| 020000133 |
Driftwood Healthcare Center - Hayward |
020009605 |
B |
15-Nov-12 |
JH9I11 |
8214 |
T22 DIV5 CH3 ART5-72527(a)(6) 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:(6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record.Patients have the right to be discharged only for medical reasons, or the patient's welfare, or that of other patients or for nonpayment for his stay and to be given reasonable advance notice to ensure safe and orderly discharge. Such actions shall be documented in the patient's health record.The facility violated the aforementioned regulation by failing to follow the policy and procedure for transfer and discharge, and permit Resident 1 to remain in the facility, and not discharge him on 8/16/12 at 10:35 p.m. Resident 1was involuntarily discharged to the street in front of the facility without discharge planning for his shelter, transportation, medication, wound care supplies, meals, or his ability to obtain assistance.Review on 8/20/12, of Resident 1's clinical record, showed he was admitted to the facility on 4/26/12. Diagnoses included above the knee amputations on both legs and phantom limb syndrome (pain experienced as if the missing limbs were still there), lumbago (painful condition of the lower back), insulin dependent diabetes mellitus, and four Stage II pressure ulcers (shallow open ulcers). Resident 1 depended on a staff member for bathing and toilet use.Resident 1 was often incontinent of bowel and had a catheter in his bladder for urine drainage and collection. Resident 1 used a battery equipped wheel chair which required recharging from an electrical outlet.In an interview at 3:45 p.m., on 8/17/12, Resident 1, who is currently living in a Board and Care home, stated that on 8/15/12, he was absent without leave from the facility for approximately one hour, from 9 p.m., until 10 p.m. When he returned to the facility, he was informed that he was being discharged. Resident 1 stated that he told the staff that he did not want to go. Resident 1 also stated that he was escorted from the building at 10:35 p.m., on 8/15/12 by the Sheriff's department and was left on the street by the facility sign. He stated that he remained there overnight, until the following evening, because he didn't know where to go.Review of the Physician orders showed a telephone order dated 8/15/12, at 9:30 p.m. The order reflected, "Resident discharge himself AMA AFA May not release with meds Go to ER if needs help". (against medical and facility advice) In a written declaration, dated 8/23/12, the Resident's daughter, (RP) stated that she received a phone call from the facility at 12:48 a.m., on 8/16/12. The caller told RP that there was an incident at the facility, the police were called, Resident 1 was taken away in an ambulance, and he would not be allowed to return. Later in the day, RP tried to locate Resident 1. She called the facility, and Resident 1 was not there. She called the Sheriff's Department, and was told that Resident 1 was at the facility. The sheriff told RP that Resident 1 was not taken away in an ambulance.RP found Resident 1 around 5 p.m., on 8/16/12, beside the facility's sign. He was slumped over in his wheelchair. Resident 1 was drowsy and extremely puffy in the face, arms and hands and his catheter bag was very full. Resident 1 told her he was in severe pain. RP called 911. Paramedics arrived at 8:38 p.m., on 8/16/12. Resident 1 was on the street for nearly 23 hours before transportation to the hospital by the paramedics. The quarterly Minimum Data Set (MDS - resident assessment) dated 7/3/12, did not show current discharge planning. A care plan, titled, "Community Discharge Potential", dated 7/9/12, reflected that staff were to, "Coordinate discharge plans with the resident and responsible party," and to, "Assist in community referral for continued care."There was no documentation in Resident 1's clinical record to show that Resident 1 or his Responsible Party were given an opportunity to participate in creating a discharge plan addressing his needs for housing, activities of daily living (ADL) care, food, medications, wound care, or safety. There was no documentation in Resident 1's clinical record to show 30 day notice was given. During an interview at approximately 3 p.m., on 9/18/12, the Director of Nursing Services (DNS) stated that the Interdisciplinary Team (IDT) did not assess the post discharge care needs of Resident 1 with the participation of the resident and his Responsible Party (RP). In an interview with RN 2 at 4:11 p.m., on 9/21/12, she stated Resident 1 was escorted to the street at 10:35 p.m., on 8/15/12 without a destination for shelter or a meal plan, transportation, medication (antibiotics for an infection, insulin to reduce blood sugars, pain medication for severe pain) wound care supplies, or a means of contacting anyone for help. RN 2 stated that if Resident 1 did not have a cell phone, he could go to a phone booth to make calls. Review on 8/20/12, of facility policy dated 12/18/02, entitled, "Transfer and Discharge" showed: "Procedure: 4. At least 30 days prior to transfer or discharge, notify the resident and if known, the family member... of the transfer and the reasons for the move. a. Provide the information in writing... b. Explain the resident's right to appeal the transfer/discharge. c. Provide the name, address, and phone number of: -the State long term care ombudsman, -the agency responsible for advocating for individuals [with special needs] 5. Provide preparation and orientation to the resident to ensure safe and orderly transfer/discharge from the facility... -Informing the resident where [s/he] is going; -taking steps to assure safe transportation; -involving the resident and family in selecting the new residence..." During an interview at approximately 4:30 p.m., on 9/25/12 the Director of Nursing Services (DNS) stated that when Resident 1 was being escorted from the facility, on 8/15/12, RN 1 gave him a Post Discharge Plan of Care. The document was not developed with the participation of Resident 1 and the family member as required. The form reflected that Resident 1 had the following nursing needs: wound care; suprapubic catheter care (catheter inserted directly into the bladder through a small hole in the abdomen), medication, and pain management. The document lacked instructions for the current antibiotic prescription; for checking blood sugars, drawing up and giving insulin, catheter care, where to buy wound care and catheter supplies, and where to get his medications. The document did not include information about how to arrange for transportation, meals, a method of recharging the wheelchair battery, and resources for areas in which Resident 1 was dependent on staff, such as care in toileting and bathing. In a space titled, "Procedures you should do", a facility employee wrote, "Go to ER if needs help". The spaces for a pharmacy name and phone number, and community resources, were blank. Therefore the facility failed to: 1. Give reasonable advance notice to ensure safe and orderly discharge. 2. Permit Resident 1 to remain in the facility and not to discharge him, when on 8/15/12, he was involuntarily discharged to the street in front of the facility. 3. Develop a discharge plan of care with the participation of Resident 1 and a family member designed to help Resident 1 adjust to a new home. 4. Issue a written discharge notice containing the required information to the resident and a family member at least 30 days prior to discharging Resident 1. The above violations had a direct or immediate relationship to the health, safety or security of the patient. |
| 020000133 |
Driftwood Healthcare Center - Hayward |
020011051 |
B |
19-Nov-14 |
SRD811 |
4853 |
483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSIONThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility violated the aforementioned regulation when it failed to protect one (Resident 1) of 3 sampled residents from a second assault by another resident (Resident 2) resulting in Resident 1 sustaining nose and mouth bleeding, a bruise on his forehead and on the bridge of his nose.Staff found Resident 2 holding down Resident 1's arm on 6/4/14 and separated them. Resident 2 left the room and returned shortly after and again attacked Resident 1, causing bruises on his forehead and the bridge of his nose, and bleeding near his nose and mouth. On 6/4/14, the facility reported to the Department that on 6/4/14 at 8:30 a.m., CNA 1 observed Resident 2 yelling at his roommate (Resident 1) and holding his hand down in their room. The residents were separated and Resident 2 left the room. Resident 2 returned in a few minutes to his room and when CNA 1 returned to check on the residents, she observed Resident 2 holding one hand near the face of Resident 1. Resident 1 had blood near his nose and mouth. On 6/11/14, Record review showed Resident 1 was admitted on 11/10/12 with a diagnosis of paralysis agitans (a progressive disorder of the nervous system that affects movement).In an interview on 6/11/14 at 10:05 a.m., Registered Nurse 1, (RN 1), was asked to describe the incident between Resident 1 and 2 which took place in their room on 6/4/14. RN 1 stated she was called by CNA 1 (Certified Nursing Assistant), at 8:30 a.m. on 6/4/14 and informed that Resident 2 was holding down Resident 1's arm. RN 1 stated she, "Went to the room and separated Residents 1 and 2. Resident 2 went out of the room and she went to talk to the supervisor about changing their rooms. After 5 minutes, CNA 1 came to me and said that Resident 2 was again holding Resident 1's arm down." RN 1 stated that she again went to the resident's room and talked with Resident 2 about not touching Resident 1 and the need to move him out of that room. RN 1 was asked why Resident 1 was left alone with Resident 2 following the first incident of holding his arm down. RN 1 stated that Resident 2 had, "Gone out for a smoke. No one saw him go back into the room. CNA 1 walked in and saw the second incident and reported it to me.It would have been better if the CNA had been instructed to stay in the room to ensure Resident 1's safety." RN 1 was asked to describe Resident 1's condition following the second incident. RN 1 stated that there was, "Swelling on Resident 1's forehead and bleeding coming from his nose and mouth. There was discoloration on his right arm".In an interview on 6/12/14 at 11:25 a.m., RN 1 was asked to confirm that the bruising and bleeding occurred after the second incident and not the first. RN 1 stated, "Yes, that is correct." In an interview on 6/12/14 at 11:50 a.m., CNA 1 was asked to describe the incident on 6/4/14 between Resident 1 and 2. CNA 1 stated that she saw, "Resident 2 holding down Resident 1's arm. I called the charge nurse. We both intervened and separated them. Then Resident 2 went out of the room. I then left the room and finished seeing the rest of my residents. I circled back and again found Resident 2 holding down the right arm of Resident 1 with one arm and his other hand near Resident 1's face. I asked Resident 2 to stop and took him out of the room." CNA 1 stated that Resident 1 had, "Nose and mouth bleeding. He had a bruise on his forehead and on the bridge of his nose. I did not see this following the first incident." In an interview on 6/12/14 at 12:15 p.m., the Director of Nursing, (DON), was asked why Resident 1 had been left alone following the first assault from Resident 2. The DON stated that Resident 1, "Should not have been left alone." In an interview and concurrent observation on 6/12/14 at 10:50 a.m., Resident 1 was asked if, following the first assault from Resident 2, he felt staff did all that they could to keep him safe. Resident 1 stated, "No." Resident 1 was observed to have bruising in the middle of his forehead and on his arms. Record review of the facility's policy and procedure entitled, Abuse and Neglect Prohibition, and dated 10/2004, showed that each resident has the right to be free from mistreatment, neglect, and abuse. Physical abuse includes hitting, slapping, pinching, and kicking. Therefore, the facility failed to protect Resident 1 from further abuse after an altercation with Resident 2. This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients |
| 020000133 |
Driftwood Healthcare Center - Hayward |
020011230 |
B |
15-Jan-15 |
J9Y311 |
9133 |
483.10(c)(2)-(5)FACILITY MANAGEMENT OF PERSONAL FUNDSUpon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)-(8) of this section.The facility must deposit any resident's personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.)The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund.The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. The facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.The facility violated the aforementioned regulation, by failing to protect the personal funds of Resident 11. Resident 11 had withdrawn money from his personal bank account and had it sent to the facility so that he could set up a trust fund to buy clothes and toiletries. The facility received the funds, cashed the checks and without Resident 11's knowledge, used the money to pay Resident 11's facility share of cost bill. This resulted in Resident 11 becoming very angry, as evidenced by yelling at the nurse's station, because his trust fund was not set up for basic needs that included clothing and toiletries. On 7/22/14, review of the medical record, showed Resident 11, 36 year-old, was admitted to the facility on 3/4/14, with a diagnosis of Paraplegia, (an inability to move his legs). Resident 11 was alert, oriented, and able to wheel himself in a wheelchair. During an interview on 7/22/14 at 12:05 p.m., Resident 11 was asked about his personal belongings. Resident 11 stated that he "Needed clothes. I had sent $1,000 to this facility and I had to wait a long time to get it. It went to the main office. It was only last week that I finally got the money." During an interview on 7/23/14 at 7:30 a.m., the Social Services Director (SSD) was asked about Resident 11's money. The SSD stated that, at the time of admission, Resident 11 asked the SSD how he could transfer his money to the facility so that he could buy things such as shampoo. The SSD stated that she "Directed him to the administrator for a trust fund (an interest bearing account that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account) information. She told Resident 11 that when the money arrives, they would let him know. On 3/7/14, Resident 11 went to the SSD and stated that he had gone to the bank and asked them to send money to the facility. The SSD stated that she told Resident 11, "Let's check with the front office and I asked the front desk to contact me if they received any mail for Resident 11". The SSD stated that on 3/17/14, Resident 11 came to her office and asked for his $500. She told him that this money never came. Resident 11 stated that it should have been at the facility by now. The SSD asked him to call and check with the bank and said that he became upset. He went to the administrator and asked about the money and was showed a piece of paper from the bank that showed that the check was cashed. She said, "On March 21, 2014, the resident [Resident 11] became very upset and was yelling at the nurses' station and asking where his money was. We called the police - 5150." [A 5150 is a section of the California Welfare and Institutions Code, the Lanterman-Petris-Short Act, which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him or her a danger to themselves, a danger to others, and/or gravely disabled.] During an interview on 7/23/14 at 7:55 a.m., the SSD stated that, on 5/14/14, Resident 11 told her that he had another $500 check transferred from the bank to the facility. The SSD stated that, "No one ever knew what happened to the first check. I told the administrator, who was no longer working at the facility, about the second check. The administrator said that the facility had not received the first or second check." During an interview on 7/23/14 at 8:25 a.m., Resident 11's emergency contact, Family 1, was asked about the missing money. Family 1 stated that the facility had told her that they had "Not received the money. I told them that they had to get to the bottom of this. It had been 4-5 weeks since Resident 11 had written the first check. After he wrote the second check, I called the facility and asked them to look out for the second check. This went on for several months. I told the Social Service Director that if this continued, we may have to prosecute. I told her that someone or somehow the facility had cashed the checks. Approximately one month ago [6/23/14], the facility said that they found the money and it had gone into the corporate office. I asked them why it went there since it was for the resident's personal use. He (Resident 11) told me that he needed clothes and he was angry." During an interview on 7/23/14 at 8:55 a.m., the Accounts Receivable Supervisor (ARS) for the facility was asked about the missing money. The ARS stated, "In the beginning, the first check was cashed and it went towards Resident 11's care. He had a balance and no secondary insurance. It wasn't until the second check was cashed in April that I was asked by the SSD if we could give him a refund. I reminded her that we still had a balance due. I then gave the file to our Medical Representative and she expedited Resident 11's application process for secondary insurance. The resident's money then went into his personal trust on 7/10/14 [4 months after the first check had been sent]. During an interview on 7/24/14 at 10:00 a.m., the facility's Director of Patient Advocacy (DPA), was asked about the incident of the missing money. The DPA stated that he had spoken with Resident 11 in May, 2014 and said "I checked his account with the facility. Sure enough, the facility had cashed the checks and processed them as a facility share of cost. We realized this was wrong. The former administrator said that there were no checks made out to the facility. I then went through the ledger with him and showed him that yes, there were checks that had come in and were cashed. Once he saw this he reversed the whole process and we apologized to Resident 11. I was brought into this case in May. I am not sure why it took so long to reverse this". During a concurrent observation and interview on 7/24/14 at 8:45 a.m., Resident 11 was asked how he felt regarding the delay in finding his personal funds. Resident 11 stated that he felt as if he were "Running up against a brick wall. They were telling me that it did not exist. The Social Service Director and the Administrator told me that there was no money. It was rough. They were totally disinterested. I even showed them the bank statements. At the time they called the police on me, I wanted someone to pay attention to me. The administrator and the Social Service Director told me to make the second check out to the facility. They never told me to make it out to myself. I had absolutely no clothes whatsoever. I finally bought sweat pants and shirts yesterday [7/23/14]. It is very important for me to have clothes. It was rough and they never even tried to get me clothes. I asked repeatedly for basic toiletries." Resident 11 was then observed lifting up a new, unopened toothbrush and stated, "I just bought this last night." The facility did not protect Resident 11's personal funds that the resident needed it to buy his clothes and toiletries. Instead, the facility used his personal funds to pay the resident's share of cost without informing him. This caused the resident to become angry and upset to the point of yelling at the nurse's station and asking where his money was. The facility called the police and Resident 11 was sent 5150 to an acute hospital emergency department. This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 020000133 |
Driftwood Healthcare Center - Hayward |
020011522 |
A |
25-Jun-15 |
9GS911 |
7558 |
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 violated the aforementioned regulation, by failing to start an intravenous line and give intravenous fluids when ordered and failing to evaluate the medications for one (1) of 7 sampled residents. Resident 1 had diarrhea, became dehydrated and the doctor ordered an intravenous line to give her fluids, but the facility could not start the intravenous line. Resident 1 continued to receive a diuretic medication, (Lasix) even though her fluid intake was extremely low, resulting in Resident 1 being sent to the hospital on 9/17/14, diagnosed with "C- diff colitis, acute kidney injury due to dehydration likely secondary to diarrhea and medication, low sodium and low potassium likely secondary to dehydration and diarrhea, borderline hypotensive likely due to...dehydration." Resident 1 expired on 9/28/14 due to septic shock, acute kidney injury. Definition: C- diff or Clostridium Difficile- The Centers for Disease Control and Prevention bulletin dated 3/22/11: "Clostridium difficile is a spore- forming bacteria that produces exotoxins (a poisonous substance excreted into the surrounding medium). The main clinical symptoms are watery diarrhea, fever, loss of appetite, nausea, and abdominal pain or tenderness. The diseases that can result from a C- diff infection include colitis (inflammation of the colon), perforation of the colon, sepsis (a system- wide infection) and death. "(Reference: www...cdc.gov/HAI/organisms/cdiff/Cdiff_faq-HCP.hml) On 10/18/14, review of the medical record showed that Resident 1 was admitted to the facility from a hospital on 4/17/14 with diagnoses that included congestive heart failure (CHF), hypertension, and weakness. The complete resident assessment, dated 7/25/14, showed that Resident 1 walked to the bathroom with the supervision of one staff and used a walker, was alert and communicative. The Activities of Daily Living (ADL) flow sheet, documented every shift by the CNAs (certified nursing assistant), showed Resident 1 had a total of six bowel movements on 9/12/14: one on night shift, one on day shift and four on p.m. shift. On 9/13/14: one stool was charted for each of the three shifts. On 9/14/14: two stools on day shift and one on p.m. shift; on 9/15/14: two stools on day shift and one on p.m. shift. On 9/16/14: one stool on night shift, three on day shift and two on p.m. shift.Review of the nurse practitioner's (NP) telephone orders, dated 9/16/14 at 9:30 p.m., showed: "Flagyl 50 mg (milligrams) orally three times per day for C- diff; Start (intravenous) D5NS (5% dextrose in normal saline) at 75 cc. (cubic centimeters) per hour times two liters via peripheral line." A nurses' note, dated 9/16/14 at 11:00 p.m., signed by RN 2, showed, "Received lab results and faxed to NP...Received telephone order from her (NP) to start Flagy for C- diff. LN (licensed nurse) tried to start IV but unsuccessful so called IV nurse...they said they will call us back for ETA (estimated arrival time)."A nurses' note, dated 9/17/14, showed, "Phone call to the NP: Patient complains of urinary retention; Resident is alert and oriented to person, place and time; complains of dizziness. Received order to send to hospital for further evaluation. Increased fluids as tolerated...Resident left the facility with two emergency medical technicians at around 9:45 a.m." During phone interview on 10/15/14 at 9:00 a.m., the DON stated, "There is no documentation that the IV was not started on 9/17/14 and the physician was notified. The RN was unable to start an IV (intravenous) on 9/16/15 and called the contracted IV nurse to come in. There's no documentation that the IV nurse arrived. I don't know if IV fluids were given." During phone interview on 10/23/14 at 9:30 a.m., the NP stated, "They told me she had no urinary output. Her appetite was poor. I was not informed that the IV was not started. I gave the telephone order for IV fluids and antibiotics and to send her to the hospital." During phone interview on 10/28/14 at 10:00 a.m., LVN 3 stated, "When I did rounds at 7:00 a.m. on 9/17/14, she (Resident 1) complained of no urine output. She was on a fluid restriction but I offered her water. She only took a few sips. The RN (registered nurse) assessed her and found no problem. I didn't know about the diarrhea. She must have become dehydrated."During a phone interview on 10/28/14 at 3:15 p.m., RN 2 stated she received the abnormal lab results on 9/16/14 and contacted the NP. When she was unable to start the IV, she called the facility's IV nurse. RN 2 stated, "The IV nurse did not arrive on my shift. I did not inform the NP. I told the next shift nurse about it." Review of the hospital's emergency department records, dated 9/17/14 at 10:03 a.m., showed, "Chief complaint: Patient presents with low blood pressure. Per staff at facility, alert and oriented. Bowel problem- no BM for 3 days. Urinary retention- per staff at facility, no urine for 3 days. Currently being treated for C- diff, started treatment 2 days ago." Resident 1 was on Miralax (one packet daily for treatment of constipation) and Lasix, a diuretic. "Upon placing a Foley (urinary) catheter in the emergency department, immediately drained 500 ml (milliliters, approximately 16 ounces) of dark brown urine." A CAT scan of the abdomen was performed and showed "Probable colitis with thickening involving the ascending colon. This is new. Some thickening of the descending colon." The diagnostic list showed "Colitis, C-difficile colitis, urinary retention, low sodium, low potassium, renal insufficiency, acute kidney injury, and atrial fibrillation."The hospital admission physician wrote an assessment and plan, dated 9/17/14, that showed, "C- diff colitis, acute kidney injury due to dehydration likely secondary to diarrhea and medication, low sodium and low potassium likely secondary to dehydration and diarrhea, borderline hypotensive likely due to...dehydration." The hospital Death Summary, dated 9/28/14, written by a hospital physician, showed, "Principal Problem: Comfort measures only status, cardiopulmonary arrest for minutes, septic shock for days, C- diff for weeks, acute renal failure for days. Active problems: dehydration, acute kidney injury, low sodium, low potassium, sepsis..." In this summary, the hospital physician also wrote that despite all treatment, Resident 1 "continue to deteriorate with worsening leukocytosis, elevated lactate, and renal failure and oliguria, delirium. Also patient being a Jehovah's witness (a religion) and refused surgery and blood products. Palliative consult was obtained and patient was made comfort care and thus transferred to floor on morphine drip." Therefore, the facility failed to follow a nurse practitioner's order to give intravenous fluids to Resident 1 to prevent her dehydration. The facility also failed to re-evaluate Resident 1's medication, which caused Resident 1 to suffer severe dehydration because she was on diuretic medication while she had diarrhea. These failures resulted in Resident 1 dying on 9/28/14 due to complications of dehydration. 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. |
| 100000006 |
Davis Healthcare Center |
030009213 |
B |
10-Apr-12 |
F2RX11 |
8874 |
F205 Notice of Bed-Hold Policy Before/upon Transfer 483.12 (b) (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on a therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies - (i) the duration of the bed hold policy under the State plan, if any, during which the resident is permitted to return to the facility; and (ii) the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b) (3) of this section permitting a resident to return. 483.12 (b) (2): Bed-Hold notice policy and readmission. Bed-hold upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed hold policy described in paragraph (b) (1) of this section F206 Policy to Permit Readmission beyond Bed-Hold 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 policy 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.F 241 Dignity and Respect of Individuality 483.15 (a) The facility must promote care for residents in a manner and an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. An unannounced visit was made to the facility on 7/24/09 to investigate Complaint numbers CA00195147, CA00195440, CA00195523, CA00195336 and CA00196268.The Department determined that the facility failed to:1) Ensure Resident A's 7 day bed hold was honored and failed to provide notice prior to moving him from the room that was his home since 3/22/08.2) These failures resulted in Resident A being denied the dignity and respect residents should receive from the facility.Resident A was admitted to the General Acute Care Hospital (GACH) on 7/11/09 and upon his return to the facility on 7/15/09, 4 days later, he discovered he had been moved from the room that served as his home since 3/22/08.On 7/24/09 at 8:50 a.m., an unannounced visit was conducted at the facility to investigate several complaints related to quality of care/treatment. An interview (confidential) was conducted with Residents E and F. Both residents stated Resident A was transferred to E wing while he was in the hospital. "They (Administration) are known for changing rooms when residents leave and go to the hospital." stated Resident F.On 7/24/09 at 10:22 a.m., an interview was conducted with AS (Administrative Staff) 1. AS 1 stated they expected Resident A to return to the facility and they moved him because they wanted to paint the room. When questioned further, AS 1 stated the painting of the room was not done and two other residents were placed in the room.On 7/24/09 at 10:25 a.m. Resident A's clinical record was reviewed with AS 3. Based upon the documents in the clinical record, Resident A's last room change occurred on 3/22/08 and this change was completed after Resident A was out of the facility for 25 days. The "Bed Hold Notification Form" was signed by Resident A on 9/19/07 and indicated "I desire a bed hold." There were no other "Bed Hold Notification Forms" in the clinical record.Resident A, a 52 year old was admitted to the facility on 9/14/07 with diagnoses that included severe sepsis (blood infection) and paraplegia (inability to move from the waist down). Patient A's 4/7/09 annual Minimum Data Set (MDS - an assessment tool) indicated no memory problems or problems with the ability to understand others and be understood.On 7/24/09 at 11:20 a.m. during an interview with AS 1, she stated the facility is required to give a room change notification when a room change was done. AS 1 was unable to provide documentation indicating a room change notification was given to Resident A. AS 1 also stated Resident A was moved so that the wing, which was close to the rehabilitation department, could be used for short-term rehabilitation patients. AS 1 stated one of the residents placed in the room, Resident C was thought to be short-term and was not "discharged as they originally thought."On 7/24/09 at 11:45 a.m. an interview was conducted with Resident C. Resident C was asked about his move and he stated AS 1 and AS 2 came to his old room and told him that he was being moved. Resident C was given a tour of the room by AS 1 and AS 2 and when he inquired about Resident A, (who had been the previous occupant of the room) AS 2 stated Resident A "had been in this room too long." Resident C stated he felt that he was being used as a "pawn." Resident C also pointed out other residents on this wing that had resided in their rooms longer than Resident A. "It's like they have a vendetta against Resident A.," stated Resident C.On the afternoon of 7/24/09 several staff members at the facility were interviewed individually. The following was the results of those confidential interviews:Facility Staff (FS) 3 stated AS 3 knew Resident A would be upset about the move. "Resident A was up-front about his feelings. Room change was out of spite." NS 3 admitted witnessing the exchange between Resident A and AS 2 when Resident A returned from the hospital on 7/24/09. NS 3 stated while in a room caring for another resident and heard the raised voices of Resident A and AS 2. NS 3 stated AS 2 was yelling at Resident A, "We don't have to hold your room, just a bed." NS 3 also indicated the loud talking continued until Resident A stopped and passed out. NS 3 further stated, Resident A was being mistreated for a while, "Was gone for 2 days and they were packing his stuff." FS 6 stated Resident A was met at the door when he arrived from the hospital and told about the room change. "I knew he (Resident A) would be upset about his room change, everybody did." stated FS 6.During an interview with FS 4, FS 4 stated he/she had never seen the "abuse from the authority figures" at other facilities. He/she felt that the behavior displayed by administration was "harassment. (Administration) Did it out of spite. They knew he was going to be upset." FS 4 stated hearing AS 2 "yelling, over talking" Resident A. FS 4 also stated hearing AS 2 tell Resident A "We just have to have you a bed; we don't have to save the room."During an interview with FS 5 when questioned about the incident with Resident A and his room change, FS 5 stated "Could tell he was upset. I think they did it on purpose. They don't like patients that call the State. They don't like patients that stand up for themselves." On 7/24/09 at 3:25 p.m. Resident A was interviewed. Resident A stated the first he knew of the change in his room was when FS 6 met him at the door of the facility when he arrived back from the hospital, and told him. Resident A stated he had been asked by the facility various times if he wanted to move, the last time on June 22, 2009. Resident A stated each time the answer was "no". Resident A stated when he was talking to AS 2 about the move, her voice was "going up" and he passed out. "This is my home." stated Resident A.The facility's undated policy "Room Change Documentation" indicated the following: "It is the policy of this facility to assess and coordinate room changes that will be satisfactory to all residents of the facility and/or family or responsible party members. Procedure: 2. Move/Changes will be discussed with and approval obtained from resident and /or responsible party." The facility's 9/13/04 policy "Resident Admission Agreement Bed-Holds and Readmissions" indicated the following; "The facility shall offer to hold a bed in the facility for up to seven (7) days if the resident must be transferred to an acute care hospital. The facility shall give the resident, and a family member or legal representative notice of the right to this bed-hold at the time the resident is transferred to the hospital. The resident/representative has twenty -four (24) hours from receipt of the notice to request the bed-hold." The facility was unable to provide evidence of the notice of the right to hold his bed given to Resident A.The Department determined that the facility failed to provide notification to Resident A prior to moving him from his room which resulted in Resident A being treated disrespectfully without concern for his welfare. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000006 |
Davis Healthcare Center |
030010112 |
A |
27-Aug-13 |
EKZV11 |
10431 |
