the Clients? medical records, indicated both Client 1 and 2 were dependent on staff for all activity of daily living including walking, transferring, eating and toileting.
A review of Client 1's and Client 2's ledgers indicated Client 1 has a balance of $ 689 and Client 2 has a balance of $1,326.
During an interview with the facility's ADM, on 1/24/17, at 10:45 a.m., she stated she keep the clients' monies in a bank account. The ADM stated she does not have the bank account statement with her but she has a deposit slip that proved she deposited the clients? monies in the bank account.
A review of the bank deposit slip indicated the ADM deposited the clients' monies in a business checking account. A concurrent interview was conducted with the ADM; she stated the business account was the facility's business account. The ADM further stated she deposited all clients' monies and other monies to run the business in the same account.
The facility's licensee/administrator failed to ensure Client 1?s and 2?s personal funds/monies were maintained separately from the licensee?s funds. The facility's ADM kept the clients? personal funds in the facility's business account. This deficient practice placed the clients at risk for financial abuse.
The above violation had a direct relationship to the safety and security of the clients. |
| 940000074 |
California Post-Acute Care |
940013689 |
A |
19-Dec-17 |
H3QS11 |
10617 |
F314
?483.25 (b) (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that?
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
The Department received a complaint alleging neglect of a resident (Resident 1), who had multiple unstageable wounds on the sacral, left/right heel, left arm, right foot 5th toe, abdominal and right elbow.
F 309
? 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.
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 who enters the facility without pressure sores does not develop pressure sores; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, including but not limited to:
1. Failure to accurately assess Resident 1, who had a high risk for pressure ulcer development.
2. Failure to implement the facility?s policy regarding skin care management.
3. Failure to implement the Resident 1?s plan of care for the use of pressure relieving devices for preventative care.
4. Failure to notify the physician of Resident?s 1?s change in condition, as stipulated in the plan of care.
These deficient practices resulted in Resident 1's developing pressures sores, requiring a transfer to the general acute care hospital (GACH), being admitted for five days with the diagnoses of pressures sores, acute dehydration, sepsis requiring antibiotics, elevated BUN/creatinine, and high blood sugar levels.
A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was a 66 year-old female who was admitted to the facility on 4/19/17 and readmitted on 5/12/17. Resident 1's diagnoses included hypertension (high blood pressure) and diabetes (high blood sugar in the blood).
A review of Resident 1's Significant Change in Status Minimum Data Set (MDS), a resident assessment and care planning tool, dated 5/26/16, indicated Resident 1 was severely impaired in cognitive skills for daily decision-making and had memory problems. The MDS indicated Resident 1 did not ambulate and was totally dependent in care with a one-person physical assist for activities of daily living including toilet use, personal hygiene and bed mobility. According to the MDS, Resident 1 was at risk of developing pressure ulcers, however assessed as not having any.
A review of Resident 1's "Skin Weekly Condition Record," dated 5/13/17 indicated the resident's skin assessment on the coccyx (tailbone) had blanchable (when skin loses redness with pressure) redness.
A review of the facility's document titled, "Skin Weekly Condition Record," dated 6/20/17 indicated Resident 1 was assessed with redness to the coccyx area with excoriation.
A review of Resident 1's "Skin Weekly Condition Record," dated 7/3/17, indicated Resident 1 was assessed with a sacral-coccyx (tailbone with sacrum) intact leathery necrotic tissue (dead tissue) with the length measuring 9.1 centimeters (cm) by 14 cm in width and the depth was unstageable ([UTD] undetermined depth).
A review of Resident 1's "Resident Care Plan Skin," dated 6/27/17, indicated Resident 1 had a sacral-coccyx with UTD pressure injury. The goal indicated the pressure sore will improve by the next review date. The staff's interventions included using a low air loss mattress ([LAL] tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float), physicians notification and applying alginate dressing (highly absorbent, biodegradable alginate dressings derived from seaweed used to cleanse a wide variety of secreting lesions) and cleaning the wound with a wound cleanser.
A review of a Resident 1's care plan titled, "Diabetes Mellitus (high blood sugar)," dated 4/20/17, indicated under interventions that the staff would perform body checks for skin breakdowns and treat promptly.
On 8/11/17 at 12:33 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated once the certified nurse assistants (CNAs) identified any new skin problems, including pressure ulcers, LVN 1 would notify the physician.
A review of the Nurses Progress Note, dated on 6/20/17, did not indicate that Resident 1's primary physician was notified of the change in skin condition as stipulated on the resident?s plan of care.
A review of a Nurse's Note, dated 6/20/17, and timed at 8:20 a.m., indicated Resident 1 was transferred to a GACH) for an episode of hyperglycemia (high blood sugar), temperature of 100.5 Fahrenheit ([F] normal reference range [NRR] is 97.8-100.8 øF) and shortness of breath (SOB).
A review of Resident 1's Skin Weekly Condition Record, at the GACH, dated 6/12/17, indicated redness to coccyx extended to the resident?s buttocks (tailbone).
A review of the GACH's pictures, dated 6/20/17, indicated the left buttocks had two skin tears along the tailbone and redness around the buttocks.
A review of the GACH?s history and physical (H/P) for Resident 1, dated 6/21/17 indicated the resident was brought in to the emergency room due altered mental status and was identified with sepsis, an elevated white blood count of 23.2 (thousands) (NRR=4500-10,000 mcl), an elevated blood sugar of 670 mg/dl (NRR= 70-90) and was admitted for further evaluation. Resident 1 received intravenous (into the vein) fluid due to an elevated BUN of 89 (NRR=10 to 20 mg/dL) and creatinine 2.0 (NRR=.6 mg-1.2). Resident 1 remained in the hospital for five days for wound care, nutrition and infection disease consultations.