F323 - Free Of Accident Hazards/supervision/devices - 42 CFR 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made to the facility on 3/2/11 to investigate Complaint #CA00260735 and Entity Reported Incident #CA00230035. As a result of the investigation, the Department determined the facility failed to:Ensure Resident (patient) A received adequate supervision to prevent a fall from the bed while being prepared for transfer from the bed to the wheelchair.The facility failures which led to the fall caused pain and suffering for Resident A, the need for acute care hospital transfer and admission for required surgical intervention.These failures resulted in Resident A experiencing a fractured left hip, which required surgery. Resident A had surgery on 5/24/10 and died on 5/25/10. Review of Resident A's clinical record indicated she was readmitted to the facility on 1/24/10 after being hospitalized for a right hip fracture which occurred when Resident A fell out of a wheelchair while in the facility dining room. Resident A's diagnoses on admission included aftercare for hip fracture, rehabilitation procedures, anemia, dementia, and Alzheimer's disease. A Minimum Data Set (MDS- an assessment tool used to plan nursing care) dated 4/15/10 documented that Resident A had severely impaired (never/rarely made decisions) cognitive skills for daily decision-making. Resident A also had short and long term memory loss. Resident A was totally dependent on staff for transfer in and out of bed and required physical assistance from two or more persons. Other pertinent resident characteristics included in the 4/15/10 MDS were: inability to walk, inability to stand unassisted, total dependence on one staff member for locomotion in the wheel chair, and total dependence on staff for dressing and bathing.Fall Risk Assessments completed on 1/24/10 and 4/7/10 indicated Resident A was at high risk for falling due to confusion, history of a fall in the past 3 months, chair bound status, poor vision, inability to stand or walk, received 1-2 medications that could contribute to a fall, and had 1-2 diseases that could predispose Resident A to experiencing a fall. Resident A's assessment numerical score was 16 for both assessments. The assessment instructions indicated any score above 10 represented a high risk for falling. A pre-printed care plan titled "Risk for Injury" (undated) was reviewed. In the "Problem/Need" section the following problems were noted for Resident A: poor balance, limited mobility, recent fracture, gait disturbance, loss of coordination. Not noted were the following conditions related to Resident A: poor vision, lack of awareness, medications and diagnosis of Alzheimer's. There were no hand written problems specific to Resident A. In the "Approach Plan" section of the Care Plan the pre-printed interventions were listed: orient resident to environment, remove hazards from the environment, open curtains, call bell in reach, remind resident to use call bell, answer call light promptly, assist resident as necessary, bed in low position, rounds every two hours, wear glasses, encourage use of wheel chair, and PT (physical therapy) and OT (occupational therapy) evaluation. There were no handwritten interventions specific to Resident A's condition and/or level of function. The CNA's (Certified Nursing Assistant) Activities of Daily Living (ADL) records dated March, April and May, 2010 indicated Resident A did not help at all during transfer, staff performed transfer with a lift, and two people participated in the procedure. Review of Resident A's PT (Physical Therapy) records revealed PT was provided five times a week from 1/25/10 through 3/19/10. The original PT evaluation listed Resident A as requiring a standing lift for transfer. Precautions/complications were decreased mobility, fall risk and hip precautions. PT Weekly Progress Report dated 3/14/10 indicated Resident A had progressed to attempting to assist with transfers (using transfer pole- a stable pole a person grabs while standing which helps balance and allows the arms to help lift up off the bed). Dementia was listed under "Barriers to Progress." The Resident's response to care was noted as being "fair", and "continues to yell with movement." A Nurses Note dated 5/24/10 at 7:15 a.m. indicated "Resident experienced a fall. No injuries noted." A Nurses Note dated 5/24/10 at 7 a.m. indicated "Received a report from outgoing . . . nurse that resident had fallen out of bed when CNA [certified nursing assistant] was getting [Resident A] up... expecting a call back from [Physician] on how to proceed." At 7:30 a.m. the nurse wrote "... CNA came up to me to tell me about resident's fall and that resident c/o [complains of] pain." The note went on to state that Resident A was returned to bed and assessed with no injury noted at 8 a.m. The Patient Transfer and Referral Record, dated 5/24/10, indicated Resident A fell, complained of pain, and was transferred to the General Acute Care Hospital (GACH). In a hand written, signed statement, dated 5/24/10, CNA 1 wrote: "I was trying to transfer the resident (A) from bed to wheelchair then I turned to take the standing machine... I turned back I saw her on the floor." In a typewritten, signed statement, no date, Registered Nurse (RN) 1 wrote: "[CNA 1] said 'the patient (Resident A) slid out of bed onto the floor'... [CNA 1] had 'turned away to grab the lift' and when she turned back the patient was on the floor... I asked if the side rails were down and she said yes, because she was getting the patient up." In a termination letter addressed to CNA 1, dated 5/27/10, the facility's Administrator wrote: "On 5/24/10 at approximately 6:25 a.m., you did not ensure that your resident was in a safe position upon turning your back and the resident fell out of bed. This is a direct violation of the Nursing Home Federal Requirements F324 section 483.25 (h) (2) ...you did not act prudently when it came to providing patient care, therefore ... I ... terminate your employment ... effective immediately." In an interview with the Administrator on 3/4/11 at 9:05 a.m., she stated that CNA 1 brought the lift into the room but did not position it close enough to the bed. She lowered the side rail, turned to reach for the lift, and took her eyes off Resident A. She turned her back and Resident A fell out of the bed. The Administrator clarified the "lift" in question was the sit-to stand lift (an assistive device that allows the resident to rise from the bed to a standing position). In an interview on 3/4/11 at 11:20 a.m., the interim Director of Nursing (IDON) stated the lift required two persons at all times. She stated the facility was "very strict" regarding the two person rule. In a subsequent interview with the DON on 7/26/11 at 11:45 a.m., she stated the sit-to stand lift was recommended by the manufacturer to be a one person operated device, but the facility taught the staff to always have two persons in attendance when using the device. She stated "Staff was aware there should have been two people." Review of a facility policy titled "Resident Lifting and Assisting with Transfers" revealed (in part) under section I. General Guidelines: "LIFTS REQUIRE TWO CLINICAL PERSONNEL AT ALL TIMES DURING OPERATION AND TRANSFER." In an interview with Licensed Vocational Nurse (LVN) 1 on 7/26/11 at 11:55 a.m., she stated Resident A was not the same after her readmit to the Facility in January 2010. She was "crankier, had out bursts of anger, and didn't want to get out of bed.' She stated Resident A was combative with care, showers, dressing, and getting in and out of the wheelchair. LVN 1 stated Resident A was a fall risk and the sit-to stand lift was used to get her out of bed. LVN 1 remembered seeing two CNA's in attendance any time she observed the lift being used to assist Resident A in or out of bed. LVN 1 stated at the time of the fall, Resident A was on an air mattress which was covered in a nylon-like material that was "slippery." She stated "if she put herself to the edge she could slide off." In an interview with Resident A's daughter on 3/3/11 at 10:48 a.m., she stated the facility Administrator told her she had fired CNA 1 because she "shouldn't have moved [Resident A] by herself." She further stated her mother had experienced "much suffering the last 24 hours of her life." Resident A was assessed as being at high risk for falls. The facility provided PT and RNA care, and Resident A progressed to moderate assistance using a pole for transfer, with overall a "fair" response to PT care/treatment. Resident A suffered from dementia and Alzheimer's disease and exhibited resistance to care by refusing to continue therapy with the RNA. There was no assessment in the record after RNA care was discontinued that spoke to Resident A's ongoing ability or lack of ability to transfer- neither with the pole or the sit-to stand lift. Resident A's fall risk care plan neither addressed the extent of her risk nor individualized interventions to decrease the likelihood of a fall. The care plan was not updated to reflect Resident A's combativeness during care. The General Acute Care Hospital (GACH) x-ray report dated 5/24/10 indicated Resident A had a "high femoral neck fx [fracture]." An orthopedic surgeon's consultation report dated 5/24/10, indicated Resident A had a "Displaced left femoral neck fracture" and "this fracture has very poor results with nonsurgical treatment ... this particular patient is very high risk." The Department determined the facility failed to ensure that Resident A received adequate supervision to prevent a fall when the CNA lowered the side rails of the bed and turned her back preparing to transfer Resident A to the wheelchair. These failures resulted in Resident A experiencing a fall and fracture requiring surgery. Resident A expired in the GACH on 5/25/10. 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. |
| 100000059 |
Double Tree Post-Acute Care Center |
030010222 |
B |
22-Oct-13 |
38S611 |
1899 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 6/22/11 at 2:30 p.m. the Department made an unannounced visit to the facility to investigate complaint #CA00272704 regarding an incident of alleged resident abuse filed by an Ombudsman (a community patient advocate). The Department determined that the facility failed to report an allegation of suspected abuse to the Department within 24 hours of being apprised of the allegation, as required per statute. Patient A's clinical record review revealed that he had been admitted with diagnoses including episodic moods disorder and a mental disorder but that he was alert and aware of his surroundings. An interview was conducted by the Department on 6/22/11 at 2:40 p.m. with Patient B. Patient B confirmed that Patient A entered her room uninvited, offered her some water and then put his hand in her gown and grabbed her left breast. A review of Patient B's clinical record was conducted and it revealed that Patient B was cognitively intact, alert and oriented. A review of the facility Nursing Risk Meeting notes dated 6/9/11 revealed that on 6/7/11, Patient A entered Patient B's room and offered her some water and then grabbed her breast without permission. A review of the complaint information indicated that the person who filed the report with the Department was the Ombudsman, who is not a member of the facility staff. The facility was not able to provide any documentation that the facility had reported the 6/7/11 incident/allegation of sexual misconduct to the Department. The facility was unable to provide any documentation that the Department was notified of the allegation. |
| 070000044 |
DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ |
070008901 |
B |
23-Jan-12 |
7F6O11 |
5972 |
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 prevent an avoidable accident for residents when they failed to use footrests on a resident's wheelchair. Resident 1 was known by staff to drag her feet under her wheelchair. The facility failed to develop a care plan to address the practice of wheeling the patient without footrests although she was dependent on staff to move in the wheelchair. On 11/28/11, an X-ray indicated Resident 1 sustained a fracture of her left femur, the long upper bone of the leg. The facility's medical director (MD A) and Resident 1's physician (MD B) stated the fracture was due to a strong force applied to the leg. The facility was unable to ascertain the exact cause of the fracture, but the director of nurses (DON) stated it may have occurred from an improper transfer or having her leg caught under a wheelchair. The facility was unable to provide other possible explanations for the fracture.Resident 1 was admitted to the facility with diagnoses including depression and dementia (loss of brain function). Resident 1's 10/25/11 Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had poor memory function. The MDS indicated Resident 1 required two people to assist in transfers (moving from a chair to a bed and back) and was extensively and totally dependent on staff for bed mobility, and locomotion in a wheelchair.During observation on 12/2/11 at 09:10 a.m., Resident 1 was awake in bed wearing a brace on her left leg. Resident 1 stated she could not remember how she was injured. A record review was done on 12/2/11. The 8/30/10 care plan, "Extensive to Total Assist," last revised on 8/11, indicated Resident 1 required extensive to total assistance with activities of daily living which included mobility. There was no care plan intervention to address Resident 1's need for assistance to propel in a wheelchair and safety precautions to ensure the resident's feet were safe.On 11/29/11 at 8 a.m., a nurse's note late entry written by licensed nurse B (LN B) indicated on 11/28/11 certified nurse assistant A (CNA A) noted a bruise on the back of Resident 1's left knee. LN B assessed the resident at 3 p.m. The note indicated Resident 1 had increased pain "upon palpation and movement" and had moderate edema (swelling) to the front of the knee. A nurse's note written by LN B on 11/28/11 at 3:50 p.m. indicated Resident 1's left posterior leg was bruised, cold to touch and "wobbly." On 11/28/11 an X-ray report indicated Resident 1 sustained a fracture of the left distal femur (just above the knee joint). At 11:45 p.m. on 11/28/11, Resident 1 was transferred to an acute care hospital for further evaluation. An Interdisciplinary Team (IDT) note dated 11/29/11, indicated the facility could not identify the cause of the fracture. The note indicated Resident 1 was non-ambulatory and required extensive assistance with transfers and activities of daily living. The note indicated staff were not able to ascertain any incident leading to the fracture. During an interview on 12/2/11 at 2:12 p.m., CNA A stated on 11/28/11, during morning care around 9 a.m., she noticed Resident 1's left leg was bruised and swollen and felt loose. She stated she told LN B that the resident's leg was loose and asked her to "come and see the resident." CNA A stated she was not aware of any incident which could have injured the resident. During an interview on 12/2/11 at 1:50 p.m., LN B stated on the morning of 11/28/11, after breakfast, CNA A asked her to check the resident's left leg. She stated at 3 p.m. when she did the assessment she noted a dark purple discoloration twice the size of a quarter. LN B stated Resident 1's left leg was wobbly from the knee to the ankle.During an interview on 12/5/11 at 9:20 a.m., the director of nursing (DON) stated she was informed by CNA A regarding Resident 1's pain and discolored and loose leg on 11/28/11 at 3 p.m. The DON stated she believed the fracture occurred due to an unsafe transfer. DON stated she believed staff did not realize Resident 1's lower limbs might have gotten caught in the wheelchair. During an interview on 12/6/11 at 8:48 a.m., medical director A (MD A) stated the fracture was a result of a twisting force which was less likely caused by a fall. MD A stated the leg may have been caught in a bedrail or wheelchair.During an interview on 12/6/11 at 8:54 a.m., MD B stated Resident 1's leg could have been trapped or twisted somehow. She stated it was a "pretty big" fracture. She stated "twisting occurred" as a component of the fracture. During an interview on 1/4/12 at 1:40 p.m., CNA D stated staff habitually propelled Resident 1 in a wheelchair without footrests. CNA D stated had to remind the resident to lift up her legs when she was being wheeled in the hallway. She stated there had been times when the resident's feet "got stuck" under the wheelchair. During interview on 1/4/12 at 2:49 p.m., CNA A stated she propelled Resident 1 in her wheelchair and it was not equipped with footrests. She stated Resident 1 was tall and therefore had to raise her feet when transported in a wheelchair. She stated it was not unusual for Resident 1 to drag her feet when being propelled.The facility failed to use wheelchair footrests for the resident and care plan for the known behavior of dragging her feet when pushed in the wheelchair. Resident 1 was totally dependent on staff when pushed in the wheelchair or for transfers and locomotion when she fractured her left leg. The facility was unable to identify other causative factors which may have resulted in the "twisting" nature of the leg fracture. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 070000044 |
DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ |
070009970 |
B |
26-Jun-13 |
0O0911 |
7120 |
F203 - 483.12(a)(4)-(6) Notice Requirements before Transfer/Discharge Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to ensure the legal representative was notified in writing of the reason for the move when Resident 1was transferred to the acute care hospital and then subsequently discharged. At the time of the transfer, the facility failed to record in the clinical record the reason for the transferResident 1 was admitted to the facility on 1/30/13. The Minimum Data Set (MDS, an assessment tool) dated 5/6/13 indicated the resident was moderately impaired in cognition and unable to make decisions for himself. Resident 1's clinical record also indicated a family member (FM) was his legal representative for medical care decisions. On 5/27/13 at 7:30 a.m. the nurse's notes indicated Resident 1 was found lying in Resident 3's bed in Resident 3"s room. Resident 1 "apparently struck" the two residents in this room. When Resident 1 was asked to leave the room by the staff, he became severely agitated and combative. The facility called 911. Resident 1 was removed from the facility, sent to an acute hospital for evaluation on 5/27/13 and admitted. There were no physician's notes documenting the reason Resident 1 was transferred.On 6/10/13 at 9:25 a.m. Resident 2 was interviewed in his room. He was alert and oriented. His face was clean and no blemishes were noted. He stated Resident 1came out from the bathroom and attacked him. He said he was hit in the face. Resident 1 then went to the other bed and hit Resident 3. "The staff came right away and helped us". He stated the police then arrived and took Resident 1 away.Resident 3 was asleep in his bed in the room during the interview with Resident 2. No bruises or scratches were noted on Resident 3's face.On 6/10/13 at 10:50 a.m. during an interview with the unit manager, she stated the physician was notified about the incident, but she did not document Resident 1 was discharged at the time of transfer. She agreed there was no physician's progress note written in the chart.On 6/10/13 at 12:25 p.m. during an interview with the administrator, he stated Resident 1 was not readmitted on 6/4/13 when the hospital called and asked if the facility would readmit the resident. He said the medical director agreed with the decision not to readmit the resident. He also confirmed there was no physician's documentation for discharge with the rationale. On the same day at 12:45 p.m. during an interview with the medical director, he stated he did not document the reason for discharge. He said the nursing staff had documented the incident very well and should have written the discharge order. He also said that it was unsafe for Resident 1 to return to the facility due to his unpredictable mental state. He said he would document this in the clinical record. On the same day at 1:45 p.m. during an interview with the social worker, she stated she knew Resident 1 as a polite and quiet person. There was nothing unusual, and said no incident like this ever happened before.On the same day at 3:30 p.m. during an interview with the licensed nurse (LN), she stated at around 7:05 a.m. during shift change, the restorative nursing assistant (RNA) asked for help. When the LN came to the room, Resident 1 was lying with Resident 3 in Resident 3's bed in another room. Resident 3 had a bruised face with traces of blood. His left eye had a small scratch. She also noticed small amounts of blood on Resident 1's knuckles. She stated Resident 2 was in the other bed had a bloody face with a cut on the bridge of his nose. Resident 1 was asked to leave the room and he became severely agitated and combative. She said an incident like this never happened before with Resident 1. She said she had seen Resident 1combative when he had a seizure (a fit of uncontrolled movement) sometime ago. She said nobody witnessed this incident.On 6/11/13 at 2:20 p.m. during an interview with the FM, she said the unit manager called her on 5/27/13 at 8:00 a.m. and told her Resident 1 would be transferred to the hospital. She said she called the facility the following day for more information. She stated she was not given a written notice of Resident 1's transfer/discharge. The FM said on 5/30/13 the director of nursing told her the facility had not decided whether to readmit Resident 1. She said the facility had not given her information as to what was planned for Resident 1. On 6/6/13 Thursday, The FM stated the acute hospital told her Resident 1 was going to a different facility. The FM said she was not aware this was going to happen.The facility failed to ensure the legal representative was notified in writing of the reason for the move when Resident 1 was transferred to the acute care hospital and then subsequently discharged. There was no documented evidence to support the discharge of the resident from the facility. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000044 |
DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ |
070011383 |
B |
17-Apr-15 |
GFPY11 |
6184 |
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 protect one of three sampled residents (1) from abuse. Resident 1 complained to a staff member about rough treatment and a cold shower on or about the week of 3/15/15 and also to the ombudsman (a state official who represents the interests, rights, and complaints of the public) on 3/23/15. The facility did not start or fully investigate the abuse allegation or report it to the California Department of Public Health (CDPH) until 3/26/14. The facility also allowed the alleged abuser access to Resident 1 prior to the completion of the abuse investigation.Failure to report the abuse can prevent an analysis of the occurrence to determine what changes, if any, were needed to prevent any further occurrences. Failure to investigate the abuse in a timely manner potentially allowed the abuse to continue and would not prevent further occurrences. Allowing the alleged abuser to have access to the resident, prior to the completion of the investigation, failed to protect the resident and others from harm. Resident 1's clinical record was reviewed on 4/7/15. Her 3/20/15 minimum data set (MDS, an assessment tool) indicated her cognition was intact and she was alert and oriented. During a telephone interview with Resident 1 on 4/7/15 at 10 a.m., she stated about a week before her discharge from the facility, while sitting in a shower chair under a stream of water, she informed certified nurse assistant A (CNA A), the water was ice cold. She further stated CNA A told her the water was not cold. Resident 1 stated she next stood up to move out of the stream of water when CNA A pushed her back down into the chair. She had a second shower with warmer water. Resident 1 stated she later informed a staff member in the rehabilitation department and ombudsman F (OMB F) of the incident. During an interview with CNA A on 4/7/15 at 3 p.m. she stated while assisting Resident 1 with a shower a week before her discharge, she recalled an incident where the resident abruptly stood up and she had to guide her to sit down in the shower chair. She was concerned about Resident 1 falling on the soapy, wet floor. CNA A stated she had not been rough with Resident 1. She remembers both she and the resident tested the first shower stall and found it was too cold so they moved to the second stall.During an interview with certified occupational therapy assistant B (COTA B) on 4/8/15 at 10:10 a.m., she stated about a week before discharge, Resident 1 complained a CNA placed her in a cold shower and "was a little rough". She stated she reported this incident to a nurse on Station Two but she did not remember which nurse. She did not report the incident to either the director of nurses (DON) or the administrator (ADM). She also stated she should have called the ombudsman. During an interview with OMB E on 4/10/15 at 2 p.m., she stated OMB F heard about the alleged abuse from Resident 1 on 3/23/15 and reported the incident to the DON on the same day. She further stated on 3/26/15 around 3 p.m., both she and OMB F visited Resident 1, discussed the alleged abuse, and reported the alleged abuse to the ADM.During an interview with OMB F on 4/13/15 at 10 a.m., she stated she reported the alleged incident of abuse to the DON on the afternoon of 3/23/15. She also reported Resident 1's allegation of a cold shower and rough treatment. OMB F stated Resident 1 complained she had wrenched her shoulder muscle trying to get out of the stream of cold water and when CNA A pushed her back into the chair.A record review of the investigation summary on 4/7/15 indicated an investigation of Resident 1's complaint of alleged abuse was begun on 3/26/15 at 4:10 p.m. and consisted of only one interview with CNA A at 5 p.m. There was no documentation Resident 1 was interviewed.During an interview with the DON on 4/7/15 at 3:30 p.m., she stated she became aware of Resident 1's alleged abuse by CNA A on the afternoon of 3/26/15. She stated she interviewed CNA A the same day at 5 p.m. The one interview was the extent of her investigation. She did not interview Resident 1. The DON also stated she only suspends an employee from working if the abuse was substantiated or if there was an injury. She further stated she did not suspend CNA A because Resident 1 was being discharged to home on the following day.The facility shower list record, reviewed on 4/7/15, indicated Resident 1 was assigned to have a shower on Wednesdays and Saturdays. The facility nursing staffing assignment and sign-in sheet indicated CNA A cared for Resident 1 on Wednesday, 3/18/25; on Monday, 3/23/15; on Wednesday, 3/25/15 and on Thursday, 3/26/15. A review of the facility's 10/2004 policy, "Abuse and Neglect Prohibition", indicated the facility's code of conduct requires employees to immediately report the facts of suspected instances of abuse to the ADM or the DON. The facility should conduct an investigation of any alleged abuse/neglect as soon as possible and in accordance with state law. It further indicated the facility should report such allegations to the State, immediately or within 24 hours, and should protect the residents from harm during the investigation.Therefore, the facility failed to act on the allegations of rough treatment and a cold shower for at least three days after the first accusation was given to the staff. They failed to report to the CDPH within 24 hours as required. They allowed the alleged abuser to continue to work with the resident before they had investigated the validity of the allegations, opening the resident, as well as other residents to potential psychological as well as physical harm. The investigation was not started until three days after the incident was reported and contained an interview of the alleged abuser only. The investigation did not include any statements from Resident 1. The above violations had a direct relationship to the health, safety, or security of the residents. |
| 070000044 |
DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ |
070012789 |
A |
29-Dec-16 |
MW1C11 |
13871 |
F157--483.10(b)(11) NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in ?483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in ?483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. The facility failed to ensure a physician was notified of a change in condition for Resident 1 when he had decreased food and fluid intake, weight loss and hypoxemia (reduced amount of oxygen in the blood). These failures did not allow for the interventions needed to ensure Resident 1 received adequate nutrition, hydration, and treatment for acute respiratory failure. Review of Resident 1's clinical record indicated he was admitted to the facility from the acute hospital on 10/27/16. Resident 1 had diagnoses of aspiration pneumonia (a lung infection from taking in food and/or fluid into the lungs), dysphagia (swallowing difficulty), seizure disorder (electrical disturbance in the brain) and severe developmental delay (intellectual challenge). These were discharge diagnoses received during his most recent acute hospital stay of 10/20/16 to 10/27/16. Review of the acute hospital record, "Nutrition Services Assessment," dated 10/24/16, at 2:20 p.m. indicated Resident 1's weight was 119.9 pounds at the acute hospital. Review of the facility's November "Monthly Weight Record" indicated a weight of 98.8 pounds was recorded on 11/1/16, a 21 pound drop in weight or 17.5% weight loss over eight days (loss of five percent over one month is considered a significant weight loss). During an interview with the director of nursing (DON) on 11/22/16, at 4 p.m., she stated Resident 1 should have been weighed on admission and the weight compared to the previous weight taken at the acute hospital. The DON stated nursing staff should have been aware of Resident 1's significant weight loss. The DON stated the nurse should have informed the primary care physician (PCP) and the registered dietician (RD) of Resident 1's lower body weight, and Resident 1 should then have been weighed on a weekly basis, but the DON was unable to find a record of weights taken at the facility prior to 11/1/16. Review of Resident 1's clinical record showed no record of weights taken at the facility prior to 11/1/16. Review of the facility's 2004 policy, "Weight Change" indicated residents with significant weight change should be assessed by the interdisciplinary team and interventions should be implemented to minimize further weight change. Interventions included: 1. Weigh and screen all residents upon admission for their risk for weight change. 2. Weigh all residents weekly for the first month after admission to the facility. 3. Residents with weight variance defined as five percent or greater weight loss in one month or three pound weight loss for resident's less than 100 pounds should be reweighed within 24 hours after the admission weight is completed. 4. Residents identified at risk for weight change will have interventions to minimize weight change included in their care plan. 5. Nursing staff should communicate the above weight changes to the attending physician and to the registered dietician. Review of the facility's "Nutrition Care Assessment" dated 11/4/16, signed by the RD indicated Resident 1 had a poor food intake of less than 25 percent of his meals and an average fluid intake of less than 1000 milliliters (ml, a unit of measure) per day. The RD assessment indicated Resident 1 required an average of 1500 to 1800 ml of fluid to meet his daily fluid needs. Review of Resident 1's "Meal Intake Record" (MIT) from the date of admission until the date of death on 11/9/16 indicated Resident 1 took in meals and liquids as follows: 10/28/16: Breakfast: 25%, Lunch: 50%, Dinner: 25%, Daily fluids: 720 ml. 10/29/16: Breakfast: Less than 25%, Lunch: 50%, Dinner: 50%, Daily fluids: 600 ml. 10/30/16: Breakfast: 75%, Lunch: Less than 25%, Dinner: 25%, Daily fluids: 600 ml. 10/31/16: Breakfast: 75%, Lunch: less than 25%, Dinner: Less than 25%, Daily fluids: 600 ml. 11/1/16: Breakfast: Liquids only, Lunch: Liquids only, Dinner: 25%, Daily fluids: 720 ml. 11/2/16: Breakfast: Less than 25%, Lunch: Less than 25%, Dinner: 25%, Daily fluids: 720 ml 11/3/16: Breakfast: Less than 25%, Lunch: 25%, Dinner: 100%, Daily fluids: 840 ml. 11/4/16: Breakfast: Less than 25%, Lunch: 25%, Dinner: 100%, Daily fluids: 960 ml. 11/5/16: Breakfast: Less than 25%, Lunch: 0, Dinner: 0, Daily fluids: 240 ml. 11/6/16: Breakfast: Refused, Lunch: Refused, Dinner: 100%, Daily fluids: 360 ml. 11/7/16: Breakfast: Refused, Lunch: Refused, Dinner: 25%, Daily fluids: 120 ml. 11/8/16: Breakfast: Refused, Lunch: Refused, Dinner: Less than 25%, Daily fluids: 240 ml. 11/9/16: Breakfast: Refused, Lunch: Refused, Daily fluids: 200 ml. During an interview with the RD on 11/22/16, at 10 a.m., she stated she saw Resident 1 on 11/4/16 when completing a routine dietary admission assessment eight days after Resident 1's admission to the facility. The RD stated no one informed her of Resident 1's weight prior to the assessment but she would have assessed Resident 1 at the time she was informed of his weight. The RD stated she was "very concerned" about Resident 1 being underweight and his reduced fluid intake, so wrote the following dietary recommendations and gave them to the nursing unit manager (NUM): 1. Fortified Diet [a diet with extra nutrients added to the food] 2. A liquid drink enriched with protein, fats, carbohydrates, vitamins, and minerals three times a day 3. A liquid drink with a highly concentrated form of liquid protein one time per day. Review of Resident 1's clinical records indicated there was no documentation the above dietary recommendations were communicated to the physician or followed by the nursing staff. During an interview with the NUM on 12/19/16, at 3:15 p.m., she stated Resident 1's dietary recommendations were placed in her inbox but she did not pass them on to the physician prior to Resident 1's death. During an interview with the DON on 11/22/16, at 4 p.m., she stated the dietary recommendations should have been acted upon immediately. The DON stated the RD should have notified nursing staff immediately of the dietary recommendations and of her concern for Resident 1's lowered body weight. The DON stated the nursing staff should have notified the physician immediately of the dietary recommendations to help Resident 1 increase his body weight and his fluid intake. The DON stated she was unable to find a record the PCP was notified of Resident 1's significant weight loss or of his low food and fluid intake or of the RE's dietary recommendations. Review of Resident 1's clinical record confirmed there was no documentation the PCP was notified of Resident 1's significant weight loss, of his low food and fluid intake, or of the RD's dietary recommendations. During an interview with Resident 1's PCP on 11/28/16 at 4:45 p.m., he stated he did not, but should have received, a call from the nursing staff informing him Resident 1 was not eating or drinking well, had a significant weight loss, and of the dietary recommendations. Review of the facility's 3/2000 policy, "Fluid Intake and Output Measurement" indicated intake and output measurements should be taken and monitored for all residents identified as high risk for dehydration, and should have documentation in the progress notes, and the plan of care is updated to reflect interventions. The policy indicated to notify the physician of significant variations of intake and output and to document the physician response and the interventions implemented. Review of Resident 1's "Vital Signs and Weight Flow Sheet," dated 10/28/16, indicated Resident 1 was placed on oxygen at 2 liters per minute via nasal cannula on 10/28/16 for an oxygen reading of 89% (levels below 90% indicate a need for oxygen intervention). Review of Resident 1's "Daily Medicare Notes" dated 11/28/18 to 11/5/16 indicated the following record of oxygen levels taken without oxygen unless noted as with oxygen: 10/28/16, 7 a.m.: 93% 10/28/16, 3 p.m.: no entry 10/28/16, 11 p.m.: 98% 10/29/16, 7 a.m.: 96% 10/29/16. 3 p.m.: 94% 10/29/16, 11 p.m.: 93% 10/30/16, 7 a.m.: no entry 10/30/16, 3 p.m.: 95% with oxygen 10/31/16, 11 p.m.: 95% 11/1/16, 7 a.m.: 92% 11/1/16, 3 p.m.: 95% 11/1/16, 11 p.m.: 92% 11/2/16, 7 a.m.: no entry 11/2/16, 3 p.m.: 94% with oxygen 11/2/16, 11 p.m.: no entry 11/3/16, 7 a.m.: 92% 11/3/16, 3 p.m.: 94% 11/3/16, 11 p.m.: 95% 11/4/16, 7 a.m.: 97% 11/5/16, 7 a.m.: 96% 11/6/16, 3 p.m.: 93% 11/7/16, 7 a.m.: 95% 11/8/16, 7 a.m., 93% Review of the situation, background, assessment, recommendation (SBAR, a communication tool), dated 11/9/16, at 12:30 p.m., indicated Resident 1 had labored breathing, was lethargic, and had a blood oxygen saturation level of 81%. The SBAR indicated the nurse placed an oxygen mask on Resident 1 at 2 liters per minute. During an interview with licensed vocational nurse C (LVN C), on 12/5/16, at 10:10 a.m., she stated at around 12:30 p.m. the certified nursing assistant informed her Resident 1 had trouble breathing. LVN C stated she found Resident 1 "cool and clammy" with an oxygen level of 80%. LVN C stated she changed Resident 1's oxygen from nasal cannula to a face mask at 2 liters per minute, called the PCP's office and heard a message the office was closed for lunch. LVN C stated she did not wait for a receptionist to come on the line or for an answering service but completed the change of condition report and faxed it to the office. LVN C stated she did not wait for a confirmation report and planned to call the office when the lunch hour was over. LVN C stated she checked Resident 1 after 30 minutes, found his oxygen level was 86%, did not record the findings, and did not inform her supervisor of Resident 1's condition change because she did not expect Resident 1 would expire. Review of Resident 1's nurse's note dated 11/9/16 at 2 p.m. indicated at 1:55 p.m., Resident 1 was found unresponsive without a heartbeat or breath sounds. Review of Resident 1's "Certificate of Death" dated xxxxxxx, indicated Resident 1's time of death was 1:55 p.m. and the cause of death was aspiration pneumonia. Review of the facility's facsimile dated 11/9/16 at 2:01 p.m. indicated the SBAR was faxed to the physician, one and one-half hours after Resident 1 was found in respiratory distress and five minutes past the time of death. During an interview with the PCP on 11/28/16, at 4:45 p.m., he stated he did not receive any communication from the facility regarding Resident 1's low oxygen level. During an interview with the DON on 11/29/16, at 1:40 p.m., she stated LVN A should have contacted the facility's medical director if unable to reach the PCP, and LVN A should have informed a physician about Resident 1's change of condition so as to receive orders for medical treatment of Resident 1's low oxygenation. Review of the facility's 2008 policy, "Changes in Resident Condition," indicated the physician should be notified when there is a significant change in the resident's physical status and when there is a need to commence a new form of treatment. Review of photocopies of Resident 1's medical record obtained on 11/21/16 indicated no POLST (Physician Orders for Life-Sustaining Treatment) was present. Review of a facsimile from the group home where Resident 1 resided prior to his hospitalization indicated Resident 1 had a POLST dated 10/21/16. The POLST indicated Resident 1 would not be resuscitated if he was not breathing and did not have a pulse and would not be intubated (have a tube inserted in his windpipe for mechanical ventilation) or receive intensive care. The POLST did specify, however, that Resident1 would receive "medical treatment, antibiotics, and IV [intravenous] fluids as indicated...May use non-invasive positive airway pressure." (a situation in which a patient is connected to a ventilator via a face mask instead of a tube in the windpipe). Review of a facsimile from the facility dated 12/15/16 indicated it included a POLST for Resident 1 prepared 10/27/16, but not signed by the physician until 11/25/16, which was after Resident 1's death. The facility failed to ensure a physician was notified of a change in condition for one of three sampled residents (Resident 1) when he had decreased food and fluid intake, weight loss and hypoxemia (reduced amount of oxygen in the blood). These failures did not allow for the interventions needed to ensure Resident 1 received adequate nutrition, hydration, and treatment for acute respiratory failure. This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to the resident. |
| 070000044 |
DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ |
070012966 |
B |
16-Feb-17 |
GSK211 |
2541 |
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 failed to implement their abuse policy. The facility did not report Resident 4's allegation of abuse to the California Department of Public Health (CDPH).
Review of Resident 4's Incident Post Review form dated 12/6/16, indicated certified nursing assistant E (CNA E) hit the resident on the left arm and the left shoulder.
Review of Resident 4's Social Service Progress Notes dated 12/6/16, indicated the director of nursing (DON) talked to the social services director (SSD) after the resident reported the allegation of abuse.
During an interview with SSD on 2/1/17, at 4:30 p.m., she acknowledged Resident 4 reported the allegation of abuse.
During an interview with DON on 2/1/17, at 4:40 p.m., she reviewed Resident 4's clinical record and was unable to find documentation the allegation of abuse was reported to the CDPH.
During an interview with the administrator (AD) on 2/2/17, at 8:20 a.m., he stated he could not find documented evidence Resident 4's allegation of abuse was reported to the CDPH. He stated he thought it was already reported.
Review of the facility's 10/2004 policy, "Abuse and Neglect Prohibition" indicated the facility will report all allegations and substantiated occurrences of abuse to the state agency and law enforcement officials as designated by state law.
Therefore, the facility failed to implement the abuse policy by not reporting Resident 4's allegation of abuse to the CDPH.
The violation of this regulation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000044 |
DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ |
070013398 |
B |
27-Jul-17 |
RSSD11 |
3331 |
F250, 483.40(d) PROVISION OF MEDICALLY RELATED SOCIAL SERVICE
(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
The facility failed to provide adequate medically-related social services in coordinating discharge planning for Resident 2. The social services director (SSD) failed to document and follow-up on requests made by the conservator (a guardian and protector appointed by a judge to protect and manage the financial affairs and/or the person's daily life due to physical or mental limitations or old age) in making Resident 2's transfer arrangements back to her former skilled nursing facility (SNF). In addition, Resident 2 had an unsafe transfer when she was placed in a taxi by herself. These failures had the potential for a delayed and/or unsafe discharge.
Review of Resident 2's face sheet (document that gives a resident's information at a quick glance) indicated she had diagnoses including dementia and that she had a conservator. Her Minimum Data Set (MDS, an assessment tool) dated 6/19/17, indicated she had moderate difficulty in daily decision-making skills.
Review of Resident 2's Interdisciplinary (IDT, team members from different departments involved in a resident's care) Care Conference Notes dated 6/21/17, indicated the discharge plan was to return Resident 2 back to her former SNF. There was no further documentation of discharge planning until 7/5/17, one day before discharge when the rehabilitation director documented that social services was to follow-up.
During an interview on 7/24/17 at 12 noon, the SSD who reviewed the record recalled the conservator had contacted him two times in person and by telephone regarding the request to transfer Resident 2 before she would lose her bed at her former SNF. The SSD stated he did not and should have documented the conservator's request, did not follow-up in coordinating discharge, and thought the former SNF was providing transportation.
Review of Resident 2's IDT Progress Notes dated 7/6/17 indicated Resident 2 was discharged to her former SNF by taxi.
During an interview on 7/24/17 at 3:15 p.m., registered nurse (RN) A confirmed Resident 2 left the facility alone in a taxi when she was transferred back. RN A said when she arrived to work on 7/6/17 she was told transfer arrangements were made for Resident 2 and she was assured by the director of nurses and administrator (ADM) that it was okay to have the resident ride alone in a taxi. RN A stated she gave Resident 2's medications to the "Handicab" (transportation service capable to transporting individuals in wheel chairs) driver.
During an interview on 7/24/17 at 5:15 p.m., the ADM stated if he knew about the situation he would have offered to have someone accompany Resident 2.
Review of the "Social Services Manager" job description, dated 10/1/03, indicated an essential duty and responsibility included coordination of discharge planning.
The facility failed to provide adequate medically-related social services in coordinating discharge planning for Resident 2 to ensure a timely and safe discharge.
The violations of this regulation had a direct or immediate relationship to resident health, safety, or security. |
| 010000801 |
Danny's Place |
110010091 |
A |
30-Dec-13 |
J80F11 |
5718 |
A008 W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility violated the regulation by failing to protect Client 1 when Client 1 was put in a shower chair that did not have a seat belt attached. Direct Care Staff used a gait belt instead (gait belt wrapped around a patient's waist and used to assist the patient in transfer and ambulation). Client 1 coughed and slid to the floor and fractured the left hip and required surgical repair. This failure to maintain the shower chair with an attached seat belt contributed to client's left hip fracture Client 1's clinical record revealed the client was admitted to the facility in 1997, with diagnoses which included spastic quadriplegic (motor and sensory loss in all extremities), seizure history, mild intellectually delayed functioning and osteoporosis (brittle bones). The client, who was dependent for all care needs, was unable to ambulate and used a wheel chair for mobility.Client 1's clinical record included the most current orthopedic assessment dated 1/09, was not signed by the occupation therapist which indicated that the client was severely impaired due to physical limitations and was able to speak but with difficulty due to dysarthria (difficulty in motor speech.)During an interview, on 2/28/13 at 10:35 a.m., the Qualified Intellectual Disabilities Professional (QIDP) stated that after she received the incident report from the CNA, she reported the incident to Nurse B, who came to evaluate the client that same morning.Client 1's clinical record on 2/28/13 at 10:40 a.m. revealed that a Change of Condition report was completed on 02/03/13, and confirmed the reported incident.During an interview on 2/28/13 at 10:40 a.m., the QIDP, was asked who trained the direct care staff regarding the use of gait belts. The House Manager, who was present and overheard the questions, stated he trained staff and had not trained the direct care staff to use a gait belt for anything other than for transfers. During an interview on 3/5/13 at 3:20 p.m., CNA A stated that during the morning of 2/3/13, he assisted Client 1 onto the shower chair, which he had placed next to the client's bed, for the client's morning toileting. He stated he placed a gait belt (belt used to assist patient transfers and ambulation) around the back of the shower chair and around the client's hips because the shower chair's seat belt had been broken some time ago and the shower chair no longer had the seat belt that had been attached to the chair when it was purchased. While the client was sitting on the chair, CNA A stated he turned around to look in Client 1's closet to select the client's clothes for the day. When his back was turned, he heard Client 1 cough. CNA A stated he turned around and saw that the client had slid under the gait belt and onto the floor on his back. He stated he asked the client if he had any pain and the client indicated his left ankle had pain. CNA A stated that he assisted the client on to the bed and elevated the client's left leg and reported the incident to the QIDP. CNA A stated he knew the shower chair was not up to standards and that after the incident, the staff decided to throw the chair away. When asked how long the chair had not had a seat belt, he stated he couldn't say but it had been a while ago. He also stated he did not report the broken chair and didn't know if anyone else had. When questioned as to whether or not he believed the gait belt should have been used for Client 1 or any other client, he stated he was using it as a substitute for the chair's missing seat belt. When asked if he had any training, on the use of the gait belt, he stated that the Red Cross (humanitarian organization which provides emergency assistance) had taught him to use the gait belt 3 years ago when he was trained to be a CNA. He also stated a staff member who is no longer at the facility had also trained him when he began his work, at the facility 3 years ago. During an interview on 2/28/13 at 11:20 a.m., the House Manager stated there was no policy for the use of gait belts and no policy regarding reporting or maintenance of facility equipment used on clients. The facility gait belts did not have the manufacturer's brand name however, Thompson Medical, Inc. manufacturer of gait belts pamphlet titled "How to Use a Transfer/Gait Belt" indicated "Never - use a transfer belt for any other purpose - such as a wheelchair belt or Geri chair safety belt!" The facility violated the regulation by failing to protect 1 of 6 clients (Client 1) when the client was put in a shower chair that did not have a seat belt attached. Direct care staff used a gait belt instead, the client coughed, while the direct care staff was not looking, and slid under the gait belt and onto the floor which resulted in the client's left hip fracture. The violation of the regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120009285 |
A |
03-Oct-12 |
6D9K11 |
8414 |
F323 The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On July 22, 2010 at 11:50 AM, an unannounced visit was made to the facility to investigate one entity reported incident and one complaint of a resident eloping from the facility and sustaining an injury. Based on observation, interview, and record review, the facility failed to protect Resident 1 from eloping from an unmonitored door, which resulted in second degree burns to the bottoms of both of her feet and left knee. Resident 1 was admitted to the facility with a diagnosis of dementia of Alzheimer's type (a loss of brain function that affects memory, thinking, language, judgment, and behavior). During an interview with Family 1 on July 21, 2010 at 4 PM, she stated Resident 1 was sent to a burn unit after eloping from the facility because both of her feet and her right knee were badly burned. She stated this was the second time her mother had eloped from the facility. The first time she was found blocks away from the facility by a person at a convenience store. So now after this incident, she will keep Resident 1 home with her. During an observation of the door Resident 1 eloped from and interview with the Administrator on July 22, 2010 at 11:50 AM, he stated the door was not locked between the hours of 4:30 AM and 8 PM and when it was unlocked, it was not monitored by staff. The door was located at the back (north side) of the facility, next to the personnel office. He stated because the incident happened on a Sunday, the staff in the personnel office was gone. When the door was opened, no alarm sounded. Beyond the door was a large parking lot which opened to a side street. The Administrator stated Resident 1 left through the door, went across the parking lot, crossed the street, and sat down on the grass in front of the apartments located there. He stated it was about 102 degrees Fahrenheit and Resident 1 had removed her shoes sometime before crossing the street. When she was found she was picking skin off of the bottoms of her feet. He stated a resident of the apartment building called the facility to let them know she was sitting on the lawn. He confirmed Resident 1's room was located four resident rooms down from the exit door.The clinical record for Resident 1 was reviewed on July 22, 2010 at 12:15 PM. The Licensed Nurses Progress Notes dated May 22, 2009 at 5:45 indicated a previous elopement when an employee of a convenience store located on Cecil Street (approximately 1.5 miles from the facility) called the facility to inform them Resident 1 was there at the store. The facility sent two staff members to bring her back. At that time, a care plan dated May 22, 2009 was implemented with the goal of "prevent further episodes and resolve it to protect from injuries" and the interventions of: monitor res (resident) whereabouts and intervene as needed, redirect behavior, and assure pt (patient) safety." This plan of care was found in the thinned chart in the medical records office. No current care plan for wandering care plan was found in the active chart kept at the nurse's station. The Minimum Data Set (MDS) for Resident 1 dated May 14, 2010, under "BEHAVIORAL SYMPTOMS" read "Wandering (moved with no rational purpose, seemingly oblivious to needs or safety): behavior of this type occurred 1 to 3 days in last 7 days." This MDS also indicated Resident 1 had difficulty with short and long term memory, moderately impaired decision making skills, and rarely understood verbal information content. The Licensed Nursed Progress Notes dated July 18, 2010 at 2:40 PM indicated LN 1 received a call about Resident 1 sitting on the grass by an apartment building. The facility staff found Resident 1 under a tree at the street corner by the apartment building. The LN 1's notes read "According to those who saw her she was running on the street bare footed." During an interview with the Director of Nursing (DON) and a review of Resident 1's chart on July 22, 2010 at 1 PM, she confirmed the chart did not contain an assessment for wandering or a wandering care plan. When asked for the facility's policy and procedure for a resident who wanders, she stated, "We don't have one."During an interview with Certified Nursing Assistant 1 (CNA 1) on July 22, 2010 at 1:22 PM, she stated the kitchen and maintenance staff, as well as delivery people, use the back door. She stated the door was unlocked during the day and it was not monitored by the staff unless the staff happened to be in the hallway at the time. She stated other residents have gone out that same door.During an interview with CNA 2 on July 22, 2010 at 2:10 PM, she stated she had seen other residents leave by the same door and staff would go outside and bring them back into the facility. During an interview with CNA 3 on November 16, 2010 at 4 PM, she stated that on July 18, 2010 she saw Resident 1 sitting on the grass by the apartment building on 5th street, peeling skin off of her burned feet. She stated it was about 105 degrees that day. She stated Resident 1 knew how to take off her body alarms (alarms used to alert staff) and would always wander around the facility saying she wanted to go home. She stated Resident 1 was located on the east wing of the facility and then was moved to the north wing. She was not sure why Resident 1 was moved. She stated it was easier to watch her on the east wing because there were no doors that were left unlocked that led to the outside.The medical record for Resident 1 from Hospital A was reviewed on December 2, 2010. The emergency provider record dated July 18, 2010 indicated: 1. Resident 1 had 2nd degree burns (a burn marked with pain, blistering, and superficial destruction of the skin with swelling and bleeding of the tissues beneath the burn) to both her feet. 2. She had a burn to her left knee. 3. She was referred to Hospital B's burn unit for treatment and follow-up. 4. She was given Dilaudid (a medication for pain) in her intravenous fluid line (tubing with a needle or catheter at the end that is inserted into a vein) for her pain. The medical record for Resident 1 from Hospital B was reviewed on December 2, 2010. The discharge summary notes dated July 22, 2010 read "She (Resident 1) presented to (Hospital B) emergency department on July 19, 2010 where it was determined she required admission to the burn unit for observation and possible debridement (the removing of damaged skin) and grafting (taking undamaged skin and surgically attaching it to a damaged skin area). On examination, she had a second-degree burn of the left knee, which was less than 1% (of body surface) and she had second-degree burns of the plantar aspects of the bilateral feet, all totaling approximately 2% total body surface area. She had serial hydrotherapies (the therapeutic use of water) and dressing changes of the burns of her bilateral feet and left knee...." This record indicated she was admitted on July 19, 2010 and discharged on July 22, 2010. The medication administration record (MAR) sheets dated July 19, 2010 indicated Resident 1 required pain medications before her hydrotherapy treatments. The pain assessment for Resident 1 documented on July 19, 2010 at 4 PM indicated her pain level was an eight on a pain scale of 1 to 10 with 10 being the highest level of pain ever experienced and the pain negatively impacted her activities of daily living (ADLs). The MAR dated July 20, 2010 at 10 AM indicated Resident 1 received Fentanyl (a drug used for severe pain) 50 milligrams into her intravenous access (an access used to administer drugs into a vein) to control her pain before her hydrotherapy treatment.The pictures of Resident 1's feet provided by Hospital B showed the skin on the entire soles of her feet appeared burned away and had left reddened areas. The picture of her left knee showed a large round burn the width and height of her knee cap. Therefore, the facility failed to protect Resident 1 from eloping from an unmonitored door, which resulted in second degree burns to the bottoms of both of her feet and left knee.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. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120010169 |
B |
29-Jan-14 |
1E5911 |
3635 |
F 309 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 8/20/12 at 3:25 PM, an unannounced visit was made to investigate an allegation that a patient had inadequate pain relief which resulted in undue suffering for the patient.Based on interview and record review, the facility failed to ensure adequate pain relief for one patient (Patient A). This resulted in undue suffering for the patient.Findings: During an interview with Family Member 1 (FM 1), on 7/23/12 at 3:42 PM, he stated in July of 2012 Patient A had complaints of pain while at the facility which resulted in the patient being transferred to the emergency room.During an interview with Registered Nurse 1 (RN 1), on 8/20/12 at 4 PM, Patient A's clinical record was reviewed. The nurse documented on 7/10/12 at 1 PM, the patient complained of pain to the left lateral side of the body and left breast and Tylenol was given "but no help...Faxed a communication to (MD) regarding the above concern. Awaiting for the response." At 4:30 PM the nurse documented, "Reviewed fax back from (MD office) the MD/Nurse comm. (communication) (with) new order to do chest x-ray in AM..." At 6:10 PM the nurse documented, "(Patient A) c/o (complained of) pain to her (right) upper abdomen. Tylenol given but she said it does not help her at all. She (is) still in pain...Redirecting behavior and emotional support provided..." At 6:20 PM the nurse documented, "daughter came in, explained to her what is going on...(Patient A) still yelling to call doctor because she (is) still in a lot of pain...Called (MD and) informed him regarding the above concern. He ordered...give Toradol (pain medication) 40 mg (milligrams)... (Injection) x 1 dose only for pain..." At 6:45 PM the nurse documented she called the pharmacy to order the Toradol injection and the pharmacist stated they will send at the 10:30 PM run. From 1 PM until 6:45 PM, there was insufficient documented evidence pain relief was sustained. At 11:15 PM, the nurse followed up on the order for Toradol. The nurse called the pharmacy to inform them the Toradol had not been delivered. According to the pharmacy the Toradol interacted with another medication; therefore, the pharmacy did not send it. She then contacted the MD; a new order was received for Morphine and then administered.During an interview with RN 1, on 8/20/12 at 5:03 PM, she indicated if a situation was determined to be an emergency then the physician should have been contacted. These emergency situations would include: code situations, shortness of breath and severe pain. RN 1 stated if the Tylenol was ineffective for Patient A then the nurse should have gotten a "stronger pain med". The nurse should have let the MD know a stronger pain medication was needed. RN 1 acknowledged, in regards to Patient A waiting for pain relief, it was "too long" to wait.The facility policy and procedure titled, "Comprehensive Pain Assessment", dated 6/26/09, read in part, "The resident's pain shall be alleviated or reduced to a level of comfort that is acceptable to the resident in order to enhance the quality of life." Under the procedure subheading it read in part, "C. Licensed Nurse is to reassess pain as necessary for the effectiveness of the pain control method and shall notify the Physician if measures are unsuccessful..." The above violation has a direct relationship to the health of the patient and therefore is constituted a B level citation. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120010176 |
B |
23-Oct-13 |
5ZQJ11 |
2635 |
HEALTH & SAFETY CODE 1418.91 (a) A long- term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" citation. On 7/24/12, at 3:00 PM, during a recertification survey, a resident (Resident 19) stated "The lady who works in the front took my $200."Based on interview and record review, the facility failed to report to the California Department of Public Health an allegation of fiduciary abuse within 24 hours for one resident (Resident 19).Findings: During an interview with Resident 19, on 7/26/12, at 3:00 PM, he stated, "The lady (Office Personnel) who works in the front took my $200." Resident 19 also stated his daughter gave him the money but could not recall when. His wife told the Office Personnel (OP) working at the front office to give the money to him and put it in his trust fund. OP went to his room and took the money, but did not give him a receipt. OP took off right away. He trusted OP so he did not ask for a receipt. But when he saw his monthly statement, he noticed that the $200 was not in the statement. He asked OP, but she denied his allegation and asked, "What 200 dollars?"During an interview with the Social Services Director (SSD), on 7/30/12, at 9:25 AM, she stated on 6/12/12, Resident 19 reported a loss of $200. The facility did the investigation, but did not report the incident to the Department of Public Health because it did not appear that it was an abuse case. During an interview with the Administrator (Admin), on 7/31/12, at 1:30 PM, she stated they did not report the incident to the Department of Public Health because according to their policy, they would not report theft or misappropriation of resident property to facility management. The facility policy and procedure titled ABUSE PREVENTION PROGRAM, revised 10/3/11, read in part "...Policy Interpretation and Implementation...4. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the Supervisor on duty of the mandated reporter, will notify the appropriate person or agencies of such incident: a. The Ombudsman; b. The Department of Public Health; c. The Resident's Representative of Record; d. Local Law Enforcement (as needed); e. The Resident's attending Physician..." Therefore the facility failed to notify the Department of an allegation of fiduciary abuse within 24 hours in accordance with Health and Safety Code Section 1418.91, this violation is a class "B" violation. |
| 120000399 |
DELANO REGIONAL MEDICAL CENTER D/P SNF |
120011410 |
B |
05-May-15 |
QBHK11 |
4867 |
Health and Safety Code 141.91(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 class "B" citation. On 2/23/15, at 3 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an alleged verbal and physical abuse. Based on interview and record review, the facility failed to report an allegation of verbal and physical abuse by Patient 1within the required timeframe. Findings: Patient 1 was a 60 year old female with diagnoses of Hyperventilation Syndrome (a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly), Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (COPD- to a group of lung diseases that block airflow and make breathing difficult), Respiratory Failure (Inability of the lungs to perform their basic task of gas exchange), and Tracheostomy (the construction of an artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing). She had a Brief Interview for Mental Status (BIMS) dated 11/15/14, score of eleven out of a possible fifteen (11- moderately impaired). During a review of the clinical record for Patient 1, the Social Services notes dated 2/9/15, at 1500 (3:00) PM, read, "...The email stated (sic) that (sic) Patient 1 had complained to her (Registered Nurse) and Respiratory Therapist (RT) that (sic) she (Patient 1) was scared of the two CNA's. She stated that she was afraid because they were rude to her, had made comments that (sic) made her upset and were laughing at her while cleaning her...The resident (Patient 1) stated that (sic) there were two CNA's...that (sic) they were rude to her and mistreated her. She stated that (sic) the two CNA's had attitude and when she asked them to be careful they would sigh and say, "We know we know we know." The resident (Patient 1) said. "I was asking them to be careful because I didn't think they could turn me between the two of them, but they said they could but they pulled my arms. They (CNA 1 and 2) were rough with me and hurt me." She also said, 'When they were moving me they moved my bed and I was not comfortable so I asked them to move my bed and they said well if you can play on your computer you can move the bed and they threw the remote at me." During a review of the clinical record for Patient 1, the written report of the SWA dated 2/9/15, read, "...(Patient 1) exclaimed, "Oh you know what, it had happen on the fifth (5th) then because that was the day of my anniversary and the day my husband brought me a cake..." During an interview with the Social Worker Assistant (SWA), on 2/23/15, at 3 PM, she stated, "I received a message from a charge nurse that Patient 1 complained to her that she (Patient 1) was scared of the two (2) Certified Nursing Assistants (CNA 1 and 2)...The incident happened 2/5/15 and was reported to me on 2/6/15...They were changing her (Patient 1) and a CNA (1) made a comment that if she can use her computer (tablet), then she (Patient 1) can use the remote of her bed. They were rough with her (Patient 1)." During an interview with the Administrator, on 2/23/15, at 3:15 PM, she stated, "...The Registered Nurse was suspended because she received the report of abuse from the patient on 2/6/15, the incident happened on 2/5/15, and she did not report it to the California Department of Public Health until 2/9/15 (3 day after she was made aware of the allegation of abuse)." During an interview with the Registered Nurse (RN) 1, on 3/27/15, at 5:50 AM, she stated, "...On our first day back on 2/6/15, the Patient (1) told the incident to me. She said it happened on the fifth (5th) day of February. Then it was reported on the ninth (9th February). The facility policy and procedure titled "Elder and Dependent Adult Abuse Prevention" under procedure paragraph three read, "All cases of suspected abuse/neglect must be reported to authorities. A person (including employee, volunteer, or other person) associated with the hospital (D/P SNF), who is receiving medical services, has been, is or will be adversely affected by abuse or neglect by any person shall, as soon as possible, report the information supporting the belief to the Department of Health, or the appropriate healthcare regulatory agency, by telephone, in writing or by personal visit." Therefore the facility failed to notify the department of an allegation of verbal and physical abuse within 24 hours in accordance with Health and Safety Code 1418.91. The violation caused or occurred under circumstances likely to have a direct relationship to the health, safety, or security of the patient. |
| 120000399 |
DELANO REGIONAL MEDICAL CENTER D/P SNF |
120011425 |