On 8/11/17 at 2:10 p.m., during a telephone interview, Resident 1's family member (FM 1) stated that the times she visited the resident, Resident 1 would be sitting on the wheelchair with no pressure relieving devices and/or no special mattress on the bed to prevent the skin from breaking, as indicated in the plan of care for prevention of pressure sores.
On 8/11/17 at 3:56 p.m., during an interview, LVN 2 stated when a pressure sore was identified, the primary physician and the wound physician would be notified of the initiation of pressure reliving devices are implemented. LVN 3 stated the resident?s wound assessment with measurements are performed weekly.
On 8/11/17 at 4:15 p.m., during an interview, CNA 1 stated they are supposed to turn the resident every two hours, but since the facility has been short-staffed, sometimes it takes her four hours to turn the resident. CNA 1 stated she mentioned to the Director of Staff Development (DSD), of how being short-staffed affects the care provided to the residents.
On 8/11/17 at 4:57 p.m., during an interview and record review, Registered Nurse 1 (MDS Nurse/RN [RN 1]) stated that Resident 1's assessment completed on 6/26/17 indicated the sacral-coccyx wound measured length was 9 cm by width of 12 cm by UTD. RN 1 stated that there were no pressure reliving devices ordered for Resident 1. A review of an assessment, dated 7/3/17, indicated there was an increase in the size of the resident?s sacral-coccyx wound to 14 cm x 9.1 cm x UTD. RN 1 stated devices, such as a LAL mattress, should have been ordered for Resident 1.
On 10/13/17 at 5:56 p.m., during a telephone interview, FM 1 stated she had not seen staff turning Resident 1 during the times they would visit and was told by the staff not to turn the resident due to her illness.
On 10/26/17 at 2:12 p.m., during a review and concurrent interview of the GACH's pictures of Resident 1's coccyx area, with LVN 3, indicated the pictures were taken on 6/20/17. LVN 3 stated after reviewing the pictures that Resident 1's coccyx images had redness excoriation and it could have been prevented with a LAL mattress.
A review of Resident 1's physician orders from May 2017 through July 2017, did not indicate an order for a LAL mattress.
On 10/26/17 at 6:20 p.m., during an interview and record review of the GACH's images dated 6/20/17, with the Director of Nurses (DON) she stated that the coccyx area had redness with old scabs that opened possibly due to the resident not being repositioned, moisture, and/or perspiration.
A review of the facility?s policy and procedure titled, "Skin Care Management," dated 2/2005, indicated that when a pressure ulcer was identified, the licensed nurse will document in the progress notes and the Weekly Pressure Ulcer Record. The documentation should include size, stage, location, drainage, odor, and pain and initiation of the care plan and treatment.
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 who enters the facility without pressure sores does not develop pressure sores; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, including but not limited to:
1. Failure to accurately assess Resident 1, who had a high risk for pressure ulcer development.
2. Failure to implement the facility?s policy regarding skin care management.
3. Failure to implement Resident 1?s plan of care for the use of pressure relieving devices as preventative care.
4. Failure to notify the physician of Resident?s 1?s change in condition, as stipulated in the plan of care.
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. |
| 630013324 |
Citrus Home ICF/DD-N |
030013591 |
B |
1-Nov-17 |
26RO11 |
2651 |
Health and Safety Code 1418.91
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The following citation was written as a result of an unannounced visit to the facility on 9/5/17 for the Annual Recertification survey.
As a result of the survey, the Department determined the facility failed to report to the Department a suspected abuse of Client X immediately, or within 24 hours.
Client X was admitted to the facility in September 2012. His diagnoses included moderate intellectual disability, cerebral palsy (damage to the brain that results in difficulty with movement), and spastic quadriplegia (partial loss of range of motion). On 9/5/17 at 10:12 a.m., Day Program Staff 1 (DPS 1) was interviewed. She stated several weeks ago, Client X came to program with a black-eye. She stated he told her it happened at home.
On 9/6/17 at approximately 7:15 a.m. Licensed Nurse 1 (LN 1) was interviewed. She stated about a month ago, Client X and Client Y had a disagreement about the TV which resulted in the clients "laying hands on one another." She stated she did not recall Client X having a black-eye.
On 9/6/17 at 8:25 a.m. Direct Care Staff 1 (DCS 1) was interviewed. She stated she recalled Client X having a black-eye. She stated about a month and half ago Client X and Client Y got into a disagreement over the TV. DCS 1 stated she did not witness the incident but she thought Client Y caused Client X's black-eye.
On 9/7/17 at 11:21 a.m. Client Z was interviewed. He stated about a month ago Client Y and Client X "got into it" over the TV. Client Z stated Client Y started hitting Client X and Client X was hitting back. He stated the staff separated them right away. Client Z stated Client Y gave Client X a black-eye.
Review of Nurse's Notes dated 7/26/17, revealed at 7 p.m. Client X and Client Y got into an altercation.
On 9/11/17 at 10:48 a.m. the Qualified Intellectual Disabilities Professional (QIDP) was interviewed. She acknowledged that about a month and half ago Client X and Client Y were involved in an altercation with one another. She stated no, when asked if she reported the client to client abuse to the Department.
Therefore, the facility failed to report to the Department a suspected abuse of Client X immediately, or within 24 hours.
This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility residents. |