B |
05-May-15 |
QBHK11 |
6430 |
A 880-72527(a)(9)-Patients' Rights 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 public upon request. Patients shall have the right: To be free from mental and physical abuse. On 2/23/15, at 3 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an alleged verbal and physical abuse of two (2) Staff (1and 2) to a Patient (1). Based on observation, interview, and record review, the facility failed to ensure one patient (Patient 1) was free from verbal and physical abuse from two Certified Nursing Assistants (CNA1and 2), which resulted in Patient 1being afraid and experiencing mental anguish from the verbal and physical abuse. Patient 1 was a 60 year old female with diagnoses of Morbid Obesity, Hyperventilation Syndrome, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, and Tracheostomy Status. She had a Brief Interview for Mental Status (BIMS) score of eleven (11- moderately impaired). During a review of the clinical record for Patient 1, the Social Services (SWA) notes dated 2/9/15, at 1500 (3:00) PM, read, "...The email stated (sic) that (sic) Patient 1 had complained to her (Registered Nurse) and Respiratory Therapist (RT) that (sic) she (Patient 1) was scared of the two CNA's. She stated that she was afraid because they were rude to her, had made comments that made her upset and were laughing at her while cleaning her...The resident (Patient 1) stated that (sic) there were two CNA's...that (sic) they were rude to her and mistreated her. She stated that (sic) the two CNA's had attitude and when she asked them to be careful they would sigh and say, "We know we know we know." The resident said. "I was asking them to be careful because I didn't think they could turn me between the two of them, but they said they could but they pulled my arms. They (CNA 1 and 2) were rough with me and hurt me." She also said, 'When they were moving me they moved my bed and I was not comfortable so I asked them to move my bed and they said well if you can play on your computer you can move the bed and they threw the remote at me." During a review of the clinical record for Patient 1, the Social Services (SWA) notes dated 2/11/15, at 16:39 (4:39) PM, read, "...Resident awoke with verbal stimulation but had sad facial expression...Resident began to cry and was stating that she was upset because she wasn't sure if she did the right thing by reporting because she felt like that staff was treating her different...the resident stated, 'When they come in now they don't talk to me they just do what they need to do and they leave'." During an interview with the Social Worker Assistant (SWA), on 2/23/15, at 3 PM, she stated, "I received a message from a charge nurse that Patient 1 complained to her that she (Patient 1) was scared of the two (2) Certified Nursing Assistants (CNA 1 and 2)...The incident happened 2/5/15 and was reported to me on 2/6/15...They were changing her (Patient 1) and a CNA (1) made a comment that if she (Patient 1) can use her computer (tablet), then she (Patient 1) can use the remote of her bed. They were rough with her." During an interview with the Administrator, on 2/23/15, at 3:15 PM, she stated, "...The Certified Nursing Assistant (CNA) 1 was suspended and terminated later. She was also suspended before because of allegation of being rude to a patient." During a concurrent observation and interview with Patient 1 in her room, 2/23/15, at 3:30 PM, she stated while holding her computer (tablet). "...They (CNA 1 and 2) need to put the bed flat and I was using my tablet. I told them to be careful with my operation, they said (CNA 1 and 2) they could but still they pulled my arms when they turned me They were rough with me and hurt me. I asked them to sit me back up. I didn't have strength on my finger. One of the CNA's (1) told me if I can use and play with my tablet, then I can use the remote of the bed to move on...I was afraid that's why I told my husband to stay...The CNA (CNA 1) on the left side was the one who talked to me about the tablet." During a review of the personnel file of CNA 1 dated 4/29/14, a disciplinary action, final written warning was issued to her on 4/29/14. It read, "...CNA) 1 was reported being rough to Resident (AM). This resident (AM) stated that she is rough during care and seems in a rush each time. This resident was emotionally affected, was crying and insisted on not having her (CNA 1) again as her CNA. The husband confirms with the resident and really concern about other residents that are not able to communicate." During an interview with the Registered Nurse (RN) 1, on 3/27/15, at 5:50 AM, she stated, "The Patient (1) informed me that one of the CNA's (1) told her if she can play with the computer she can also push the button of the bed remote herself...She even told me that while they were changing her pad they were rough with her (Patient 1)." During an interview with the Respiratory Therapist (RT), on 3/27/15, at 6:15 AM, she stated, "It was in the Patient's (1) room with the Charge Nurse. She (Patient 1) told us the two CNA's ((1 and 2) were rough with her (Resident 1) while changing her. She asked one of the CNA's (1) to adjust her bed but she said CNA (1) responded that 'If you can use your computer then you can do it with your remote.' She (CNA 1) threw the bed remote to her (Patient 1)." The facility policy and procedure titled "Suspected Child, Adult, Disabled Person or Elderly Abuse / Neglect / Exploitation" dated 8/22/12, under Policy read, "Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. It is the policy of the hospital (D/P SNF) to protect patients from real or perceived abuse, neglect, exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members." The facility failed to ensure Patient 1 was free from verbal abuse which adversely affected her physical and emotional well-being. Therefore the above violation presented a substantial probability that a serious physical and emotional harm to the patient would result and constitute a Class "B" citation. |
| 120001440 |
Dinuba Healthcare |
120011437 |
B |
12-May-15 |
23VF11 |
2125 |
1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 2/20/15, an unannounced visit was made to the facility to investigate a compliant regarding an alleged incident of abuse reported by Patient 1. Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health within 24 hours of the discovery of the allegation, which had the potential for other abuse allegations to go unreported.On 2/13/15, the Department received a complaint concerning an allegation of abuse reported by Resident 1 to medical clinic staff during a medical appointment. During an interview with the Director of Nursing (DON) on 2/20/15 at 9:59 AM, she stated Resident 1 made an allegation of abuse while she was at a medical clinic appointment. When asked if the allegation of abuse by Resident 1 was report to the Department, she stated, "No, we did not." The clinical record for Resident was reviewed. The Social Services Notes dated 2/13/15, indicated Social Service received a call from the Ombudsman stating she had received a call from the medical clinic staff informing her that Resident 1 had made an allegation she was being abused at the facility and refused to return to the facility.During a concurrent review of Resident 1's clinical record and interview with the DON on 2/20/15 at 11:21 AM, she verified the Ombudsman had notified the Social Service Department on 2/13/15 concerning the allegation of abuse made by Resident 1. The facility policy and procedure titled "Abuse Policy and Procedure" undated, read "If abuse is suspected or confirmed, a report will be made within 24 hours to the appropriate state agency." This policy and procedure did not include the Regulation concerning reporting allegations of abuse to the Department. Therefore the facility failed to notify the Department of an allegation of abuse within 24 hours. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120011566 |
A |
23-Jun-15 |
PTLS11 |
6621 |
F 323 - Accidents - 483.25 (h) The facility must ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents.On 3/2/15, at 2:05 PM, an unannounced visit was made to the facility to investigate an entity reported incident of a fall with injury. Based on interview and record review, the facility failed to adequately supervise one sampled resident (1) while in the dining room who was at high risk for falls. This failure resulted in Resident 1 falling and sustaining a fractured left hip.Findings:Resident 1 was a 90 years old female who was admitted to the facility on 10/31/14 with diagnoses of Alzheimer's disease (a chronic, progressive cognitive disorder), senile dementia (general loss of cognitive abilities including impairment in memory), and anxiety disorder.The document titled "Fall Risk Assessment" dated 11/1/14 indicated a score of 14 and on 2/6/15 indicated a score of 12 (total score of 10 or above represents High Risk for falls).The Minimum Data Set (MDS, assessment tool) dated 2/6/15 was reviewed. The "Brief Interview for Mental Status (BIMS-a brief screener that aids in detecting cognitive impairment)" score was 3 out of 15 (severe cognitive impairment). The "Functional Status" under the "Transfer...Self Performance..." was coded as 3 (extensive assistance-resident involved in activity, staff provide weight bearing support)..."Walk in Corridor...Self Performance..." was coded as 2 (limited assistance-highly involved in activity, staff provide weight bearing support)..."Support..." was coded as 3 (two or more persons physical assist)..."The care plan dated 2/6/15, indicated "Resident is at risk for falls secondary to weakness, impaired cognitive skills and safety judgement, gets up quickly without regards to safety. Resident is non-compliant with care, does not call for help when resident needs something especially with transfer. Resident is high risk for fractures... Fall risk score: 12... Approach... Observe frequently and place in supervised areas when out of bed... Frequent staff monitoring for steadiness and balance... Frequent verbal reminder so [sic] safety issues and the complications of fall as well [sic] the importance of calling for help whenever resident needs anything...Staff awareness of resident's risk for falls and history of falls...". The "Plan of Care (Actual Fall)" dated 2/14/15, indicated "Resident with actual fall secondary to/Risk factors... Strength deficit/weakness... History of falls... Impaired cognitive skills and safety judgement... potential for: Fractures... Fall risk score: 14". The care plan dated 2/16/15, indicated "Resident has diagnosis of left hip fracture. (Status Post - condition after) fall on 2/14/15..."The "Licensed Nurses Progress Notes" dated 2/14/15, at 6 PM, indicated in part, "...Upon hearing an alarm in the dining room, I attended to the alarm and saw the resident out of her w/c, unattended, ambulating in the middle of the floor next to the dining room table. Resident fell on the floor next to the dining room table... assessed for any injuries. No injuries noted..."The "Investigation of unusual occurrence report... Time of investigation: 2/17/15 at 9 AM... Date incident occurred: 2/14/15 at 6 PM...", indicated in part "...Monday 2/16/15 - RNA's (restorative nursing assistants) were attempting to assist resident with ambulation when resident started complaining of pain to her left hip. Physician was notified who then ordered x-ray of the left hip. Results came back with "subcapital fracture of the left hip (a break at the top of the long thigh bone where it fits into the hip socket)... Summary of interview/Summary of investigator's findings... She was up in the (wheelchair) in the dining room during dinner time, when (Licensed Vocational Nurse-LVN 1) heard the alarm and saw resident walking by the table. He was about within 10 feet from the resident, when resident fell and could not get to her on time..."During an interview with Certified Nursing Assistant (CNA) 1, on 3/2/15, at 3:35 PM, she stated, "(CNA 3) told (CNA 2) to pick up (assist the resident out of the dining room) resident (Resident 1) in the dining room because she was by herself". CNA 1 added, CNA 2 did not assist Resident 1 from the dining room so Resident 1 remained by herself in the dining room.During an interview with LVN 1, on 3/4/15, at 8:50 AM, he stated, "When I walked into the dining room, Resident 1 was already up in her wheelchair. Resident 1 got up by herself. She was all alone. I was around 7 feet away from her when she fell. I can't [sic] grab her to prevent the fall. While ambulating she fell on her left side".During an interview with Registered Nurse 1, on 3/4/15, at 9:08 AM, she stated, "There was no CNA in the dining room (when Resident 1 fell). The dining room was in front of the nurses' station. Her alarm went on. It happened so fast. We couldn't catch her. CNAs should not leave resident while eating".During an interview with CNA 2, on 4/20/15, at 5:05 PM, she stated she was told by another CNA to take Resident 1 out of the dining room. CNA 2 stated she went to check Resident 1. She saw she was still eating. She proceeded to help another resident. CNA 2 stated she did not take Resident 1 out of the dining room. She added, "I thought someone was still there (referring to the dining room)".The document "Diagnostic Laboratories" dated 2/16/15 indicated, "Exam: (Left) Hip...Pain Pelvis/Hip Upper Thigh... Results: ... There is a subcapitellar fracture (a fracture located just below the head of a bone that pivots in a ball-and socket joint) at the left hip..."The facility policy and procedure titled "Fall Prevention" review dated 4/29/14, indicated "Purpose: ...monitor residents who are risk for falls. The goal of this program is to reduce both incidences of falls and injuries that may accompany fall... Procedures: ... 11...Based upon the Fall Risk Assessment, if the resident is assessed as a high risk (10 or above), the licensed nurse will: ... implement a plan of care for falls... 111...A. The staff...will identify appropriate interventions to minimize incidence [sic] falls and reduce the risk of falls... E. Staff will identify and implement relevant interventions... to try to minimize serious consequences of falling..."Therefore, the facility failed to adequately supervise Resident 1 while in the dining room who was high risk for falls which resulted in Resident 1 falling and sustaining a fractured left hip and constitute a "Class A" citation. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120011608 |
A |
17-Aug-15 |
WPH911 |
5812 |
F221 The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. On 6/24/15 at 8:38 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of improper physical restraint of a resident. Based on observation, interview, and record review, the facility failed to protect one of one sampled resident (1) from involuntary physical restraint when a staff tied Resident 1's legs together with a small blanket to prevent Resident 1 from getting out of bed for staff convenience. This failure resulted in Resident 1 having emotional and psychosocial distress.Resident 1 was an 83 year old female with a history of bipolar disorder (A mood disorder characteristically involves cycles of depression and elation), Alzheimer's disease (behavioral pattern associated with subjective distress, functional disability, or impaired interactions with others or the environment), dementia with delusions and depression (a loss of mental functions accompanied by incorrect beliefs not based on reality and a biologically based illness that affects a person's thoughts, feelings and behavior), diabetes (a serious disease in which the body cannot properly control the amount of sugar in the blood), congestive heart failure (a condition in which the heart is unable to maintain adequate circulation of blood in the body). The MDS (Minimum Data Set-an assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 6/15, severely cognitively impaired. During a review of the clinical record for Resident 1, the "Licensed Nurses Progress Notes", dated 6/18/15, at 3:55 PM, indicated in part "...Resident [1] is in bed noted that she is restless and with baby blanket tied to her legs/both lower leg." During an interview with the Director of Nursing, on 6/24/15, at 8:54 AM, when asked if there was a staffing issue, she stated, "No staffing issue."During an observation on 6/24/15, at 9:05 AM, in Resident 1's room, Resident 1 was not in her room. Resident 1's bed had both 1/3 side rails up, beam alarm (wireless alarm) attached at the foot board, bed at a normal height, no bed sheets, and a small blanket on top of the bed.During an interview with Resident 1, on 6/24/15, at 9:15 AM, when asked if she remembered the day when someone tied her legs with a small blanket, she stated, "They tied my legs because they don't want me to get out of bed." When asked how she felt about it, she stated, "It's awful." When asked if she was scared of staff in general, she stated, "Kind of. This is the only place I've been, I don't know if other places will also tie your legs."During an interview with Resident 1's daughter, on 6/24/15, at 9:28 AM, she stated, "My Mom pulls all the blankets thinking someone will tie her legs again."During an interview with the Housekeeper, on 6/24/15, at 11:07 AM, when asked about the incident on 6/18/15, in Resident 1's room, she stated, "I went to clean the room and I saw her [Resident 1] legs were tied so I ran outside [the room] and reported to the first person I saw [Activity Director]. Resident [1] was crying and restless."During an interview with Certified Nursing Assistant (CNA) 1, on 6/24/15, at 3:10 PM, when asked what happened on 6/18/15, in Resident 1's room, she stated, "Resident [1] was restless since the start of the shift. Resident [1] was in bed because her wheelchair was being washed." When asked what she did to Resident 1, she stated, "I tied her legs with a small blanket, below her knees." When asked the reason for tying Resident 1 up, she stated, "I just want to protect her [Resident 1] from falling, she was putting her legs down first." When asked if Resident 1 had fallen before, she stated, "No. Resident [1] had never fallen out of bed." When asked what she did after tying Resident 1's legs, she stated, "It was the end of the shift, I was behind with my charting. I left the resident [1] and went to the Nurses' station to do my paperworks." When asked if she asked for help when Resident 1 was restless, she stated, "No. I did not think about that." When asked if she could get an extra wheelchair to replace Resident 1's while the wheelchair was being washed, she stated, "I did not think of looking for one." CNA 1 stated, "I'm sorry, Ma'am, I did not mean to hurt the resident [1]. It was a mistake."The facility policy and procedure titled, "Physical Restraints", dated 7/25/11, indicated in the Purpose: "To ensure that written policies and procedures concerning the use of restraints and postural supports are followed and to establish guidelines for the use of restraints. To ensure residents' right to be free from any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Policy Statements: It is the policy of this facility that each resident reach his/her highest practicable well-being in an environment that prohibits the use of restrains for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Restraints: Any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body."Therefore, Resident 1 was restrained for staff convenience when CNA 1 tied Resident 1's legs to prevent her from getting out of bed, so that CNA 1 could complete her charting, which presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120012162 |
B |
18-Apr-16 |
VJ6211 |
2693 |
Health and Safety Code Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of the section shall be a class "B" violation. Based on observation, interview, and record review, the facility failed to report allegations of abuse within 24 hours to the California Department of Public Health for one of one sampled resident (1) which had the potential for abuse incidents to go unreported.On 2/17/16 at 9 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an incident of alleged resident abuse. During an interview with Family Member (FM 1), on 2/17/16, at 8:40 AM, she stated, "Saturday [2/6/16], my brother picked him [Resident 1] up [from the facility] to take him out to lunch. We saw his [Resident 1] arms were bruised up, there's a fluid built up. [Resident 1's] legs were checked, there was a big skin peeled off like somebody kicked him. His arms' bruises looked like someone held him down." When asked if she reported, she stated, "I went to the facility and talked to the nurse. They claimed they called me to notify me of the bruises but I did not receive the phone call because they called my husband's cell phone." During a review of the clinical record for Resident 1, the "Licensed Nurses Progress Notes", dated 2/6/16, at 2:05 PM, indicated, "Received a call from [FM 1] saying that brother called her and said that we (nurses) have to hold [Resident 1] just to give medication and suspicious why [Resident 1] has the skin tear and bruise." During an interview with the Director of Nursing (DON), on 2/17/16, at 9:20 AM, when asked if the allegation of abuse was reported within 24 hours, she stated, "No. It was not reported within 24 hours because [FM 1] did not indicate anything about abuse on Saturday [2/6/16] when she came to the facility. All she wanted was an investigation of the bruising of her father [Resident 1]." During an interview with the Social Service Director (SSD), on 2/17/16, at 9:25 AM, she stated, "I reported and filled up the SOC 341 on 2/8/16." The facility policy and procedure titled, "Reporting Abuse to Facility Management", undated, indicated, "All employees and persons working in a Long-Term Care facility are mandated by California Law to report incidents of resident abuse or suspected incidents of abuse. Such reports shall be made without fear of retaliation from the facility or its staff." This policy did not indicate the facility was to report to the Department incidents of alleged abuse as per the regulation. |
| 120000325 |
Delano PostAcute Care |
120012461 |
B |
15-Aug-16 |
HW9W11 |
8532 |
F 226 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Based on interview and record review, the facility failed to implement it's policy and procedure for abuse prevention for two of 12 sampled residents (2 and 12) when four staff (Administrator, Director of Nursing (DON), Social Services Designee (SSD) and Licensed Nurse (LN) 3) were made aware of allegations of sexual abuse. The allegations of abuse were not investigated, not reported, and the patients were not protected. This failure resulted in Resident 2 and Resident 12 suffering emotional fear and mental anguish. These failures have the potential for abuse to be widespread, unrecognized, not investigated or reported. Findings: 1. During an interview with Resident 12's family member on 5/11/16, at 4:20 PM, she stated, "My mother made an allegation about sexual abuse that occurred early 2016 (January) or late 2015 (December). She told me that a CNA (Certified Nurse's Assistant) came up behind her and hugged her, the CNA's hands cupped my mother's breasts, then moved her hands down to my mother's privates..." During a record review and interview with the Administrator and the DON, on 5/11/16, at 5:20 PM, they stated, "That didn't actually occur. We investigated this inappropriate hugging and determined the allegation was not true." The DON stated, "It was not a sexual abuse allegation after I spoke with her. I met with the daughter. It was care planned. We didn't report the incident to the Department because we didn't think it happened." The Administrator provided a document she identified as the facility's investigation dated 3/18/15. The Administrator stated, "The DON investigated the allegation and I wrote it because he doesn't like to write." The document was unsigned. The Administrator stated she had not spoken with Resident 12 about the alleged incident. The Administrator identified the previously unnamed CNA as CNA 19. CNA 19 was not suspended during the investigation. During a review of the clinical record for Resident 12, the Minimum Data Set (MDS, an assessment tool used to identify care needs), dated 4/6/16, indicated Resident 12 had a BIMS score of 15 (Brief Interview for Mental Status [BIMS-a cognitive assessment tool with a score from 0-15.] A score of 0 is severe mental impairment compared to a score of 15 with no mental impairment). The "Behavioral Symptoms" care plan, not dated, indicated "False accusations about sexual things hx (history)." During an interview with Resident 12, on 5/12/16, at 11:58 AM, she was asked about her care plan indicating "accusations about sexual things." She stated that back around December at approximately 4 AM, she was standing facing the nurses' station and all of a sudden someone hugged her from behind and squeezed both of her breasts. Patient 12 stated, "I got so scared, I turned and looked at her. Her face was on my shoulder. She, (CNA 19), then held both of my hands and put my hands to my private (Resident 12 placed her hands cupped on her vaginal area) and squeezed. Then she (CNA 19) took my hands and put them on her (CNA 19's) private area... That evening (LVN [Licensed Vocational Nurse] 3), came into my room, I told her... I also told my daughter." Resident 12 stated that LVN 3 told her that she would talk to her (CNA 19)." Resident 12 identified CNA 19 and stated that neither the DON nor the Administrator talked to her about the incident. During a second interview with Resident 12's daughter, on 5/15/16, at 12:30 PM, she stated, "I thought hard about the date after we spoke. It was later than what I told you... I am not exactly sure, but the incident occurred sometime in March or April, 2016. I walked into my mother's room while she was telling the SSD about the incident." During an interview with CNA 19 on 5/16/16, at 8:56 AM, CNA 19, stated "Yes, I hugged her out in the hallway by the nurses' station... Back in March the Administrator and the DON talked to me about hugging her (Resident 12) and they told me to never hug her again... I kept working my regular schedule. They never removed me from the schedule until now..." During an interview with the Administrator on 5/16/16, at 10:55 AM, she stated, "I am the Abuse Coordinator. I didn't get the 'hands on breasts and private area'. I thought I did investigate it at the time, but now I realize the investigation was insufficient." The Administrator verified there was no documentation of the alleged incident within Resident 12's clinical record and no notation of the alleged incident in CNA 19's personnel file. She stated, "I'm going to do that." The Administrator checked her records and stated the facility had not reported any allegations of abuse to the Department since 3/10/15 through 5/10/16. During a concurrent interview and clinical record review with the DON, on 5/16/16, at 5:28 PM, he reviewed the clinical record and was unable to find documented evidence of Resident 12's report of sexual abuse. The DON stated, "I did the care plan but we did not report it to the Department because we (DON and Administrator) determined that's not abuse... We (DON, and Administrator) spoke to (CNA 19) and told her not to hug the resident anymore..." 2. During an interview with Resident 2 on 5/12/16, at 11:58 AM, she was asked about her care plan indicating "accusations of staff..." She stated, "It was night time and I was sleeping and woke up because I felt someone touching my part" (she pointed to her vaginal area). Resident 2's face began to frown, her voice began to crack and lowered her tone of voice. She turned and looked around her. She stated, "I'm scared to go to sleep, because I'm scared that those two girls (unidentified) are coming back to my room. One girl grabbed my hands, I couldn't move... I told my husband and the owner (DON)... I also told the skinny activity girl". She pointed to the Social Service Designee (SSD). During a review of the clinical record, the MDS, dated 4/6/16, indicated Resident 2 had a BIMS score of 9. The "Behavioral Symptoms" care plan, not dated, indicated "Resident (2) stated false accusations, accusations of people slapping her... Accusations of slap to resident face from staff... Resident states she wish she dies..." The "Social Work Progress Notes," dated 4/28/16, indicated "SSD notified R (resident's) daughter of R accusations and asking that her family take her home." During a concurrent interview and clinical record review with the SSD, on 5/16/16, at 3:32 PM, the SSD stated, "...Yes, she (Resident 2) did tell me about two weeks ago that two girls went into her room and touched her private... I told the DON... I did not document her accusations, I just documented "accusations" on my note... we did not investigate." During an interview with the DON, on 5/16/16, at 5:43 PM, he stated, "I didn't do an investigation because I did not consider that as abuse... I did the care plan of 'false accusations'." The facility policy and procedure titled "Abuse Policy" dated 7/2015, Indicated "The facility will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occupancies; 4. Identification of possible incidents or allegations which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and, 7. Reporting of incidents, investigations, and facility response to the results of their investigations. Purpose: to ensure that facility staff are doing all that is within their control to prevent occurrences of abuse... Process: The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse...5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the Administrator or designee and other officials in accordance with state law... 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... 6.1 Enter allegation into the abuse tracking form." The above violation has a direct or immediate relationship to the patients' health, safety and security. |
| 120000325 |
Delano PostAcute Care |
120012463 |
B |
15-Aug-16 |
HW9W11 |
1532 |
Health and Safety 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) Based on interview and record review, the facility failed to report an alleged abuse allegation for one sampled patient (12) to the Department within 24 hours. During an interview with Patient 12's daughter on 5/11/16, at 4:20 PM, she stated, "My mother made an allegation about sexual abuse that occurred early 2016 (January) or late 2015 (December). She told me that a Certified Nurses' Assistant (CNA) came up behind her and hugged her. The CNA's hands cupped my mother's breasts, then moved her hands down to my mother's privates." During a record review and interview with the Administrator and the Director of Nurses, on 5/11/16, at 5:20 PM, they stated, "That didn't actually occur. We investigated this inappropriate hugging and determined the allegation was not true." The Director of Nurses stated, "It was not a sexual abuse allegation after I spoke with her. I met with the daughter. It was care planned. We didn't report the incident to the Department because we didn't think it happened." The Administrator provided a document she identified as the facility's investigation of the alleged incident dated 3/18/15. In accordance with Health and Safety Code section 1418.91, this violation is a class "B" violation. |
| 120000325 |
Delano PostAcute Care |
120012465 |
B |
15-Aug-16 |
HW9W11 |
1666 |
Health and Safety 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 class "B" violation. On 5/16/16, at 5:45 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding Patient 2's sexual abuse allegation. Based on interview and record review, the facility failed to report an alleged sexual abuse allegation to the Department within 24 hours for one sampled patient (2). This has the potential to result in a delay in investigating abuse. During an interview with Patient 2, on 5/16/16, at 3:20 PM, she stated she made an allegation about sexual abuse which occurred the night of 4/27/16. She stated, "I was sleeping and woke up because I felt someone touching my part (vaginal area) two girls...One girl held my hands I couldn't move." During an interview and clinical record review with the Social Service Designee (SSD), on 5/16/16, at 3:32 PM, SSD stated Patient 2 did inform her and the DON of the sexual abuse allegation on the morning of 4/28/16. SSD stated, "We did not investigate the allegation." During an interview with DON, on 5/16/16, at 5:20 PM, he reviewed the clinical record and was unable to find documented evidence of the sexual abuse allegation investigation. DON stated, "That did not occur, she makes false accusations towards staff... I did not report the allegation to the Department." In accordance with Health and Safety Code section 1418.91, this violation is a class "B" violation. |
| 120000399 |
DELANO REGIONAL MEDICAL CENTER D/P SNF |
120012699 |
B |
1-Nov-16 |
0B7411 |
4963 |
F309-483.25 The facility must ensure that- Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Based on observation, interview, and record review, the facility failed to ensure one Resident (4) was free from pain during care of his wound. This failure resulted in Resident 4 having pain during the procedure. Findings: Resident 4 is a 53 year old nonverbal male, with a diagnosis of Anoxic Brain Injury (an injury to the brain caused by a lack of oxygen), Stage 4 Decubitus Ulcer to coccyx (a sore caused by pressure that is very deep, reaching into muscle and bone and causing extensive damage) with infection consisting of E.Coli (bacterium commonly found in the intestines of humans and other animals) and Proteus Mirabilis (a bacterial species found in putrid meat, infusions, and abscesses). Resident 4 is completely dependent upon staff for all aspects of care. During a review of the clinical record for Resident 4 the Wound Consultant Notes dated 9/29/16, at 5:53 PM, indicated Resident 4 had a stage 4 coccyx (tail bone) wound. The wound nurse documented the wound was tender and necrotic (dead tissue), with slough ( yellow tissue that consist of pus). The Infectious Disease Consult report dated 10/5/16, by the Infectious Disease Medical Doctor (IDMD) indicated Resident 4's "wound was deep ... able to probe the bone." During an observation on 10/12/16, at 9:55 AM, in Resident 4's room, the resident was observed on his right side. Wound Nurse (WN) 1 was observed removing the dressing to Resident 4's coccyx. Licensed Vocational Nurse (LVN) 3 was assisting WN 1 with the wound care. When WN 1 began to peel the dressing from the bed of the wound, Resident 4 was observed to be in pain. He began to flail (to wave or swing wildly) his left arm, his body tensed, and his facial expression became tense. After the dressing was removed, Resident 4's body and facial expression relaxed and he stopped flailing his left arm. However, when the IDMD began to assess the size and depth of the wound by placing his gloved hand into the wound, Resident 4 once again began to flail his left arm, and again his body and facial expression became tense. When the IDMD removed his hand from the wound Resident 4 immediately stopped flailing his arm, his body and facial expressions became relaxed. At that time the IDMD asked staff if Resident 4 could feel pain. Staff did not respond. The IDMD gave verbal instructions for staff to pack (with material to increase wound healing) and cover Resident 4's wound. While WN 1 was packing and covering the wound of Resident 4, he once again began to flail his left arm, and again his body, and facial expressions became tense. Resident 4 appeared to be in pain during the entire dressing change procedure. During an interview with WN 1, on 10/12/16, at 11:25 AM, he stated Resident 4 was only able to move his left arm. He was also non-verbal and the only way to assess his pain was by observing his facial expressions. WN 1 stated the non-verbal indicators (arm flailing, facial, and body tensing) were an indication Resident 4 was in pain, and stated, "I was so focused on the wound I failed to see that the resident was in pain." During an interview with LVN 3, on 10/12/16, at 11:50 AM, she stated, "He (Resident 4) was showing signs and symptoms of pain ... Now looking back, I would have pre-medicated the resident before doing any wound care ... We will do it from now on." During an interview with Administrator/DON, on 10/12/16, at 12:03 PM, she stated Resident 4's behaviors during the wound care were an indication he was in pain, and staff should have pre-medicated him. "The wound extends to the bone ... I think we really have an issue with education ..." During an interview with Licensed Vocational Nurse (LVN) 5, on 10/12/16, at 2:45 PM, she stated Resident 4 did not have an order to pre-medicate him prior to his wound care, and she had never been asked to pre-medicate him prior to his wound care. During a review of the clinical record for Resident 4, the care plan titled Alteration in Comfort: PAIN, dated 8/5/16, indicated staff are to anticipate need for analgesic (a drug to relieve pain) to relieve pain, and to assess for pain characteristics. The facility policy and procedure titled Pain Assessments for Adults, dated 10/2015, indicated all clinical staff are responsible for screening patients for pain. When screening for pain, staff are to consider the resident's physical and cognitive limitations. It also indicates that staff must evaluate the non-verbal cues of pain such as restlessness, tenseness, and jerking. Therefore, the facility failed to ensure Resident 4 was free from pain during care of his wound. The above violation has a direct relationship to the health of the resident. |
| 120000325 |
Delano PostAcute Care |
120012757 |
B |
1-Dec-16 |
T1O911 |
3624 |
Health and Safety Code 1418.91(a)(b): (a) A long-term health care facility shall report all allegations 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 10/20/16, at 9:15 AM, an unannounced visit was made to the facility to investigate a complaint regarding alleged financial abuse. Based on observation, interview, and record review, the facility failed to report an allegation of financial abuse to California Department of Public Health (CDPH) which had the potential for abuse to continue. Resident 1 was a 39 year old female with a history of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiplegia (total or partial paralysis of one side of the body), anxiety disorder (ongoing anxiety and worry that interfere with day-to-day activities), major depressive disorder (a mental disorder characterized by at least two weeks of low mood that is present across most situations), and glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight). During a concurrent observation and interview with Resident 1, on 10/20/16, at 9:23 AM, in Resident 1's room, Resident 1 stated, via a Spanish interpreter (CNA 1), she had $773.00 inside the safe box (box used to store money or other valuable things) while she was pointing to the night stand on the left side of the bed. The top drawer of the night stand was noted open and inside the top drawer was a black safe box. Resident 1 stated the safe box had a key but she just threw the key in the top drawer. Resident 1 stated she last checked the money on Tuesday (10/11/16), she did not check the money on Wednesday (10/12/16), and when she checked the safe box on Thursday (10/13/16), the money was gone. Resident 1 stated the facility knew she had the money. During an interview with Social Services Designee (SSD), on 10/20/16, at 10:20 AM, she stated the facility started the investigation the day (10/13/16) the resident informed the facility she lost her money. During an interview with the Administrator, on 10/20/16, at 10:36 AM, she stated she did not report the incident to the department. Administrator stated she was not reporting "Losses." During an interview with CNA 2, on 10/20/16, at 10:50 AM, she stated two to three weeks ago, Resident 1 went to the nurse's station with the envelope containing money. CNA 2 counted the money with the resident and there was more than $800.00 in the envelope. CNA 2 stated Licensed Nurse (LN 1) was also in the station when she counted the money with Resident 1. During an interview with LN 1, on 10/20/16, at 10:55 AM, she verified Resident 1 had money and she was at the nurse's station when Resident 1 and CNA 2 counted the money. The facility policy and procedure titled "Misappropriation of Resident Property" release date 4/05, indicated under PROCEDURE "...3. When an alleged or suspected case of misappropriation of resident property is reported, the facility administrator, or his or her designee, will notify the following persons or agencies of such incident: Regional Vice President of Operations; Risk Management; law enforcement officials; Ombudsman; resident's representative; and Adult Protective Services." The facility's policy and procedure did not include reporting to the California Department of Public Health as per the above regulations. |
| 120000638 |
DELANO DISTRICT SKILLED NURSING FACILITY |
120013405 |
B |
7-Aug-17 |
THMN11 |
16876 |
F309-483.25
The facility must ensure that-
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.
An unannounced recertification survey was conducted at the facility during the dates of 6/5/17 to 6/8/17.
Resident 20 was a 69 year old female with the diagnoses of Parkinson disease (a chronic disease of the nervous system that usually strikes in late adult life, resulting in a gradual decrease in muscle control), Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety, Alcohol dependence, Major Depressive disorder (a mental health condition in which feelings of sadness, loss, anger, or frustration interfere with daily life for weeks or longer), Epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hypertension (elevated blood pressure). Resident 20 had been a resident at the facility for over three years and had been prescribed multiple Central Nervous System (a nervous system, includes brain and spinal cord, integrates information it receives from, and coordinates and influences the activity of all parts of the bodies, CNS) depressants.
The facility failed to perform a comprehensive assessment to identify immediate care needs, initiate monitoring, and develop and implement an individualized plan of care for one of 24 sampled residents (20), when Resident 20 had a significant change in condition secondary to binge drinking. These failures resulted in Resident 20's two falls, vomiting, and two emergency room visits.
Binge Drinking - according to the "Center for Disease Control and Prevention- https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm" binge drinking is the most common form of excessive drinking and is defined for women as consuming four of more drinks during a single occasion. A drink is considered 45 milliliters (ml) of 40% alcohol distilled spirits or liquor (gin, rum, vodka, whiskey).
According to "FDA.GOV [Food and Drug Administration]" Central Nervous System (CNS) Depression - is specifically the result of inhibited brain activity that can lead to decreased rate of breathing, decreased heart rate, profound sedation, and loss of consciousness possibly leading to coma or death. CNS depression is generally caused by the use of depressant drugs such as ethanol (alcohol), narcotic pain medications, anxiety medications, sleep medications, muscle relaxants, and antidepressant medications. Alcohol acts as a Central Nervous System (CNS) depressant and when a resident is seriously intoxicated may lead to falls, blur speech, or vomiting (https://www.atsdr.cdc.gov/csem/csem.asp?csem=12&po=9).
During an observation and concurrent interview with Resident 20, on 6/5/17, at 9:19 AM, she stated, "I messed up. I got drunk over the weekend and today." Resident 20 had a grimaced facial expression and was visibly upset as she sat in her wheelchair.
During a review of the clinical record for Resident 20, the document titled "Minimum Data Set" (MDS, a standardized and comprehensive assessment tool), dated 4/13/17, indicated she had a Brief Interview for Mental Status (BIMS) score of "15" (the highest score possible, which indicated she was cognitively intact, and had the capability to appropriately process perception, memory, judgment, and reasoning).
During a review of the clinical record for Resident 20, the document titled "Special Problems", dated 6/4/17, at 5:30 AM, indicated "When checking on resident at around [5:30 AM] I noticed a bottle of vodka on the floor on the left side of her bed. I asked [Resident 20] if she had drank[sic] it but [Resident 20] didn't respond. Vodka bottle was empty."
During a review of the clinical record for Resident 20, the document titled "Licensed Nurses Progress Notes," dated 6/4/17, indicated the following entries:
7 AM: "Reported that CNA [Certified Nursing Assistant] from the [night] shift saw empty bottle of Vodka on the floor . . . also [Resident 20] slept the whole night which is not her usual routine."
11:30 AM: "Saw curling iron on . . . CNA told [Resident 20] if she will still use it. [Resident 20] was kind of sleepy and stated I don't know."
12:30 PM: "DON [Director of Nursing] was notified of above concerns."
12:45 PM: "[Resident 20] was up in W/C [wheelchair] . . . Told that she's taking a lot of medication which may interact (with alcohol)."
3 PM: "[Medical Doctor] aware."
6 PM: "[Resident 20] still has vodka at bedside 1 1/2 bottle . . . Nurse went three times to talk to her, she doesn't listen. She looks like little drunk . . . ."
The documentation indicated Medical Director (MD) 1 was not notified until nine and half hours after she was first found drunk and Resident 20 continued to drink.
During an interview with Licensed Vocational Nurse (LVN) 5, on 6/7/17, at 3:08 PM, she stated Resident 20 went "out on pass" (she temporarily left the facility) on Saturday 6/3/17, and purchased vodka. Resident 20 was noted Sunday (6/4/17) morning in her room by the night shift CNA. LVN 5 stated, "Sunday morning I checked her, she was drowsy. I found an empty bottle of vodka on the floor. Today (6/7/17) she vomited about twice."
During a review of the clinical record for Resident 20 the documents titled "Licensed Nurses Progress Notes," dated 6/5/17, indicated the following entries:
10:30 AM "[T]old [Resident 20] that medication and alcohol doesn't mix. [Resident 20] respond don't give me medication then. Explained risk of taking alcohol [and] medication could possibly lead to death . . . ."
4 PM: "s/p [status post] alcohol intake . . . ."
6:35 PM: "[Resident 20] found lying on the floor near her foot end of bed, her W/C [wheelchair] was next to her head when asked she said she didn't fall; leave me alone. She sounds drunk. She drink [sic] about 400 ml [milliliters - a unit of measurement] of vodka the one she keep at bedside." 400 ml of vodka is 220 ml more than what CDC classifies as excessive drinking.
During a review of the clinical record for Resident 20 the document titled "Interdisciplinary Form," dated 6/5/17, at 10:30 AM, indicated "[Facility staff] was worried about her because of all the medications she is taking which includes but not limited to antidepressant, anti-anxiety, sleeping pills, and other medications that mixed with alcohol could be fatal . . . I asked her if she drank this morning because her speech was somewhat slurred and she said she didn't. However, when I got near her, she had the smell of alcohol. I continued on informing her of the risk of drinking which may even lead to death . . . ."
During a review of the clinical record for Resident 20, the document titled "Resident Accident/Incident Report and Investigation Report," dated, 6/6/17, indicated Resident 20's fall on 6/5/17 was related to alcohol intoxication. The "recommended actions and interventions" indicated "1:1 observed drinking." There was no comprehensive assessment found in the resident's chart since the discovery of her alcohol intake.
During a further review of the clinical record for Resident 20, the documents titled "Medications Flowsheet," indicated Resident 20 received the following medications, all of which would depress the CNS according to the FDA:
A. Ativan (an anti-anxiety agent) 0.5 mg (milligrams - a unit of measurement) ordered to be given twice a day was administered on 6/4/17 at 4:30 AM, and 12 PM, on 6/5/17 at 4:30 AM, and on 6/6/17 at 4 AM and 12 PM.
B. Tylenol with codeine (a narcotic pain medication) ordered to be given three times a day was administered on 6/4/17 at 4 AM, 10 AM, 4 PM, on 6/5/17 at 4 AM, and on 6/6/17 at 4 AM and 4 PM.
C. Metoclopramide 5 mg (a medication that helps with digestion) ordered to be given once a day was administered on 6/4/17, 6/5/17, and 6/6/17 at 4 AM.
D. Levocetirizine 5 mg (an allergy medication) ordered to be given once a day was administered on 6/4/17 and 6/6/17 at 8 AM.
E. Benadryl 25 mg (an allergy medication) ordered to be given at bedtime was administered on 6/4/17 and 6/6/17 at 8 PM.
F. Metoprolol 25 mg (lowers blood pressure) ordered to be given once a day was administered on 6/4/17 and 6/6/17 at 8 AM.
G. Clonidine 0.1 mg (lowers blood pressure) ordered to be given twice a day was administered on 6/4/17 at 8 AM and 5 PM, and 6/6/17 at 8 AM.
H. Prozac 10 mg (anti-depressant) ordered to be given once a day was administered on 6/4/17 and 6/6/17 at 8 AM.
I. Lyrica 75 mg (pain reliever) ordered to be given twice a day was administered on 6/4/17 at 8 AM, 8 PM, and on 6/6/17 at 8 PM.
J. Ambien 5 mg (helps to sleep) ordered to be given at bedtime was administered on 6/4/17 and 6/6/17 at 8 PM.
K. Baclofen 10 mg (a muscle relaxer) ordered to be given at bedtime was administered on 6/4/17 and 6/6/17 at 8 PM.
During a review of the "Nurses Medication Notes" dated 6/5/17 for Resident 20, the following entries were noted:
8 AM: a licensed nurse attempted to administer due medications to Resident 20, but the resident had refused to take them, which included Prozac, Clonidine, Lyrica, levocetirizine, and metoprolol.
10 AM: a licensed nurse had attempted to offer Resident 20's routine Tylenol with Codeine three times, but the resident refused.
12 PM and 2 PM: a licensed nurse attempted to administer Resident 20's schedule medications three times, which included Ativan, but Resident 20 refused.
PM (evening shift): a licensed nurse attempted to administer Resident 20's scheduled medications three times during the evening, including Tylenol with codeine and clonidine, but Resident 20 again refused.
The facility licensed staff acknowledged the interactions between alcohol and these prescribed medications, there was no documentation the licensed staff had assessed Resident 20's condition for signs or symptoms of CNS depression. The licensed staff continued offering Resident 20 the prescribed medications.
During an interview with MD 1, on 6/8/17, at 12:16 PM, she stated the facility had called her associate over the weekend (the on call physician covering for MD 1 on 6/4/17 to provide him an "FYI [for your information]" and did not inform him of the seriousness in Resident 20's condition. MD 1 stated "If [Resident 20] presented with signs and symptoms of alcohol intoxication, I [MD 1] would not have given her narcotics, sleepers, or muscle relaxers. [When] giving meds while intoxicated, there is a potential for syncope [temporary loss of consciousness], episodes of dizziness, coma, and up to death. [Resident 20] told me that she has been drinking again for the last two months. I would expect the nurses to use clinical judgement when administrating medication to residents."
During a review of the clinical record for Resident 20 the document titled "Special Problems," dated 6/6/17, at "NOC" indicated, "[Resident 20] pressed her call light various times throughout the night, when answering [Resident 20] stated she needed help when answering what kind of help she stated I don't know at around [2:15 AM] [Resident 20] stated she was scared and wanted me to stay in the room with her for the remaining shift. [Resident 20] was told that I would check up on her but also other residents needed my help. [Resident 20] was assured she would be ok and I would check on her periodically. [Resident 20] continued to press her call light and only wanted me to attend to her. Charge nurse aware." There were no assessments completed by a licensed nurse found in her records.
During a review of the clinical record for Resident 20 the document titled "Licensed Progress Notes," dated 6/6/17, indicated the following entries:
6:30 AM: "[W]as continuously on the light telling somebody need to stay (with) her and also she asking for bottle of wine."
6:45 AM: "CNA told that she [Resident 20] wants to passed out...[Resident 20 stated] she feels dizzy, feels she's gonna passed out and she has pain on the back of her head. . ."
6:50 AM: Resident 20 was sent to the Emergency Department via ambulance for "fall and drunk confused."
10:45 AM: Resident 20 had returned from the Emergency Department for refusing treatment.
12:45 PM: Resident 20 vomited and requested to go back to the Emergency Department.
12:55 PM: Resident 20 was sent out via ambulance to the Emergency Department a second time that day.
4:40 PM: Resident 20 returned to the facility and continued to complain of nausea and anxiety.
6:03 PM: Resident 20 "was found sitting on floor between beds in her room . . . slid [and] fell sitting on the floor."
During an interview with LVN 2, on 6/7/17, at 3 PM, she stated Resident 20 was independent in meeting her needs, but over the last few days had a change in condition where she now required staff assistance.
During a clinical record review for Resident 20, the Emergency Department document titled "Physician," dated 6/6/17, at 8:43 AM, indicated Resident 20, "states she had a fall yesterday and doesn't remember it, c/o [complains of] dizziness, feeling of passing out upon arrival and severe back of head pain, also c/o nausea at this time . . . . The patient presents following fall and alcohol intoxication . . . ." The document also indicated Resident 20's blood alcohol level was "92" or 0.092 percent. For reference, California law considers operating a motor vehicle with a blood alcohol concentration at .08 percent or higher as "Driving Under the Influence" because at this level or above, responses greatly slowed, behavior greatly affected, and at high risk of accident.
During an observation and concurrent interview with Resident 20, on 6/7/17, at 3:16 PM, she stated "I'm still vomiting. I bought a little bottle of vodka and a big one. I drank the small one first. I drank the big one on and off over the weekend after drinking the small one. I was drunk."
The Facility Care Plan for alcoholism was initiated on 6/5/17, two days after she was found binge drinking.
During an interview with the Director of Nursing (DON), on 6/7/17, at 3:35 PM, she stated "Saturday night [6/3/17] I was called that [Resident 20] was drunk." The DON stated she was aware of Resident 20 being drunk on 6/4/17, falling and being drunk on 6/5/17, and continuously throwing up on 6/7/17. The DON stated, "My expectation is that the nurses should have called the doctor and got the medications held."
During an observation and concurrent interview with Resident 20 on 6/8/17, at 11:29 AM, she stated "I feel lousy, I'm still nauseous." Resident 20 stated she had finished the big bottle of vodka on Monday morning [6/5/17], and "I don't remember falling because I passed out drunk. On Monday [6/5/17], I refused to take the meds because I didn't want to mix it while I was drunk." Resident 20 stated nursing had continued to offer her medications throughout the day on 6/5/17, but she would refuse. Resident 20 was alone in her room, had a grimaced facial expression, and would rub her stomach area throughout the interview. She had a waste basket and small towels to her surrounding area to use while having episodes of nausea and vomiting.
During an interview with Pharmacy Consultant 1, on 6/8/17, at 2:32 PM, he stated the medications administered to Resident 20 should not have been given while she was intoxicated, stating "[T]hese medications could contribute to her fall and vomiting."
The facility policy and procedure titled "Change of Condition," dated 10/13/16, indicated "Notify the attending physician promptly, representative or family member when there is . . . A need to alter treatment significantly, (i.e., . . . a need to discontinue an existing form of treatment due to adverse consequences or resolution, or to commence a new form of treatment)."
Therefore the facility failed to perform a comprehensive assessment to identify immediate care needs, initiate monitoring, and develop and implement an individualized plan of care for one of 24 sampled residents (20), when Resident 20 had a significant change in condition secondary to binge drinking. These failures resulted in Resident 20's two falls, vomiting, and two emergency room visits. Resident 20 was not provided 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. |
| 630004081 |
Department of State Hospitals - Coalinga D/P ICF |
150007657 |
A |
16-Apr-12 |
92XB11 |
7467 |
T22 DIV5 CH4 ART3 - 73313 (a) Nursing Service - Drug Administration Nursing service shall include but not be limited to the following, with respect to the administration of drugs: (a) Medications and treatments shall be administered as prescribed and shall be recorded in the patient's health record.T22 DIV5 CH4 ART3 - 73521. Patient Care Policy Committee. Written patient care policies shall be established and followed in the care of patients governing the following services: physician, dental, nursing, dietetic, pharmaceutical and an activity program and such diagnostic, social, psychological and therapy services as may be provided. Such policies shall be developed by a committee whose membership shall consist of at least one physician, the administrator, the supervisor of health services and such other personnel as may be appropriate. These policies shall be reviewed and revised by the committee at least annually and minutes of the committee meetings shall be maintained on file indicating the names of members present, the subject matter discussed and action taken. The facility failed to comply with the above regulations and ensure that the correct type of Insulin was administered as prescribed to Patient 1 resulting in a transfer to the urgent care room and potential for serious harm or/and death. Furthermore the facility failed to follow Nursing Policy and Procedures #504 Administration of Medications and #513 Administration of Insulin which indicate, "Insulin is given by licensed nursing staff after the proper type(s) of insulin and dosage has been verified by a second licensed nursing staff." The facility failed to have two licensed staff verify the type and dosage of the insulin with the physician order before it was given, as follows:Clinical record and document review starting on 9/27/2010 indicated Patient 1 was a 69 year old male with Diabetes Mellitus, Type II(Insulin dependent) admitted to the facility on 3/6/2006.The physician orders dated 8/11/10, prescribed Lantus Insulin 35 Units subcutaneous injection daily at 7:00 PM (1900 hours). The physician orders indicate that Patient 1 may administer his own Insulin under staff supervision. However, an Individual Competency for Self Administration of Insulin dated 3/19/09 failed to address the facility policy requiring two licensed staff to verify the correct Insulin before the patient self-administered. On 8/18/10 at 6:10 PM Patient 1 incorrectly received 35 units of Regular insulin. The correct medication ordered by the physician was Lantus insulin 35 units at 7:00 PM. Staff A, a licensed psychiatric technician provided Patient 1 with the incorrect insulin without benefit of a second licensed staff witness. Interdisciplinary Notes (IDNS), Urgent Care Report (UCR) and physician orders indicate at 6:40 PM, Patient 1 was transferred to the UCR due to complaints of blurry vision and a temperature 99.1, pulse 86, respirations 24, blood pressure 131/70, oxygen 99 %, and blood glucose 185. (Glucose levels vary before and after meals, and at various times of day; the normal range for most people is about 80 to 110 mg/dl.)The Urgent Care Record, Physician orders and Medication Variance Report indicated Patient 1 required 7 tubes of Glucose, intravenous DSW solution, 25 grams of intravenous Dextrose, orange juice, packets of sugar and candy over five hours to keep his blood glucose levels within his normal range. Patient 1 was attended in the UCR until 11:15 PM under observation of a Registered Nurse and physician before being considered stable for transfer back to his home unit.Regular or short-acting insulin begins to work in about 30 minutes. It peaks 2 to 3 hours after injection, and works 3 to 6 hours. Regular insulin is used to help control the spike in blood sugar that occurs with meals. It is typically used in combination with long-acting insulin. Lantus is long-acting insulin injected once a day at the same time each day. The most common side effect of insulin is low blood sugar (hypoglycemia), which may be serious. Some people may experience symptoms such as shaking, sweating, fast heartbeat, and blurred vision. Severe hypoglycemia can be dangerous and can cause harm to the heart or brain. It may cause unconsciousness, seizures, or death. Review of Nursing Policy and procedure # 513 Administration of Insulin, dated 7/22/2010 indicated that "Insulin is given by licensed nursing staff after the proper type(s) of insulin and dosage has been verified by a second licensed nursing staff." "Leave needle in the vial for 2nd check."Nursing #504 Administration of Medications, dated 5/29/2007 stated "All injectable dosages of insulin or anticoagulant mediations must be checked by two (2) licensed nursing personnel. Check the Medication Administration Record (MAR), the physicians order, the label on the vial (for name, strength, dosage and expiration date), and the prepared syringe (for amount)."Interviews beginning on 9/27/2010 indicated, Staff A said in an interview with Staff B, ACNS on 9/26/10 at 2 PM, he neglected to check the label of the insulin and gave the wrong type of Insulin to Patient 1 to self-administer. Staff A also said he incorrectly assumed Patient 1 was the appropriate person to perform the "second person check" because Patient 1 self-administered his own insulin.In a telephone interview with Patient 1 on 9/26/10, he stated that Staff A did not show him the Insulin vial that the dose was withdrawn from. He further stated that Staff A handed him a syringe with the insulin already prepared. Patient 1 said he never had seen a second licensed person verify the correct type and dosage of insulin. Patient 1 said after receiving the Insulin he laid upon his bed but began "feeling strange." Patient 1 went back to the medication room and asked Staff A, what did you give me? According to Patient 1 at that time Staff A looked at the Insulin vial discovering it was the incorrect insulin.Interviews with facility management confirmed the failure of a second person check for insulin was a facility wide concern and until this incident occurred a second licensed check had not been occurring.The facility Pharmacist said in interview on 10/20/2010 that on a one to ten basis, ten being the worst, this was a ten and the patient could have died. The facility failed to follow their own Nursing Policy and Procedures #504 Administration of Medications and #513 Administration of Insulin which indicate, "Insulin is given by licensed nursing staff after the proper type(s) of insulin and dosage has been verified by a second licensed nursing staff." This failure was facility wide placing all patients receiving insulin at risk. The facility failed to comply with the above regulations and ensure that the correct type of Insulin was administered as prescribed to Patient 1 resulting in a transfer to the urgent care room and potential for serious harm or /and death. Furthermore the Facility failed to follow Nursing Policy and Procedures #504 Administration of Medications and #513 Administration of Insulin which indicate, "Insulin is given by licensed nursing staff after the proper type(s) of insulin and dosage has been verified by a second licensed nursing staff." The facility failed to have two licensed staff verify the type and dosage of the insulin with the physician order before it was given. These violations presented a substantial probability of death or serious physical harm to patients. |
| 630004081 |
Department of State Hospitals - Coalinga D/P ICF |
150008241 |
A |
16-Apr-12 |
S8D411 |
9145 |
T22 DIV 5 CH4 ART 3-73311(a) NURSING SERVICE GENERAL Nursing service shall include, but not be limited to, the following: (a) Identification of problems and development of an individual plan of care for each patient based upon initial and continuing assessment of the patient's needs by the nursing staff and other health care professionals. The plan shall be reviewed and revised as needed but not less often than quarterly. T22 DIV 5 CH4 ART 4 -73523(a)(9) PATIENT RIGHTS a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to comply with the above regulations to keep Patient 1 free from harm, and failed to assure nursing service on Unit 25 identified his problems, and developed an individual plan of care based on an initial and continuing assessment of his needs, as follows:Clinical record and document review starting on 10/20/10 indicated Patient 1 is 46 year old male admitted to the facility on 8/19/09. The Wellness and Recovery Plan, dated 8/11/10 indicated Patient 1's psychiatric diagnoses included Schizoaffective Disorder with depression and /or euphoric moods and delusions. His medical diagnoses included seizure like activity and chronic low back pain. He was independent in his Activities of Daily Living (shower, toileting, eating), and had been medication compliant.On 9/10/2010 Patient 1 was transferred for evaluation to the facility urgent care service for an altered level of consciousness and later admitted to the Medical Acute Unit MA-2 (MA2) from ICF Unit 25.A physical examination completed on MA2 found multiple extensive bruising all over his body including his trunk, back, and legs which had not been identified on the patient's home residence Unit 25.. Additionally, Patient 1 was noted to be "obtunded" and have "fine tremors of the lips, slow movement and flat affect." He was started on IV therapy due to dehydration and labs were drawn. On the initial work-up, he was found to be severely dehydrated and have an elevated Creatinine Phosphokinase (CPK) of 2460 and was transferred to community care via ambulance for emergency treatment on 9/10/10 at 2310 hours (11:10 pm).Normal values of CPK are between 60 and 400. On 9/11/10 Patient 1 was returned to the facility with a diagnosis of Rhabdomyolysis.According to the Medline Plus, service of U.S. National Library of Medicine and National Institutes of Health, Rhabdomyolsis is diagnosed when the CPK level is very high; it usually means there has been injury or stress to the heart, the brain, or muscle tissue. For example, when a muscle is damaged, CPK leaks into the bloodstream. The disorder may be caused by any condition that results in damage to skeletal muscle, especially trauma. When muscle is damaged, a protein pigment called myoglobin is released into the bloodstream and filtered out of the body by the kidneys. Myoglobin breaks down into potentially harmful compounds. It may block the structures of the kidney, causing kidney damage, failure or necrosis. Rhabdomyolsis has many causes. The common ones include muscle trauma or crush injury, severe burns, physical torture, prolonged lying down on the ground (people who fall or are unconscious and are unable to get up for several hours), prolonged coma, severe muscle contractions from prolonged seizures. Treatment includes early and aggressive fluids to prevent kidney damage, dialysis, medications, and rest. People with milder cases may return to normal activity within a few weeks to a month or more. However, some continue to have problems with fatigue and muscle pain. On 10/20/11 Patient 1 said in interview he had been sexually assaulted and physically beaten by other individuals in his dorm about a week prior. He said he had become depressed and did not tell because he was afraid for his life.There had been documentation of a significant change occurring in Patient 1's condition on Unit 25; not showering for eight days, no solid meals for 4 or 5 days, decompensating in the last week, but no evidence of a complete and thorough identification of the problem or development of a written plan of care. For example:An RN change in status note dated 9/10/10 at 0350 a.m. with a line thru it and 3:50 p.m. written in, indicated that that at 0350 a.m., the "individual doesn't look good and smells bad stays in room laying in his bed most of the time hasn't eaten breakfast or lunch." The note continues to document that Patient 1's "right arm cast is intact but dirty with stain of feces, he smells bad with flies following him for not showering for 8 days..." An RN transfer note written by Unit 25 WRP RN Staff A dated 9/10/10 at 5:15 p.m. indicated Patient 1 was brought to the UCR by two Unit 25 staff to be evaluated for changes in his physical condition. The written note described Patient 1 as having difficulty maintaining conversation, saliva drooling out both sides of his mouth, speech garbled, unable to follow directions, tremors noted upper extremities, no solid meals for 4 or 5 days, mucous membranes inside mouth dry, tenting present on skin, rigidity present in all four extremities. Patient 1 is disheveled, odoriferous, smells of feces, staff report of Patient 1 defecating on himself and cast over the past few days. An Interdisciplinary Note (IDN) dated 9/10/10 at 7:45 p.m. (1945) indicated that Patient 1 was having "bizarre medical ailments and has been decompensating in the last week or so, defecating on self, has shuffling gait, slobbering on himself, refusing to go to meals and sent to UCR for further evaluation by medical doctor." An IDN written 9/9/10 at 2300 - late entry for 0120 a.m. indicated that Patient 1 had defecated on himself in his room and ignored staff direction to clean up- lying on his bed. Review of the Activities of Daily Care Flow Sheet for 9/1 - 9/10/2010 indicate of the 30 opportunities for meals there are 22 refusals and /or blank areas of documentation and 2 notes of 25 % or less eaten.The physician on MA2 said in interview on 10/20/10 at 11 am the pattern of injuries and bruising appears inconsistent with reported fall injury from the staff on Unit 25 and the individual when admitted. He said that on 9/14/10 Patient 1 confided in an interview to Staff C he had been sexually and physically assaulted by his peers in the dorm. The MA2 staff reported the interview to facility management.Facility Police Report date 10/20/10, Case # 10092632 indicated: a. Patient 1 had reported to Hospital Police Officer (HPO), Staff B he had fallen out of bed. b. Staff A medically assessed Patient 1 and told Staff B, HPO the bruising on Patient 1's legs was an allergic reaction. c. 16 Special Incident Reports were completed between 8/18/10 and 9/10/11 of Patient 1 falling down, having seizures and blacking out and injuries received from seizures and falling down on the floor. d. Multiple bruising all over Patient 1's body from unknown causes which was photographed by Staff B on 9/11/10.There is no indication the facility investigation reviewed the weeks previous to the admittance of Patient 1 to MA2 to assure appropriate care and services had been provided.The facility policy and procedure titled "Incident Management System" dated 8/3/10 indicated the system is to establish requirements for investigations that involve abuse, neglect, or exploitation, and for protecting individuals while the investigation is conducted. Policy and procedure titled "Special Incident Reports" dated 9/9/10 indicated report investigations shall be complete and accurate and include precipitating events, known early warning signs and actions taken to protect the individual.Additionally, the facility did not report an allegation of sexual abuse as its facility policy and procedure titled "Duty to Warn, Inform, and Report Abuse and Serious Threats, dated 12/9/09 inaccurately indicated that an allegation of sexual assault does not require a Report of Dependent Adult Abuse (SOC 341).The facility failed to comply with the above regulations and keep Patient 1 from harm, failed to identify and develop an individual plan of care based on an initial and continuing assessment of his needs by the nursing staff and other health care professionals when he had a significant change in condition manifested by 16 Special Incident reports, bowel incontinence, multiple meal refusals, drooling, shuffling gait, falls and lastly the facility investigation failed to identify the causes of the multiple extensive bruising resulting in life threatening Rhabdomyolysis. These failures resulted in a transfer to the facility urgent care service and then transfer to an outside acute care hospital.These violations presented a substantial probability of death or serious physical harm to patients. |
| 150001227 |
Department of State Hospitals - Napa |
150008370 |
B |
12-Apr-12 |
LJEM11 |
10683 |
WELFARE AND INSTITUTIONS CODE SECTION 5325.1(c)Persons with mental illness have the same legal rights and responsibilities guaranteed all other persons by the Federal Constitution and laws and the Constitution and laws of the State of California, unless specifically limited by federal or state law or regulations. No otherwise qualified person by reason of having been involuntarily detained for evaluation or treatment under provisions of this part or having been admitted as a voluntary patient to any health facility, as defined in Section 1250 of the Health and Safety Code, in which psychiatric evaluation or treatment is offered 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 mental illness shall have rights including, but not limited to, the following: (c) A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect. Medication shall not be used as punishment, for the convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program.Title 22 DIV5 CH4 ART4-73519(a)(1) Administrative Policies and Procedures (a) Written administrative policies shall be reviewed and revised at least annually and shall include the following: (1) Written management and personnel policies to govern the administration of the intermediate care facility shall be established and implemented. Job descriptions detailing the functions of each classification of employee shall be written and available to all personnel. The facility failed to ensure patients' right to be free from neglect when it failed to establish and implement policies and procedures that promoted healthy nursing work hours and patterns that did not extend beyond the limits of safety for patients. A registered nurse who routinely worked double shifts over multiple days in succession was reported sleeping while assigned to enhanced observation of patients on more than five occasions, yet the facility did not prevent the nurse from continuing the same work patterns and further endangered patients in her care, as follows:A review of Patient 1's Wellness and Recovery Plan (WRP) dated 11/23/10 documented the diagnosis of Schizophrenia. The WRP indicated Patient 1 had a pattern of aggression toward others and victimization by others. During an interview on 4/18/11, the Acting Unit Supervisor (AUS) stated Patient 1 was assaulting staff and peers daily without provocation. The AUS stated Patient 1 was at risk for victimization due to his intrusive and assaultive behavior. For this reason, Patient 1 was on enhanced supervision of close in-sight observation (CIO) for protection of himself and others. The AUS stated CIO means the patient must be in line of sight at all times. During interview on 5/2/11, the Acting shift Lead (ASL) stated Staff A was assigned to provide CIO for Patient 1 on 9/22/10. The ASL stated Staff A was sitting in a chair in the hallway. The ASL stated the door to Client 1's room was closed at the time and Patient 1 was not in Staff A's line of sight. When the ASL asked about Patient 1, Staff A stated Patient 1 was in his room resting. When the ASL opened the door of Patient 1's room, he was not inside.A review of a police report dated 11/17/10 indicated Patient 1 was located in a bathroom at the far end of the hall ten minutes after he was discovered missing. The police report documented Staff A was previously reported after being observed with eyes closed and head bent down while providing enhanced observations on 6/15/09, 1/31/10 and 2/5/10. A review of attendance records documented Staff A was regularly scheduled to work the night shift beginning at 11 p.m. and ending at 7 a.m.Her regular work site was Unit Q-4 in Program One. After each scheduled night shift in January 2010, Staff A stayed over to work a day shift ending at 3:15 p.m. Less than 8 hours later Staff A returned to work again at 11 p.m.Staff A also worked one or two overtime shifts on her scheduled days off. On two occasions Staff A worked extra shifts in Program Five. Staff A worked 30 of 31 days in January 2010. During that time, Staff A worked 22 double shifts. On three occasions, including January 31, 2010, Staff A worked 5 successive days of double shifts with less than 8 hours break between work periods. A review of a payment history indicated Staff A worked 244 hours of overtime during January of 2010.[" ... Ongoing sleep deprivation of as little as an hour a day can lead to a sleep debt over time that is not easily erased ... When we have a sleep debt, our inclination to fall asleep the next day increases. The larger the sleep debt, the stronger the tendency to fall asleep ... Sleeping is the only way to erase sleep debt ... Reduced vigilance, reaction time, memory, psychomotor coordination, and decision making are the traits of the sleepy individual ... Involuntary episodes of sleep lasting 10-20 seconds, known as "microsleeps," are common. Such brief losses of attention can appear to others as a blank stare, head snapping, prolonged eye closure, or failure to respond to outside stimuli ... Often the person is not aware that a microsleep has occurred ... to prevent neurobehavioral deficits from accumulating, the average person needs slightly more than 8 hours of sleep per 24-hour period..." A Wake-up call for Nurses: Sleep Loss, Safety, and Health L.A. Stokowski, RN,MS. http://www.medscape ...] Attendance records indicated Staff A had a break of less than 8 hours between two double shifts on 2/5/10 when she was observed sleeping on duty for the third time.Staff A continued to work a similar pattern for the month of February without a day off. She worked 229 hours of overtime in February 2010. On five occasions in February, Staff A did extra shifts in Program Five. Staff A's personnel file reflected a counseling memo dated 3/1/10 indicated, "Your sleeping while on duty ... is unacceptable and cannot be tolerated, you put the individual, others, and yourself in danger. This is a form of abuse/neglect and reportable by law ... You will not be permitted to do enhanced observation assignments. You will not prehire or volunteer for one month, however you can be mandated ..."Attendance records indicated Staff A worked fewer double shifts in March of 2010. Records from April 2010 until June 2010 indicated Staff A returned to the pattern of successive days of double shifts with only one day off during those three months. Staff A continued to work in her regular program, Program One, but also worked extra shifts in Programs Three and Five. Records indicated Staff A worked more than 220 hours of overtime each month from April to September of 2010. A mini-memo dated 9/23/10 indicated, "On 9/20/10, (Staff A) was observed to have her head down while doing CIO. I whistled @ her twice in an attempt to catch her attention as one of the clients was standing by her watching and smiling. Unfortunately she must be soundly asleep not to feel somebody is close by her or to even respond to an unusual noise @ noc. This is not acceptable as she's putting herself @ risk and others as well." A counseling letter dated 9/21/10 indicated, "On September 20, 2010 at one thirty in the morning you were reported sleeping during your assignment of constant in sight observation. Sleeping during a work assignment will not be tolerated and is to cease and desist immediately, (sic) This puts both you and others at risk of harm. You are restricted from performing a constant insight observation assignment ..." A review of an incident report dated 9/22/10, one day after Staff A was restricted from performing CIO, documented Staff A was providing CIO for Patient 1 when Patient 1 was discovered missing as described above. Patient 1 was living on Unit Q-5 in Program Five.A review of attendance records of September 2010 documented Staff A did extra shifts in Program Five on four occasions and in Program Four on one occasion prior to the incident on 9/22/10.The police report dated 11/17/10 documented Staff A had done 209 hours of overtime and 152 hours of regular time between 9/1/10 and 9/22/10. The police report dated 11/17/10 indicated staff members reported Staff A often fell asleep during enhanced observations and they feared for her safety. During an interview on 5/2/11, Staff A stated she was continuing to work overtime and do double shifts. A review of attendance records from January 2011 until April 2011 documented Staff A continued to work the regular night shift and an additional overtime day shift on all scheduled days. On her days off she worked one or two additional shifts. A review of the administrative directive entitled, "Staffing Sequence/Overtime Guidelines ..." dated 1/28/10 indicated, "... Staff within the program will be utilized to meet staffing requirements. ... The Program Director is ... responsible for monitoring the overtime worked by individual employees to ensure they are not working overtime to an extent that it adversely affects their health or performance."During an interview on 5/2/11, the Nursing Coordinator stated there was no way to monitor staff members who volunteered to float from one program area to another to work extra shifts. The Nursing Coordinator stated Staff A took an assignment to do CIO in another program without informing program management. The Nursing Coordinator stated plans to restrict individuals from overtime or enhanced observation assignments were confidential personnel matters and such information does not pass between programs. The Nursing Coordinator stated it was Staff A's responsibility to decline enhanced observation assignments.A review of the facility policies, "Job Classification: Registered Nurse" dated 9/22/10, "Employee Ethics and Conduct" dated 12/24/09, and "Enhanced Observation of Individuals" dated 7/1/10 did not reflect discussion of the facility or nurses' responsibilities to ensure work patterns did not endanger patient safety.Therefore, the facility failed to ensure the patients' rights to be free from neglect when it failed to establish and implement facility procedures to ensure staff work patterns did not extend beyond the limits of safety. After being reported for falling asleep on duty over five times, a nurse continued to work multiple successive double shifts every month increasing the risk of further patient neglect. These facility failures had a direct or immediate relationship to the health, safety or security of long-term care facility patients. |
| 150001227 |
Department of State Hospitals - Napa |
150008371 |
B |
10-Jan-14 |
GSFK11 |
7622 |
CCR T22DIV22ART 1 73519(a)(1)(a)Written administrative policies shall be reviewed and revised at least annually and shall include the following: (1) Written management and personnel policies to govern the administration of the intermediate care facility shall be established and implemented. Job descriptions detailing the functions of each classification of employee shall be written and available to all personnel. CCR T22DIV5ART 1 73523(a)(9) (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 violated the above regulations when staff members failed to follow facility procedures regarding employee ethics and conduct as well as reporting, investigation, and response to allegations of abuse, neglect, and mistreatment. Four staff members failed to report abuse when a certified female staff member (Staff A) violated professional boundaries, had sex with a male patient (Patient 3), continued to associate with Patient 3 after his discharge, and took money from Patients 1 and 2 in exchange for illicit drugs and other contraband as follows: During an interview on 5/2/11, a Registered Nurse, (Staff B), stated that during July 2009, Patient 2 reported that Staff A was providing illicit drugs to Patient 1. Patient 2 told Staff B that Staff A had an intimate relationship with a patient on the unit and conceived a child. Staff B stated she reported the allegations directly to the county District Attorney and did not report the allegations to the facility police at that time. Staff B stated a few months later, in September 2009, she overheard two staff members, Staff C and D, discussing Patient 1's reports that Staff A owed Patient 1 money. Staff B stated she reported that allegation immediately to the Unit Supervisor, Staff F at that time. During an interview on 4/18/11, Staff C stated Staff D asked for advice after Patient 1 complained that Staff A owed patients money. Staff C stated she told Staff D to report the allegations.During an interview on 5/3/11, Staff D stated Patient 1 came up to her and said Staff A had borrowed money from her (Patient 1). Patient 1 stated she needed to pay some guys back or they would be mad and there might be violence. During the interview, Staff D stated she reported the allegations to Staff E.During an interview on 6/11/11, Staff E stated Patient 1 came up to him in an agitated state punched the door and asked for Staff A stating, "That [B----] better have my money." Staff E stated he reported the allegation to the Unit Supervisor, Staff F. A review of a special incident brief dated 9/14/09, documented an incident four days earlier on 9/10/09, when Patient 1 approached a staff member asking for assistance in the collection of money Staff A owed Patient 1.During an interview on 10/22/09, the Unit Supervisor (Staff F) stated she filed the report of fiduciary abuse against Staff A. Staff F stated several staff members reported Staff A owed Patient 1 money. Staff F stated she questioned Patient 2 who reported that Staff A was taking money from patients and providing drugs, cigarettes, and coffee. Patient 2 reported Staff A had sex with Patient 3 and the two conceived a child while he was a patient. Patient 2 reported that Staff A and Patient 3 continued to socialize after his discharge. A review of a Crime/Incident Report dated 12/7/09, documented the facility police charges against Staff A included violation of Administrative Directive 437 with allegations of sexual abuse, exploitation of individuals, and financial abuse. Staff A was charged with violation of Administrative Directive 378 with allegations of employee misconduct and violation of professional boundaries. In addition, Staff A was charged with dishonesty. A review of Administrative Directive 437 entitled, "ABUSE/NEGLECT AND REPORTING REQUIREMENTS" dated March 26 2009, indicated, "(The facility) will ensure that individuals are protected from harm, and will not tolerate any form of individual abuse and/or neglect ... All instances of suspected or alleged abuse ... and neglect shall be reported immediately upon discovery ..." The policy defined physical abuse, "... assaults, battery, sexual assault and or battery ... " and financial abuse, "... taking, secreting, appropriating, or retaining the property of ... (a) dependent adult." The policy also stated, "... All staff are required to report any incident of abuse, suspected abuse, and /or neglect that they witness or that is reported to them." A review of Administrative Directive 378 entitled, "EMPOLYEE ETHICS AND CONDUCT" dated October 26, 2006, under the heading of, "PROFESSIONAL BOUNDARIES," indicated, "Employees ... have an obligation to keep interactions with individuals served strictly professional, ethical, and business like, and to avoid interactions which could jeopardize treatment, security of safety, or result in any type of abuse ... Employees shall not engage in any personal business or financial transaction with any individual served ... Employees shall avoid any dealing with individuals served that might be reasonably interpreted as exploitation ... Staff shall not have professional or social contact with individuals who have been hospitalized at (the facility) for one year after the individual is no longer at (the facility)." The Crime/Incident Report dated 12/7/09, documented Staff A was placed on administrative leave on 9/11/09. The report indicated sustained allegations of failure to report abuse as directed in policy by Staff B, Staff C, Staff D, and Staff E.The Crime/Incident Report dated 12/7/09, documented that during a police interview on 9/11/09, Patient 1 told officers that Staff A had, "borrowed" money from her and from Patient 2. During an interview on 9/24/09 at 3 p.m., Patient 2 told police that Staff A received $60 on ten or twenty occasions from Patient 2. Patient 2 stated Staff A did not borrow the money from patients, but took money in exchange for various types of drugs. Patient 2 told the officer Staff A had sex with Patient 3, while he was a patient, and had Patient 3's baby. Patient 2 reported the two were still together and involved in drug dealing. The report documented there was a preponderance of evidence to sustain the allegations of sexual abuse, exploitation of an individual, financial abuse, employee misconduct, and violation of professional boundaries by Staff A. The police investigation included surveillance, review of a birth certificate, and review of Computer Aided Dispatch reports of traffic stops and domestic disturbances from 10/25/08 to 9/10/09.The facility failed to ensure implementation of established policies and procedures to ensure individuals were protected from the harm of abuse and to ensure employees maintained professional boundaries. Staff A had a sexual relationship with a patient and continued to associate with the patient after his discharge. Staff A took money from patients in exchange for illicit drugs and contraband. When staff members heard about the abuse they failed to report it as directed in the facility policy. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients. |
| 150001227 |
Department of State Hospitals - Napa |
150008410 |
A |
06-Apr-12 |
V80P11 |
14455 |
T22 DIV5 CH4 ART3 73311(a) - Nursing Services General Nursing service shall include, but not be limited to, the following: (a) Identification of problems and development of an individual plan of care for each patient based upon initial and continuing assessment of the patient's needs by the nursing staff and other health care professionals. The plan shall be reviewed and revised as needed but not less often than quarterly.T22 DIV5 CH4 ART 4 - 73523 (a) (9) - Patient's Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to comply with the above regulations by failing to ensure a patient's right to be free from the harm of physical abuse. A patient with increased frequency and intensity of aggression toward staff and peers did not receive effective interventions to prevent incidents of harm. The facility failed to continually assess a patient's potential need for increased supervision to ensure the safety of patients and staff.These failures resulted in a patient sustaining multiple bodily injuries, including a serious ocular (eye) injury and rib fractures, secondary to an assault by a peer, as follows:Record review on 8/18/10, indicated that Patient 1 had an alert for "Assault" and was at high risk for aggression. Patient 1's diagnoses included schizophrenia, paranoid type, anti-social personality disorder, and poly substance dependence.Physician's orders, dated 8/6/10, indicated that Patient 1 had a level one card. A level one card is a "point -to- point" card that enables patients to go unescorted to clinic appointments, the visiting center... This card requires staff to closely monitor the individual's movement.The Wellness and Recovery Plan, dated 7/8/10, indicated that Patient 1 had threatened or intimidated staff and peers as well as physically attacked them, which has caused significant injuries both while in the community and in the hospital. Nursing weekly progress notes, from 7/27/10-8/3/10, indicated that Patient 1's behavior had remained hostile and unpredictable and he had not been attending groups.Facility documentation indicated on 8/6/10 at 5 p.m., Patient 1 was found standing over a peer who was slumped on the floor barely responsive. Patient 1 was standing on a chair and was stomping on Patient 2's back and torso with his feet several times. IDNs (Interdisciplinary Notes), dated 8/6/10, indicated at 5 p.m., an alarm was activated and a unit psychologist asked for emergency assistance in the sun room. Patient 2 was found slumped on the floor in a sitting position with his head and upper body resting against a chair. His face was swollen, with blood slowly oozing out of his nose. His speech was barely audible and he was slightly cyanotic (a bluish discoloration of the skin due to deficient oxygenation of the blood). The patient was transferred to the acute care hospital. Patient 1 was physically removed, placed in locked room seclusion, given an injection of Chlorpromazine (antipsychotic medication), and was later arrested and taken to jail. A behavioral IDN, dated 8/6/10 at 9:45 p.m., indicated that Patient 1 stated, "I tried to kill someone and I'll do it again." IDNs, dated 8/12/10, indicated on 8/6/10, Patient 1 admitted to physically assaulting a peer in the day room stating he wanted to kill him. Patient 2 remained hospitalized for three days and was discharged on 8/9/10 with discharge diagnoses that included multiple right rib fractures ( ribs 6 through 9), right pneumothorax ( presence of air in the pleural/lung cavity) , small right pleural effusion ( fluid in the pleural cavity), and right retrobulbar hemorrhage (bleeding behind the eyeball). Patient 2's Wellness and Recovery Plan, dated 10/28/10, indicated he was physically attacked in a near fatal manner by a peer and developed acute stress disorder symptoms. Further documentation indicated, he was a victim of a serious assault which was life threatening. He reported nightmares, increase hypervigilance, increased anxiety, and worsened sleep secondary to this assault.The Physician's Progress Transfer Note, dated 8/6/10 at 10 p.m., indicated this assault was without provocation and Patient 1 continues to be physically aggressive towards staff and peers and is frequently placed in seclusion or restraints as well as prn ( as needed) medications for his aggressive behaviors. Patient 1 was transferred to his current unit on 4/14/10 due to verbal and physical aggression towards staff. The Wellness and Recovery Plan included the following aggressive acts since 7/2/10.7/2/10 - Placed in room seclusion at 11:10 a.m. to 12:30 p.m. after he attempted to push in a window at the nurse's station and physically assaulted the unit supervisor by hitting him in the head.7/5/10 at 4:50 p.m. - Threatened to hurt others and was placed in 5 point restraints and given a prn medication. Documentation in the 7/6/10 monthly Psychiatry Progress Notes, indicated the following: "No behaviors indicative of need for consult with PBS (Positive Behavior Support) at this time. Would no favorable response to medication achieved; and his threatening assaultive behavior continues, that will constitute grounds for referral. He is not considered a suitable candidate for 1:1 therapy at this time." 7/6/10 at 8 p.m. - Threatened to hit medication person "31 times" and had a verbal altercation with peer in a fighting stance. Received a prn medication. 7/10/10 at 4 p.m. - Verbally abusive to medication nurse. 7/14/10 (no time documented) - Yelling and screaming about his diet. Restricted from the dining room for three days. 7/16/10 (no time documented) - Cursing, yelling, and demanding a prn medication. 7/19/10 at 6:15 a.m. - Attempted to kick staff and kicked the office door. Was placed in 5 point restraints and received a prn medication. 7/19/10 at 9:35 a.m. - Made sexually inappropriate comments with tense muscles and pressured voice. Received a prn medication. 7/28/10 at 12:30 p.m. - Physical altercation with a peer, verbally threatening to staff, threw mail on the table and spit on the floor. 7/30/10 -Attempted to throw tray at kitchen staff, kicked door to nursing office, and kicked male staff. Placed in room seclusion from 1:48 p.m. to 3 p.m. 8/1/10 (no time documented) - Glaring and threatening dining room staff. "F..K them up later." 8/6/10 (no time documented) - Verbally threatened dining room staff. 8/6/10 at 5 p.m. - Physical assault to peer in the day room stating he wanted to kill him. One month prior to the 8/6/10 incident, numerous multi level committee reviews were conducted for the above aggressive behaviors and included the following: 7/6/10- PRC (Program Review Committee) - reviewed for attacking/hitting the unit supervisor in the head. (triggered 2.2 (any aggression to staff resulting in major injury). Placed in locked seclusion after prns were offered/administered and he would not redirect. Team will update the Wellness and Recovery Plan's "Focus statement 3.1" to reflect his current behavior. Focus statement 3.1 addressed the patient's intimidation and threatening behaviors toward staff.There were no further recommendations. Monthly Psychiatry Progress Notes, dated 7/6/10, indicated due to repeated refusal of WBC (white blood cell) monitoring required for individuals on Clozapine (antipsychotic medication), it was discontinued per protocol. He was placed on a titrating-up dose of Loxapine (a typical antipsychotic). "Off Clozapine and back on a typical antipsychotic (he refused any new generation atypical antipsychotic option), resurgence of his TD (tardive dyskinesia / involuntary repetitive body movements), and EPS (extrapyramidal/movement disorder), (tremors) occurred." 7/13/10- PRC- reviewed for verbally threatening and posturing to fight staff. Placed in 5 point restraint after refusing prn and would not redirect or de-escalate. Recommendation to do medication levels and ensure medication compliance due to increased assaultive behavior. Patient 1 refused to comply with the required white blood cell monitoring and Clozapine had to be discontinued. He reluctantly agreed to be on Loxapine, yet he is still non - compliant with prescribed dose despite repeated psychoeducation. Obtaining medication level is futile at this time.No new interventions were attempted at this time and despite continuing aggressive behaviors, there was still no referral to PBS as per Psychiatry Progress Notes of 7/6/10.7/20/10 - PRC reviewed for physical aggressive act towards staff. "The individual has agreed to take medication so Harper was not pursued. However, staff are concerned that he is not actually taking his medications and the doctor is considering consta or / and liquid medication to ensure compliance." Recommendation: "Please reconsider for possible Harper Hearing due to increased number of assaults." 7/27/10- PRC- reviewed for running after staff and threatening and challenging staff to fight him. Previous recommendation is pending. To be reviewed at ETRC/PSSC later today. No further recommendations. 7/27/10 - ETRC (Enhanced Treatment Review Committee) reviewed for multiple acts and triggers for aggression. Recently assaulted a female staff and ran after another. Had been on Clozaril which was discontinued due to noncompliance with blood draws, after which behaviors started to present.Another medication was tried but he began to exhibit EPS and it was discontinued. Is currently on Zyprexa which has been quite effective in controlling aggression. Team has reported that he is still quite confrontational and verbally aggressive. Recommendations to taper up Zyprexa to therapeutic dose for aggression and psychotic behavior. Refer to Dr. C. for re-evaluation of pain. (The record lacked evidence of a pain evaluation). Additional documentation in the WRP indicated, "As per my discussion of the case at the last ETRC Conf.' his Zyprexa IS ALREADY at an optimal dose. I added another antipsychotic agent (Thorazine) for its calming effect and hopefully antipsychotic effect. This is a treatment refractory case that did not respond well to all other meds except Clozapine.Unfortunately it had to be discontinued due to non - compliance with required blood testing."On 7/29/10, Patient 1 attended the Stress Management Group. At the end of the group he became extremely hostile and threatening. The WRP team met with him to inform him other units request to suspend his off unit group attendance due to his threatening behavior. 8/3/10- PRC - Reviewed for 2 aggressive incidents toward peers and staff. Recommendation: Clarify medication parameters for prn Zyprexa and Thorazine, ensure medication compliance, consider Zydis and Club med (watching individual for specified amount of time and looking for cheeking).Although a recommendation was made in August for "Club Med," record review indicated that according to physician's orders, Patient 1 had already been on a "Club Med" program since 4/14/10. There was lack of documented evidence that a re- evaluation / reconsideration of involuntary medications / Harper was addressed since the PRC review note on 7/20/10. Monthly psychiatry progress notes, dated 8/10/10, (non face to face note-met with individual on 8/6/10 morning) indicated no favorable response obtained on Loxapine (optimized to 50 mg. orally twice daily). EPS symptoms resurged. Lozapine was tapered off and Olanzapine (Zyprexa / an atypical antipsychotic) up to 10 mg. bid was instituted on 7/20/10.Additional documentation in Patient 1's 8/10/10 monthly Psychiatric Progress Notes, reviewed on 8/18/10, indicated the following: Behavioral guidelines/PBS (Positive Behavior Support) plans: "Already consulted with PBS staff regarding his inappropriate behavior despite WRP team efforts to work effectively and closely with him. A meeting was to suppose to occur today 8/10/10 with Dr. W. to discuss plans despite our strong conviction that [Patient 1's] behavior is not psychotically driven but rather a characterological presentation. " Documentation indicated this was a treatment refractory case and only Clozaril was effective. When Clozaril was discontinued (on 6/29/10) and other medications had proven ineffective, behaviors started to present.The monthly PPN previously referenced, dated 7/6/10, indicated "Would no favorable response to medication achieved; and his threatening assaultive behavior continues, that will constitute grounds for referral" (for Positive Behavior Support consult).Subsequent to the 7/6/10 PPN, Patient 1 continued to have multiple additional acts of assault and threatening behaviors requiring restraints, seclusion, and prn medications.No additional protections were put into place in the interim prior to the upcoming PBS meeting scheduled for 8/10/10, four days after the assault to Patient 2.Although changes in medications were attempted, there was no evidence of a continual assessment for the potential need for increased supervision on the unit when Patient 1's behaviors continued and medications were not effective.Some current recommendations made by the team had already been instituted in the past, and despite continuation of aggressive behaviors and ineffective medications, a PBS referral consult was not scheduled to occur until 8/10/10, four days after the assault to Patient 2.During an interview with Staff A on 3/3/11 at 3: 40 p.m., Staff A stated that Patient 1 was "Ok when he got here but progressively got more challenging. It should have been dealt with." " He is a bomb." Staff A further stated, "[Patient 1] was an accident waiting to happen."When asked if there were any changes in Patient 1's supervision level, Staff A stated, " No, but there should have been."The facility failed to ensure an effective plan to protect peers and staff from an aggressive patient with a history of sudden and unprovoked physical aggression and assault.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. |
| 150001227 |
Department of State Hospitals - Napa |
150008411 |
A |
13-Apr-12 |
B7YD11 |
9469 |
T22 DIV 5 CH4 ART4-73521 - PATIENT CARE POLICY COMMITTEE Written patient care policies shall be established and followed in the care of patients governing the following services: physician, dental, nursing, dietetic, pharmaceutical and activity program and such diagnostic, social, psychological and therapy services as may be provided. Such policies shall be developed by a committee whose membership shall consist of at least one physician, the administrator, the supervisor of health services and such other professional as may be appropriate. These policies shall be reviewed and revised by the committee at least annually and minutes of the committee meetings shall be maintained on file indicating the names of members present, the subject matter discussed and action taken. The facility failed to comply with the above regulation by failing to follow their policy and procedures regarding staff escorting individuals, staff to use good judgment in determining if the patient is appropriate to participate in the activity, obtaining approval from the unit supervisor or designee and protect Staff E from serious harm with the potential for death.On 12/13/10, the facility notified the California Department of Public Health by written notice that on 12/11/10, that a patient had assaulted a staff member while on the facility grounds. The staff member was hospitalized with several skull and facial fractures. Review of Patient 1's medical record on 12/14/10, at 1 p.m., revealed that Patient 1 was a male, 23 years of age admitted to the facility on 5/28/09. His diagnoses included Schizophrenia, undifferentiated type, (a disabling disease characterized by disturbed thinking, disorganized speech and frequently frightening behavior), malignant neoplasm of the testes and convulsions. On 12/14/10 at 2 p.m., Staff A was interviewed. Staff A stated, "This patient is extremely dangerous. He is very unpredictable and too dangerous for a 1:1 supervision level. Staff will not volunteer to be his l:1 staff as he has assaulted the staff multiple times without any warning. I go in a different direction to avoid him. He will pace around the nurses' station shadow boxing. I am so afraid of him, that I will hide in the Medication Room when he is walking around and shadow boxing." On 12/14/10 at 2:45 p.m., Staff B was interviewed. Staff B stated that Patient 1 had recently assaulted several staff and peers without provocation resulting in injuries and increasing the fear on the unit among the staff. Staff B stated that Patient 1 has a history of poor response to psychiatric medications and he frequently refused his medications due to his chronic mental illness. On 12/15/10 at 1:30 p.m., Staff C was interviewed. Staff C stated that he was informed by staff on 12/11/10 at 9:35 a.m., that Patient 1 had assaulted StaffE outside the unit, while on a nature walk on the facility grounds. Staff C stated that the Acting Unit Supervisor had advised Staff E that morning, at approximately 8:15 a.m., that Patient 1 had been agitated earlier in the morning and he should not go for a walk at that time. Staff C stated, "Although there were voiced concerns by the Acting Unit Supervisor, the injured staff insisted on taking the patient out without approval by the Supervisor or the Patient's Wellness Recovery Plan Team member." Staff C stated that on 12/11/10, at 8:45 a.m., Patient 1 returned to the unit alone and that the staff had asked Patient 1 about the location of Staff E. Staff C stated that Patient 1 would not answer and that Staff E had been found shortly after that time by the Police Department. Staff C stated that StaffE was found outside of Unit T-2 "bleeding severely from head injuries". On 4/21/11 at 10 a.m., Staff D was interviewed. Staff D stated that Staff E was taken by ambulance to a local acute hospital for emergency treatment for "severe head injuries" on the morning he was found on 12/11/10, and then transferred to another acute hospital for continuing care of his wounds. Staff D stated that Staff E did not follow the facility's policy regarding staff escorting individuals and had used poor judgment. Staff D stated, "The injured staff has worked here for many years, and he was aware of how dangerous and unpredictable this patient can be, yet he did not abide with the facility policy and took the patient out for a walk even after he was cautioned by staff of the potential safety risk." Facility document titled DMH Wellness and Recovery Plan dated 11/23/10, for Patient 1 was reviewed on 4/21/11, at 10:30 a.m. The document indicated that this was a quarterly conference and assessment for Patient 1. Review of this document revealed that Patient 1 had a focused area for Leisure and Recreation which indicated that Patient 1 will demonstrate his ability to use walking as a leisure skill, twice a week. A Rehabilitation note included in this quarterly conference and assessment indicated that Patient 1 had not made progress toward this objective due to severe psychosis and he had not been able to go outside for walks as he was not cooperative with the 1:1 staff to be safe when off of the unit. Facility documents titled Interdisciplinary Notes were reviewed on 4/21/11, at 11 a.m., and indicated the following: On 12/1/10, at 3:30 p.m., staff documented the following: "Patient 1 had assaulted a female staff, punching her in the back of her head, kicking her and elbowed another staff in the face." On 12/7/10, at 8:45 p.m., staff documented the following: "Patient 1 pacing hallway, scattering dirty linen in hallway, attempting to push staff, kicked staff and spit at staff." On 12/10/10, at 9:45 a.m., staff documented the following: "Patient 1 was walking in the hallway, met male staff (custodian) and hit staff on right side of temple resulting in an injury - unknown reason for the assault." On 12/10/10, at 6:45 p.m., staff documented the following: "Patient 1 hit a peer on the right side of his head without any provocation." On 12/11/10, at 8:45 a.m., staff documented the following: "Patient 1 assaulted licensed staff outside of unit - appeared tense with clenched fists when returned from outside without his escort. Licensed staff was found outside of the unit bleeding from head injuries." On 12/11/10, at 9:47 a.m., the staff documented the following: "Patient 1 was arrested by State Police officers and transported to the County Jail." Facility policy #780, Grounds Access Inside Security Treatment Area dated 12/2/10, was reviewed on 4/21/11, at 12:10 p.m. Under the section titled Staff Escort Ratio: General Guidelines revealed that: "Any concerns regarding escorting certain individuals are to be discussed with appropriate Wellness Recovery Plan Team members and/or supervisor." Facility policy titled Duty Statement - Job Classification: Rehabilitation Therapist dated 1/15/01, was reviewed on 4/21/11, at 12:30 p.m. Under #2 - SUPERVISION RECEIVED: indicated that the Rehabilitation Therapist receives general supervision from Program Management. The Rehabilitation Therapist will follow the bylaws of the Medical Staff, and Program/Hospital policies and procedures. Review of the facility document titled Police Department Incident Report dated 12/11/10, on 8/12/11 at 9:30 a.m., indicated that staff documented, at approximately 8:45 a.m., Staff E was observed sitting on the curb with his head down, outside of Unit T-2. Staff documented that Staff E was unable to respond to questions and that Staff E's clothes were "blood stained" and that Staff E appeared to be "weak and sleepy." Staff documented that Staff E had blood on his chin and several injuries to his face and that his sweater was "covered in blood and that his identification badge was completely covered in blood to the point, it was difficult to read his name." Staff continued to document that at approximately 9:05 a.m., staff found the location of the assault where Staff E "woke up and started walking". Staff documented, "I was looking for any signs of an area where he could have been laying on the ground bleeding. I came across a puddle of blood outside Unit T-7 and T-8. The blood on the ground was running south down a decline in the road. The blood was approximately 2 feet in length." Review of acute hospital document titled "Consultation Report" dated 12/12/10, on 8/12/11 at 10 a.m., indicated that Staff E was admitted to the acute hospital on 12/11/10, and that Staff E had been assaulted while walking with a patient who had a history of violence - Staff E had lost consciousness and had amnesia for the actual event. Staff E remembered waking up with blood on his hands and lying face down. Review of acute hospital document titled "Discharge Summary" dated 12/13/10, on 8/12/11 at 10:30 a.m., indicated that Staff E's Admission Diagnosis was assault and that Staff E's Discharge Diagnoses included multiple skull fractures and facial fractures. The facility failed to comply with the above regulation by failing to follow their policy and procedures regarding staff escorting individuals, staff to use good judgment in determining the appropriateness of the individual in participating in the activity, obtaining approval from the Unit Supervisor or designee and protect Staff E from serious harm with the potential for death. These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 150001227 |
Department of State Hospitals - Napa |
150009301 |
B |
29-Aug-13 |
TO0L11 |
3060 |
1418.91(A) 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.The facility failed to comply with the above regulation by failing to report an incident of abuse to the Department immediately, or within 24 hours.On 4/30/12, review of IDNs (Interdisciplinary Notes), dated 4/26/12 at 11:41 p.m., indicated that Patient 1 was on CIO (close insight observation) for assaulting a peer, Patient 2. Before being placed on CIO, Patient 1 had threatened to kill all of his roommates when they were asleep. Review of Patient 2's IDNs, dated 4/27/12 at 9:50 a.m., indicated on 4/26/12 at 4:40 p.m., Patient 2 reported that he had been punched on the face, four (4) times and sustained a cut to his lower lips and a "bruise on the left side of his eyes." Further review of the IDNs, dated 4/26/12 at 11:41 p.m., indicated that Patient 1, while on CIO, was standing in the hallway when he suddenly ran towards the same peer and started punching him.Patient 2's IDNs, dated 4/27/12 at 10:20 p.m. (late entry for 4/26 p.m.), indicated at approximately 7 p.m., Patient 2 was assaulted for a second time. Patient 2 had attempted to dodge punches from Patient 1 but was hit under his outer left eye and next to his left ear. Physician's Progress Notes, dated 4/26/12 at 9:40 p.m., indicated that Patient 2 was punched on his left temporal area near the eye, had scratch marks below his left lower eye lid area, and had a superficial cut in front of his left ear.Further review of the IDNs, dated 4/26/12 at 11:41 p.m., indicated the alarm was activated; staff intervened and pulled Patient 1 to the floor. Patient 1 continued to be verbally threatening, stating, "I [sic] going to kill you before I go to jail." Patient 1 was escorted to the seclusion room to calm down and to take a prn (as needed) medication for agitation. Zyprexa, 10 mg tablet, (an antipsychotic medication) was ordered by the physician. At 7:25 p.m. when the medication nurse, accompanied by two staff and 4 HPO (hospital police officers), went into the seclusion room to administer the Zyprexa, Patient 1 suddenly stood up and punched the medication nurse twice on the face and also threw several punches at the HPO.Patient 1 was immediately contained by the police officers, held on the wall for 5 minutes, and was placed into 5 point restraints.IDNs, dated 4/26/12 at 11 p.m., indicated that Patient 1 was released from 5 point restraints at 11 p.m. and was placed on administrative isolation. IDNs, dated 4/27/12 at "0030" indicated that Patient 1 was taken to jail.The above incident of peer /staff abuse was not reported to the Department of Public Health until 4/30/12. During an interview with Staff A on 4/30/12 at 9: a.m., Staff A stated that he did not hear about the incident until Friday [4/27/12] and that it did not rise to the level to report.This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150009978 |
B |
06-Nov-13 |
3TJ011 |
3126 |
T22 DIV 5 ART 4 73523 (a)(9) (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 comply with the above regulation by failing to ensure a patient's right to be free from abuse when a licensed staff member, employed by the facility, admitted to hitting a patient on the head with a clipboard. Record review on 4/11/13, indicated that Patient 1 had diagnoses that included a history of a CVA (cerebral vascular accident) with right hemiplegia (weakness on the right side), signs of vascular dementia, and disturbances in cognitive functioning which included impulsivity, disinhibition, low frustration tolerance, and aggression. Further documentation indicated that Patient 1 utilized a wheelchair to ambulate himself. A behavioral note, dated 4/10/13, documented that on 4/10/13, Patient 1 was verbally aggressive to staff in the hallway when redirected to calm down. He wheeled himself fast (in the wheelchair) and could have accidentally hurt someone. Patient 1 was offered to go to the side room to calm down but he refused. He continued to wheel himself fast in the hallway.An Interdisciplinary Note, dated 4/10/13 at 8:30 a.m., documented that Patient 1 reported, "...he accidentally bumped a staff while backing his wheelchair and staff hit him on top of his head." Further documentation indicated that Patient 1 stated, "I'm sorry," to the staff. There were no visible injuries noted. During an interview on 4/11/13 at 11:30 a.m., Staff A stated that as she was entering the nursing station, Patient 1 was in line for his medications. At that time, she observed Staff B hit Patient 1 on top of his head with a clipboard. Staff A stated that it was, "not a tap." When asked how strong the contact appeared to be, between the range of 1-10, (with 1 being a weak contact to the head and 10 being a strong contact to the head), Staff A stated that it was between a 4-5. During an interview on 4/25/13 at 11:50 a.m., Staff B stated that she was monitoring on [Unit X] and was checking the patients. She stated that as she walked toward the dining room she suddenly felt something bump her foot. She stated that she saw Patient 1 and said, "Be careful." Patient 1 told her it was an accident. After a few minutes, Staff B stated that it happened again and Patient 1 said it was an accident. Staff B stated that she was holding a clipboard and admitted to hitting Patient 1 on the head with a clipboard. When asked how hard Patient 1 was hit, Staff B stated, "I can't tell, I was mad."The facility failed to ensure a patient's right to be free from physical abuse by a staff member. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 630004081 |
Department of State Hospitals - Coalinga D/P ICF |
150010133 |
A |
02-Apr-14 |
WZ2011 |
10453 |
T22 DIV 5 CH 4 ART 4 - 73521 Patient Care Policy Committee Written patient care policies shall be established and followed in the care of patients governing the following services: physician, dental, nursing, dietetic, pharmaceutical and an active program and such diagnostic, social, psychological and therapy services as may be provided. Such policies shall be developed by a committee whose membership shall consist of at least one physician, the administrator, the supervisor of health services and such other professional personnel as may be appropriate. These policies shall be reviewed and revised by the committee at least annually and minutes of the committee meetings shall be maintained on file indicating the names of members present, the subject matter discussed and action taken. The facility failed to implement their "Unit Security" policy and patient care policy for "Suicide Prevention and Risk Reduction" by failing to observe and monitor Patient 1, who had a history of suicide attempts and self-harm behavior. These failures resulted in Patient 1 cutting himself and then swallowing razor blades he had removed from his electric razor. During an interview on 7/24/13 at 1:20 p.m., Staff 1 stated on 7/12/13 at approximately 5:05 p.m., Patient 1 cut himself with several sharp objects during a shower. The objects were later identified as three razor heads that Patient 1 had earlier removed from an electric razor. Staff 1 stated that during the time Patient 1 cut himself he was on a one-to-one (1:1) continuous observation for a previous suicide attempt. Review of Patient 1's clinical record documented that Patient 1 was admitted to the facility on 4/16/13 with a history of Self Injurious Behavior (SIB) and a history of multiple suicide attempts. Physician admission progress notes, dated 4/16/13, noted that Patient 1had a history of "multiple suicide attempts (4X) and SIB (self-cutting).... anxiety, feeling paranoid, overwhelmed, [increased] pain, suffocating feeling.... intermittent racing thoughts." A Suicide Risk Assessment, dated 6/25/13, documented that Patient 1reported three serious suicide attempts and numerous episodes of self-cutting which included an incident in 2012 when Patient 1 slit his wrist and swallowed two razor blades.Nursing notes dated 7/12/13 at 6:15 p.m., documented Patient 1 stated he had swallowed a razor blade while in the shower with a hand full of water. Patient 1 also stated he cut himself with the intention to cut blood vessels on both sides of his neck and his elbows. Patient 1 stated he was in too much anxiety and depression and that he wanted to kill himself. The nursing assessment noted serosanguinous (bloody) fluid oozing from both arms; skin abrasions to both arms, around elbow area, upper lip; and redness to both sides of Patient 1's neck.Nurse's notes dated 7/12/13 at 7:27 p.m. documented at approximately 5:05 p.m. on 07/12/13, Patient 1 was in the fourth stall taking a shower. Staff suddenly lost clear vision of the patient. When staff got closer to observe the patient staff discovered Patient 1 cutting his left hand with a razor head. Staff immediately activated his personal alarm and engaged Patient 1 to refrain from continuing to harm himself while waiting for show of support. Patient 1 immediately cut his right hand with the sharp object three times. The nursing note documented that Patient 1 had shaved before coming to the shower room and that it was discovered that during the process of shaving Patient 1 had destroyed his shaver and took out the three razor heads which he used to cut himself. The nursing note documented that two out of the three razor heads were confiscated from Patient 1 in the shower and the third one was missing. When staff asked Patient 1 about the remaining part, he stated he had swallowed it.Physician notes dated 7/12/13 at 5:43 p.m. contained the following documentation: "[Patient 1] was found in shower with a razor tip, cuts noted on both forearms and his neck. Patient also reported swallowing one of the three razor tops from the electric razor. Placed into 5-point restraint and transferred to an outside acute care hospital for further medical treatment." The acute care hospital record for Patient 1 documented on 7/13/13 at 9 a.m., an Esophagogastroduodenoscopy (EGD - a procedure to examine the lining of the esophagus, stomach, and first part of the small intestine by use of a small camera inserted down the throat) was performed on Patient 1. Findings documented: "Esophagus: Sharp foreign body in upper esophagus located 22 cm [centimeters] from incisors. The pediatric endoscope was advanced past the foreign body after examining the entire esophagus, the endoscope was withdrawn. There was no attempt at removing the foreign body due to poor patient tolerance despite moderate sedation."During a telephone interview on 7/24/13 at 4:05 p.m., Patient 1 stated he had a lot of fear and anxiety, "Sometimes I just want to kill myself." He stated on 7/12/13 while he was on 1:1 monitoring he requested to use the electric razor. Patient 1 stated when staff handed him the electric razor, he walked away and removed the blades. Shortly after, while in the shower, Patient 1 stated he attempted suicide. He stated he used the blades to cut himself and swallowed one of the blades with a hand full of water. Patient 1 stated "I told them I was going to kill myself." During an interview on 8/1/13 at 12:50 p.m., Staff 2 stated on the evening of 7/12/13 Patient 1 destroyed an electric razor and used the blades to cut himself. At the time of the injury Patient 1 was on 1:1 observation for SIB and suicide attempts. Staff 2 stated the facility policies were not followed when Patient 1 was allowed to use a razor without direct supervision. When Patient 1 returned the razor, staff failed to inspect the razor to ensure the blades were still in place. Staff 2 stated Staff 4, who was assigned the 1:1 monitoring of Patient 1, failed to observe Patient 1 while shaving and while in the shower. During an interview on 8/1/13 at 1:45 p.m., Staff 3 stated on 7/12/13 at approximately 5 p.m., he monitored the shower room while several patients showered. He stated Patient 1 came into the shower room but Staff 4, who was assigned to the 1:1 observation of Patient 1, stood outside the door and was unable to view Patient 1. Staff 3 stated he was unable to monitor Patient 1 because he had three other patients to monitor. He stated after approximately five minutes he noticed Staff 4 still had not come into the shower room to observe Patient 1. He slowly stepped over to check on Patient 1 and saw a large amount of blood on the shower floor. He activated the red light and staff immediately responded. During an interview on 8/1/13 at 2:25 p.m., Staff 5 stated on 7/12/13 at approximately 5:15 p.m., she assessed Patient 1 for multiple self-inflicted cuts to his body. Staff 5 stated Patient 1 had several cut marks on his chest, both sides of his neck and forearms. Staff 5 stated Patient 1 verbalized a suicide attempt because he stated he felt anxious and hopeless. Staff 5 stated she had treated Patient 1 in the past and was aware he had a history of suicide attempts and was often on 1:1 observation. During an interview on 8/1/13 at 2:57 p.m., Staff 4 stated on the evening of 7/12/13 he was assigned to 1:1 observation of Patient 1. He stated at approximately 4:45 p.m., Patient 1 asked for an electric razor to shave with. Patient 1 was handed an electric razor and then walked into his room with the razor in his hand. Staff 4 stated he stood at the door with only a view of Patient 1's back and never walked over to observe Patient 1. He stated after a few minutes Patient 1 walked back, handed him the electric razor and stated I changed my mind, I don't want to shave. Staff 4 stated he put the electric razor back into the case without checking to ensure the blades were still in place. Staff 4 stated he then escorted Patient 1 to the shower room and stood outside the door while Patient 1 showered. Staff 4 stated he did not have a view of Patient 1 while he was in the shower. When the red light was activated he stated he knew there was a problem. Staff 4 stated that he should have closely observed Patient 1 when he gave the electric razor and he should have inspected the electric razor to ensure the blades were still in place. Staff 4 stated he should have walked into the shower room and maintained a clear view of Patient 1. The policy and procedure titled, "Unit Security," dated 8/21/12, contained the following documentation: "Important components of any security plan are the establishment of standardized operational requirements and assigning staff to follow instructions at all time ... Controlled items include those which require staff supervision when in use: housekeeping equipment in the utility room, include electric razors .... These items when not in supervised use must be stored in a locked area or in staff's direct possession." The policy titled, "Suicide Prevention and Risk Reduction," dated 3/26/13 documented the purpose of the policy was to prevent incidents of self-harm and suicide by recognizing the importance of screening, early identification, and intervention with problems that could lead to suicide. One-to-one (1:1) observation required continuous observation by an assigned employee with no barriers between the employee and the patient and with the employee within a designated distance from the patient. The 1:1 provider shall not be occupied with other activities that take attention away from the patient. Proper observation of the patient needing 1:1 supervision required staff to actively engage with the patient in a therapeutic manner when the patient was awake and amenable. Staff would be familiar with the plan of care for the patient and the patient's risks needed to remain vigilant to the patient's needs and behavior.The facility failed to ensure Patient 1 was observed, monitored and prevented from self-injurious behavior and attempting suicide when staff failed to implement the facility's Unit Security and Suicide Prevention and Risk Reduction policies. This failure placed Patient 1 at risk for serious injury and death when Patient 1 attempted suicide by cutting himself using electric razor blades. The above violation presented an imminent danger or a substantial probability that death or serious physical harm would result. |
| 150001227 |
Department of State Hospitals - Napa |
150010134 |
B |
06-Nov-13 |
5OFN11 |
2410 |
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. The facility failed to comply with the above regulation by failing to report an incident of physical abuse to the Department immediately, or within 24 hours.Interdisciplinary Notes, reviewed on 4/11/13, indicated that Patient 1 was admitted to the facility on 3/28/13. On 4/5/13 at 3:35 p.m., Patient 1 ran from his room into the hallway with blood dripping from his right ear and stated, "I was in my room, I was assaulted..." Patient 1 stated that his roommate, Patient 2, assaulted him.Physicians' Progress Notes, dated 4/5/13 at 4:11 p.m., indicated the following findings for Patient 1:a. Bleeding, noted from inside the right ear. b. Right ear lobe swollen. c. Large lunate (crescent shaped) hematoma slightly above the ear lobe approximately 6 inches x 2 inches.d. TM (tympanic membrane/eardrum) was not visualized. e. Neck/nape area with redness/swelling approximately 3x3 inches. Impression:a. Right ear contusion with intra-canal bleeding, possible TM (eardrum) rupture. Will monitor for increased bleeding / decreased hearing. Possible ENT (ear, nose and throat physician) referral... b. Large contusion/hematoma above right ear lobe: Treatment included: X-ray, TM (temporomandibular joint), ice pack 3 times/day for 24 hours, Ibuprofen (anti-inflammatory pain medication), and neurological checks.Physician's orders indicated a skull x-ray was also ordered on 4/5/13. Patient 1's treatment plan, finalized on 4/9/13, indicated that he was compliant and was adjusting well to the unit rules and routine. Patient 2's record, reviewed on 4/11/13, indicated that Patient 2 was admitted to the facility on 4/4/13 and had a history of altercations with peers.During interview with Staff A on 4/11/13 at 10:30 a.m., Staff A stated that the incident was not reported to the Department because Patient 1 required first aid only.On 4/11/13, review of the Administrative Directive for Incident Management, #755, effective 1/30/13, documented "Standards Compliance Department reports these and other events to the Department of Public Health: ... Allegations of abuse or neglect." The failure to report an incident of physical abuse had the potential to create a delay in the investigative process. |
| 150001227 |
Department of State Hospitals - Napa |
150010161 |
B |
10-Dec-13 |
B13011 |
4146 |
Title 22 73523(a)(9) (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 1's right to be free from financial and mental abuse when Staff A intimidated Patient 1 and other patients to give her money and other items for her personal use and when the facility failed to ensure that Staff A had received the annual training on abuse prevention and reporting polices as required. Review of a facility reported incident on 2/5/13 indicated that on 11/26/12 Patient 1 alleged that Staff A had demonstrated inappropriate conduct with patients when she sold coffee to patients, intimidated them to buy her sodas and bring her food from the dining room. During an interview on 2/5/13 at 11 a.m., Patient 1 stated that Staff A kept asking "...us for a $1.50 for a soda," and said that, "if no one buys me a soda I'm not going to open up soda room." Patient 1 stated Staff A asked patients to give her things when they received packages and then would keep things in a pillowcase. Concurrent record review of Patient 1's record revealed documentation dated 11/26/12 at 12 p.m. that Patient 1 alleged that Staff A had been selling coffee to patients, intimidating them to buy her things and getting food from the dining room for her personal consumption. The allegation was reported to the Unit Supervisor, Psychologist and facility police. The record also indicated that Patient 1 had a history of making false allegations. This allegation was documented in the client's record dated 11/27/12. The facility Incident Management (IM) documentation dated 11/27/12 noted in the section titled: Unit Supervisor (US) Review, the treatment team had reviewed the incident and filed the mandatory abuse report. The US added: "This appears to be another incident of false allegations."According to the hospital Special Investigator's report, on 3/11/13 at 4 p.m., when interviewed, Staff A admitted that she received money, soda and food from patients and admitted selling two baggies of coffee to a patient for $10.00. Staff A also admitted receiving money for soda in exchange for allowing patients into the soda room. Further investigation revealed that Staff B had witnessed Patient 2 give Staff A, a pillowcase full of commissary items, three or four months prior to the date of this allegation. Staff B reported that he saw Staff A put these items in the back of an office inside the nursing station. Staff B stated that Patient 2 told him that he was trying to help out Staff A because she was going through a difficult time. Staff B reported this to Staff C the shift lead. The shift lead and Staff B confronted Staff A, who stated that she was going to give the items to other patients. Staff A then returned the items to Patient 2. Review of the personnel file of Staff A revealed that there was no evidence of prior counseling regarding the staff 's conduct. Staff A's training record indicated that she had not attended Abuse Prevention Training since 1/19/11. Review of the Facility Administrative Directive #437 titled: "Abuse/Neglect Reporting Requirements" Section l defined financial abuse as: "taking, secreting, appropriating or retaining the property of an elder or dependent adult." In addition, under section VII of this policy, subsection A: "All staff are trained in abuse reporting during orientation. All staff shall receive continued training in the identification, investigation, and reporting of abuse as part of their annual training."The facility failed to ensure Patient 1's right to be free from financial and mental abuse and failed to implement abuse prevention and reporting policies. This failure had a direct or immediate relationship to resident health, safety and security. |
| 150001227 |
Department of State Hospitals - Napa |
150010215 |
B |
19-Feb-14 |
CPX111 |
6681 |
T-22 DIV5 CH4 ART4 - 73523 (a)(9) PATIENT RIGHTS (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and 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 the rights of each patient to be free from abuse by failing to ensure that patients were not subjected to physical abuse by other patients on their respective units. Patterns of repetitive assaults by the same individuals (Patients 1, 2, 8, 10) continued to occur within the patients' living environment, placing other patients at risk for serious injury and psychological trauma. 1. Patient 1's record, reviewed on 11/12/13, revealed Patient 1 had diagnoses which include schizoaffective disorder, bipolar type and antisocial personality disorder. Patient 1's treatment plan, dated 10/1/13, documented that Patient 1 would demonstrate responsible behavior by effective management of anger and impulsive behavior and would be able to maintain his psychiatric and behavioral stability as evidenced by his ability to demonstrate good coping skills. A facility incident report documented that on 09/25/13, Patients 1 and 4 were found fighting in their shared bedroom at approximately 10 p.m. Patient 1 punched Patient 4 several times in the face.A facility incident report documented on 10/02/13, Patient 1 hit Patient 5 while he waited in line for medications. Patient 5 was struck approximately four times in the head.A facility incident report revealed on 10/03/13, Patient 1 hit Patient 3 on the left jaw for no apparent reason. No injury was noted to Patient 3's face and jaw; he refused to take any pain medication. Patient 3 stated, "I just don't understand why that guy punched me." Patient 3 was advised to stay away from Patient 1.An Interdisciplinary Report dated 10/9/13 revealed on 10/09/13 Patient 1 attempted to hit Patient 2 while Patient 2 received a treatment. "Provided patient teachings to provide and respect each other's space." 2. Patient 2's treatment plan Psychology note, dated 09/03/13, documented, "[Patient 2] triggered 25 Incident Management Reports from 08/18/2012 through 09/03/2013.Teaching and counseling provided with each incident. However, [Patient 2's] active symptoms of mental illness, mental confusion, emotional immaturity, and limited cognitive functioning inhibit his ability to gain insight to his inappropriate and dangerous behaviors."A facility incident report dated 09/28/13 revealed Patient 2 pushed Patient 1 who had talked rudely about Patient 1. The patients then exchanged punches. Staff separated the patients and both received medications. A facility incident report revealed on 10/09/13, Patient 2 hit Patient 1 in the head without provocation while in the dining room. The patients were separated and "Patient teaching" provided.On 10/10/13 at 9:35 a.m., Patient 2 hit Patient 6 with closed fists approximately five times in the head while Patient 6 sat on a chair in the TV room. Patient 6 sustained an approximate 1 cm superficial cut on the top of his head. Patient 2 was placed on enhanced observation. A facility incident report documented on 11/03/13 Patient 2 hit Patient 3 on the left cheek without provocation.A facility incident reported documented on 11/13/13, while watching TV in the day hall, Patient 2 suddenly hit Patient 6. Patient 7 attempted to intervene at which time Patient 2 began punching Patient 7. Record review revealed Patient 7 sustained a 1.5cm (approximately 5/8 of an inch) laceration on his right cheek requiring sutures at an outside acute care hospital. During an interview on 11/16/13 at 10 a.m., Staff A, (Unit Supervisor) stated that staff tried to identify those patients at risk for victimization and attempted to move them to a different unit. Staff A further stated that walking restraints (a belt around the waist with the patients hands shackled to the belt) had been requested for Patient 2 but it was not until after the 11/13/13 incident that the walking restraints were again authorized.3. On 11/12/13, review of Patient 8's record revealed a diagnosis of schizophrenia, paranoid type. Patient 8's treatment plan dated 9/11/13 revealed Patient 8 was "High risk for assault. He shows no antecedent [predictable] behaviors, and he is highly unpredictable and assaults occur without apparent provocation from peers. ... He most often hits others who are more vulnerable (i.e. patients who are deaf, shorter in stature or staff who are kneeling down or female) ..."A facility incident report revealed on 09/15/13, Patient 8 hit Patient 9 two times. Patient 9 retaliated by hitting Patient 8 three to four times in the face resulting in a swollen right eye lid and bloody nose.A facility incident report revealed on 9/26/13 Patient 8 hit Patient 10 twice in the head without provocation while Patient 10 was getting in line to receive his medications. Emotional support was provided for Patient 10 however due to a language barrier it was difficult to communicate. Review of Patient 10's Treatment Plan, dated 9/5/13, revealed Patient 10 could read and write but needed an interpreter to communicate for him with sign language. Review of a facility incident report revealed on 10/06/13 Patient 9 had another unwitnessed physical altercation with Patient 8 in the unit day hall. Patient 9 denied that Patient 8 had hit him. Patient 9 was encouraged to stay away from Patient 8 to prevent a further altercation. During an interview on 11/8/13 at 2:10 p.m., Staff B, (a Unit Supervisor) stated that when an altercation happened they separated the patients, offered them a PRN (an as needed) medication, and taken the patients to a side room if needed. When asked how they protected the more vulnerable patients from repeated assaults, he stated staff tried to keep them separated and they observed and monitored the patients.The facility failed to ensure the rights of patients to be free from abuse by failing to ensure that patients were not subjected to physical abuse by other patients on their respective units. Patterns of repetitive assaults by the same individuals (Patients 1, 2, 8, 10) continued to occur within the patients' living environment which placed other patients at risk for serious injury and psychological trauma. These failures had a direct or immediate relationship to patient health, safety, and security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010216 |
B |
24-Jan-14 |
F0OS11 |
11267 |
T22 DIV 5 CH 4 ART 4 - 73523 (a) (9) 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 the rights of each patient to be free from the harm of abuse when patterns of repetitive assaults by the same individuals, (Patients 1 and 5), continued to occur within patients' own living environments. This placed other patients at risk for serious injury and psychological trauma.1. Review of Physicians' Progress notes, dated 5/30/13, indicated that Patient 1 had been on CIO (Constant / In Sight Observation) since January 2013 due to dangerous assaults and unpredictable assaultive behavior. The Administrative Directive #766, for "Enhanced Observation of Patients," effective 12/18/12, defined CIO as follows:"Patients shall always be in direct line of sight of an assigned staff person who will be able to notice and intervene if a dangerous incident occurs."Review of Patient 1's "Walking Restraint Request and Authorization Form," dated 7/3/13, indicated that Patient 1 was assessed as needing walking restraints due to repetitive assaultive behavior related to psychotic symptoms. Documentation indicated that he assaulted (3) three staff members within that week resulting in significant physical injuries rendering all of them unable to perform their jobs. Further documentation indicated that Patient 1 had a significant history of assaults including fourteen (14) physical assaults within the last eighteen (18) months. His assaults seemed to have little observed provocation, if any at all.A Behavior Intervention Plan, dated 7/23/13, indicated that Patient 1 had delusions of persecution about being controlled, hurt, or killed and subsequently assaulted peers and staff. Documentation indicated that he assaulted others to protect himself when he felt threatened, which have led to significant injuries. Patient 1's Treatment Plan, finalized on 8/30/13, indicated that Patient 1 was an "extremely high assault risk due to his frequent past assaults while experiencing the same psychiatric symptoms that he now reports." Further documentation in the Treatment Plan indicated that Patient 1 had few if any antecedents for assault and, "THIS FACT INCREASES HIS DANGEROUSNESS."The Treatment Plan further indicated that Patient 1 had been observed to hit people from behind and strike without warning. Patient 1's physician's orders, dated 8/30/13, indicated the following: 1:1 CIO when patient is out of his room, door alarm when he is in his room, male staff only when out of room, and CIO staff to maintain a 6 foot distance.The Treatment Plan indicated that Patient 1 had four (4) assaults in 8/2013 and was placed in locked room seclusion. "His behavioral plan is continually being updated and includes prohibiting him from loitering in the hallway. Counseling and teaching provided with each incident. [Patient 1's] active delusions serious [sic] limit his ability to comprehend re-direction and many of staff's interventions." On 9/10/13, the Department received notification from the facility of an aggressive act (physical) between Patient 1 (aggressor) and Patient 4 (victim). a. Interdisciplinary Notes (IDNs), dated 9/8/13 at 12:31 p.m., indicated that Patient 1 walked out of his room up the hall towards the nurse's station with his CIO 1:1 (staff providing constant insight observation).Patient 1 approached a peer, Patient 4, and unprovoked, started punching him in the face. An IDN entry on 9/8/13 at 3:09 p.m. indicated that Patient 1 punched Patient 4 twice on his left ear without provocation. He was escorted to the side room and received an injection of Haldol Lactate, an antipsychotic medication ordered by the physician for severe agitation / imminent danger.IDNs, dated 9/8/13 at 11:55 a.m., indicated that Patient 4 sustained redness to his left ear and a painful right forearm. Patient 4's treatment plan indicated that he was the victim of multiple assaults. b. On 9/23/13, the Department received notification from the facility of an aggressive act (physical) between Patient 1 (aggressor) and Patient 2 (victim). Interdisciplinary Notes, dated 9/21/13 at 4:11 p.m., indicated that Patient 1 was walking in the hallway and passed his peer, Patient 2. Patient 1 turned to his peer, unprovoked, and began to assault him.Patient 1 threw and connected with approximately 2-3 closed fist punches at Patient 2's face and upper torso.Patient 2's treatment plan indicated that his risk of victimization was moderate to high due to his older age and weak physical status.c. On 10/1/13, the Department received notification from the facility of an aggressive act (physical) between Patient 1(aggressor) and Patient 3 (victim). Interdisciplinary notes, dated 9/30/13 at 3:58 p.m., indicated that Patient 3 was about to receive his medications. Patient 1 approached Patient 3 from behind without any provocation and threw fits [sic] at him. Patient 3 sustained a scratch to his left upper eyebrow.The supervisory review of the Incident Management document, dated 10/2/13, indicated that, "He also displayed his known behavior of attacking older or smaller in stature peers."During an interview with Staff A on 12/2/13 at 11:30 a.m., Staff A stated that Patient 1 was very delusional about others hurting him. Staff A further stated that when Patient 1 is in transit, the hallways are cleared to let people know that he is moving. Patients are conscious when he is out. Staff A stated that, "It is getting to the point that every corridor has a victim."2. Review of Patient 5's "Walking Restraint Request and Authorization Form," dated 8/5/13, outlined physical assaults or attempted assaults since his admission on 3/20/13. At that time, documentation indicated that he had punched, slapped or kicked staff and patients on at least 13 occasions since his admission 4 months ago.Assaults to patients and staff included but were not limited to the following: 4/27/13- punched a deaf patient in the face; on 5/17/13- re-entered a patient's room during the night and repeatedly punched a deaf patient and the patient sustained a fractured rib; 7/24/13- Patient 5 hit a nurse who was dispensing medications; 8/3/13- Patient 5 hit staff in the jaw with a closed fist. Physicians' Progress Notes monthly summary, dated 8/21/13 indicated that Patient 5 continued to be assaultive and had been placed in walking restraints several times in this reporting period. Further documentation indicated that his medications were adjusted again and he was now on Clozapine (atypical antipsychotic medication). He was placed back in walking restraints on 7/25/13 and was released on 8/1/13. Again, he was placed in walking restraints on 8/5/13 and released on 8/12/13. While out of walking restraints he was placed in locked room seclusion several times for attempting and threatening to assault. The physician's 8/21/13 progress note documented that Patient 5 was currently on a rover for safety of others.The Administrative Directive #766, for "Enhanced Observation of Patients," effective 12/18/12, indicated that rovers are utilized to increase supervision of the unit milieu, to prevent high risk behaviors in the unit milieu based on the overall acuity of the setting. The Treatment Plan, dated 9/19/13, indicated that Patient 5 was a moderate to high risk for aggression and had been aggressive or the victim of aggression on at least 51 occasions since his admission on 3/20/13. Additional documentation in the treatment plan indicated that Patient 5 has had a lengthy pattern of displaying "florid" psychotic symptoms and then becoming suddenly aggressive, often without any observable triggers or antecedents. He has required walking restraints on several occasions due to repeated psychotic aggression. The Psychiatry entry indicated that Patient 5 was responding well to Clozaril with decreased severity of assaults. a. On 9/17/13, the Department received notification from the facility of an aggressive act (physical) between Patient 5 (victim) and Patient 6 (aggressor). Interdisciplinary notes, dated 9/16/13 at 8:46 p.m., indicated that Patient 5 and Patient 6 were on the floor wrestling after an incident regarding a telephone call. Patient 6 had Patient 5 in a head lock, punching him on his left side with closed fists. Patient 6's treatment plan, dated 9/17/13, indicated that Patient 6 was at moderate risk for assault and could become easily angered, paranoid, and delusional. b. On 9/24/13 the Department received notification from the facility of an aggressive act (physical) between Patient 5 (aggressor) and Patient 6 (victim). Interdisciplinary notes, dated 9/24/13 at 6:13 a.m., indicated that Patient 6 was heard screaming from his room. He stated that someone attacked him while he was sleeping.Patient 6 sustained bleeding from his nose. Interdisciplinary notes, dated 9/24/13 at 6:35 a.m., indicated that Patient 5 hit Patient 6 in the face while he was asleep in bed.c. On 10/3/13 the Department received notification from the facility of an aggressive act (physical) between Patient 5 (aggressor) and Patient 6 (victim). Facility correspondence (Notification of Incident) to the Department, signed on 10/3/13, indicated that Patient 6 stated, "He did it again, he attacked me while I was asleep." Patient 6 was noted to have bleeding in his mouth and redness on the right side of his face. Patient 6 stated, "He attacked me while I was asleep; he hit me in the right side of the face 2-3 times and hit me in my mouth 2 to 3 times." Patient 5 stated, "I don't like him, that's why I hit him..." d. On 10/28/13 the Department received notification from the facility of an aggressive act (physical) between Patient 5 (aggressor) and Patient 7 (victim).Facility documentation, dated 10/28/13, indicated that Patient 5 was going inside of his room when he accidentally bumped into his roommate, Patient 7, who was coming out of the room. Patient 5 suddenly hit Patient 7 in the face multiple times with a clenched fist and Patient 7 sustained bleeding in the mouth, a 0.5 cm (centimeter) laceration on his inner lip.e. The Department received notification of an aggressive act (physical), between Patient 5 (aggressor) and Patient 6 (victim) on 11/6/13. Patient 6 sustained a scratch on his left upper forearm requiring first aid.During an interview with Staff B on 12/4/13 at 9 a.m., Staff B stated that patients ask staff to be sure their doors are locked. Staff B stated that Patient 5 has a mental illness that medications are not going to erase.The facility's failure to ensure that patients were not subjected to repeated incidents of physical harm and the failure to minimize patient assaults had the potential to affect all patients' mental and physical wellbeing. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010219 |
B |
15-Nov-13 |
WQLS11 |
2460 |
T22 DIV 5 ART 4 73523(a)(9) 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 shave the right: (9) To be free from mental and physical abuse. The facility failed to comply with the above regulation by failing to ensure a patient's right to be free from the harm of sexual abuse between a licensed staff employed by the facility and a patient who resided at the facility. Furthermore, a staff that had knowledge of the abuse failed to report the inappropriate relationship, as mandated. Record review on 1/17/12 indicated Patient 1 had multiple "Alerts" for suicide attempts, self injurious behavior, and assault.The Wellness and Recovery Plan, dated 1/25/12, indicated that Patient 1 had borderline and antisocial personality features, mood swings, depression, and a thought disorder. Additional documentation in the Wellness Plan indicated at times, Patient 1 was overwhelmed by emotions and continued to use threats of self harm to relieve these uncomfortable feelings.A Psychotherapy Note, dated 1/12/12, indicated, "Broached subject of victim of sexual assault at hands of staff. Patient 1 reported that he "was in love with him," and "It's my fault because I asked him to do that (sexual act)." Patient 1 was informed that "this was not his fault at all and he is the victim." A subsequent Psychotherapy Note, dated 1/26/12, indicated Patient 1 reported feeling confused and agitated.A facility document noted that Staff A admitted to having an inappropriate sexual relationship/contact with a patient, a dependent adult, while the patient was housed at [name of facility] and Staff B admitted to having knowledge of the relationship / contact between Staff A and Patient 1 and failed to report, as required. The facility's failure to protect individuals from the harm of abuse and the staff's failure to report knowledge of abuse, created a delay in the investigative process potentially putting other clients at risk for harm. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010220 |
B |
24-Jan-14 |
OPR511 |
7534 |
T22 DIV 5 CH 4 ART 4 73523 (a) (9) 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. These 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 implement measures to protect patients from mental and physical abuse, as evidenced by: 1) Patient 1's repeated assaults and assault attempts; 2) Patient 5's repeated assaults and assault attempts. This behavior resulted in the potential for significant physical and/or mental harm to Patients 2, 3, 4, 6, 7 and 8 and to other patients who reside in the facility. 1.) A facility "NOTIFICATION OF INCIDENT" letter, regarding a 10/2/13 incident, noted the following: Patient 2 reported he was walking in the hallway, when Patient 1 hit him in the nose. Patient 2 received first aid but refused an x-ray as ordered. Patient 1 was very difficult to redirect and would not stop arguing with staff members. Patient 1's "COMPREHENSIVE ASSESSMENT -Psychiatry," dated 10/1/13, noted the following: 1) Patient 1 had a diagnosis of psychotic disorder (abnormal mental function); 2) Patient 1 had a problem with anger. He was explosive and very impulsive. He was cognitively impaired and had problems interpreting social cues and information, which placed him at moderate risk for violence; 3) Patient 1 was admitted to the facility for the second time on October 1, 2013; 4) Patient 1 punched a peer in the face during the recent readmission. Patient 2's treatment plan, dated 9/26/13, noted a diagnosis of schizoaffective disorder (a mental condition that causes a loss of contact with reality and mood problems). A facility "NOTIFICATION OF INCIDENT" letter, regarding a 10/9/13 incident, indicated staff witnessed Patient 1 punching Patient 3 on the face with both fists, causing a nose abrasion, with bruising of the nasal area and forehead. Patient 3's "RN Progress Note for Assessment and Evaluation," dated 10/9/13, noted Patient 3 had delusions (false ideas) and paranoia (false belief that others may be trying to harm you), had a fear of getting hit, so tended to isolate himself by staying in his room most of the time.Patient 3's "INTERDISCIPLINARY NOTES," dated 10/9/13 at 1:29 p.m., noted Patient 3 stated, "He just attacked me, just like that, I don't understand why, you sent me a decoy to attack me, I wanna go back to my cell." Patient 1's "INTERDISCIPLINARY NOTES," dated 10/9/13 at 5:30 p.m., noted Patient 1 had attempted an additional peer assault on 10/9/13.A facility "NOTIFICATION OF INCIDENT" letter, regarding a 10/10/13 incident, noted the following: Patient 1 was arguing with Patient 4 in the hallway. Staff members were unsuccessful in attempts to verbally redirect Patient 1, who was placed in 5 point restraints and given a PRN (as needed) medication to calm the patient. Patient 4's treatment plan, dated 9/26/13, noted diagnoses of schizoaffective disorder and anxiety disorder. Patient 4's "Nursing Weekly Progress Note," for the period of 10/2/13 to 10/8/13, indicated Patient 4 was cooperative, pleasant, and had no behavioral issues.During an interview on 10/15/13 at 1:45 p.m., Staff A, a Unit Supervisor, stated he was familiar with the two incidents on 10/9/13, that occurred at approximately 12:40 p.m. and 5:40 p.m. Staff A stated Patient 1 was given PRN behavioral medications, but no increase in supervision was made between the 2 incidents to ensure Patient 1 did not repeatedly assault other patients. Staff A stated Patient 1 had "really low impulse control" and the psychiatrist had been adjusting his medications. When requested, Staff A located no behavior support plan (a written document to identify patient specific behaviors and interventions) in Patient 1's chart. When requested, Staff A located no charting by the psychologist or psychiatrist regarding Patient 1's assaultive behavior management. During an interview on 10/15/13 at 2:00 p.m., Staff B, a Unit Supervisor, stated he was familiar with the earlier 10/2/13 incident. When requested, Staff B located no behavior support plan in Patient 1's chart. Staff B stated that Patient 1 should have a treatment plan for "dangerousness." During an interview on 10/15/13 at 3:00 p.m., Staff C, a psychiatrist, stated she had talked with Patient 1, Patient 2 and Patient 3 since the assault incidents, but was behind in her documentation. Staff C stated Patient 1 may be targeting vulnerable patients and there were no clear antecedents (causes prior to an event) for his assaultive behaviors. Staff C stated: "probably remiss in not having a formal meeting." Staff C referred to Patient 1's medication adjustments as a behavioral intervention, but acknowledged that enhanced supervision was not addressed. 2.) A facility "NOTIFICATION OF INCIDENT" letter, regarding a 9/23/13 incident, noted Patient 5 grabbed Patient 6 and threw him against a television stand in the day room. Patient 5's treatment plan, dated 5/22/13, noted the following: 1) Diagnoses included dementia, behavioral disturbance, and personality change; 2) A long history of assaults on peers and staff that resulted in injury. Patient 6's treatment plan, dated 8/8/13, indicated a diagnosis of schizophrenia (a serious mental illness in which someone cannot think or behave normally). A facility "NOTIFICATION OF INCIDENT" letter, regarding 10/12/13 incidents, noted Patient 5 hit Patient 7 twice in the head, and then "started swinging" at Patient 8. Patient 7's treatment plan, dated 7/31/13, indicated: "It is important to use caution when interacting with him and refrain from unnecessary physical contact as to provide enough personal space for him to feel safe." Patient 8's treatment plan, dated 5/24/13, indicated a diagnosis of schizophrenia, paranoid type. During an interview on 10/23/13 at 2:10 p.m., Staff D, a psychiatrist, stated she was aware of Patient 5's assaultive behaviors. Staff D stated Patient 5 received 1:1 staff supervision, and said "What else can we do?" Staff D stated Patient 5 even tried to assault hospital police officers while on 1:1 supervision, and acknowledged that close supervision did not always stop his assaults.During an interview on 10/23/13 at 2:50 p.m., Staff E, a Licensed Vocational Nurse, stated other patients on the unit don't usually provoke Patient 5, and some try to get out of his way because they know he can be assaultive. Patient 5's "Behavior Intervention Plan," dated 9/6/12, described his behavior as sudden, highly aggressive punching, kicking, hitting and/or destruction of property and/or attempts to throw property at others. Interventions included the following: "Patients in nearby rooms are to all be ambulatory and able to understand the need to remain at least two arm-lengths away from (Patient 5) at all times." A written addendum, dated 10/30/12, indicated a staff member was encouraging unit routine. No other updates to the Behavior Intervention Plan were noted. The facility failed to adequately implement measures to protect patients from mental and physical abuse, as evidenced by Patient 1's and Patient 5's repeated peer assaults and assault attempts. These failures have a direct relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010253 |
B |
30-Jun-14 |
JD3S11 |
4928 |
T22 DIV 5 CH4 ART 4 - 73523(a)(9) Patient's Rights(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to ensure Patients 2, 3, and 4 was free from physical abuse from Patient 1, by failing to provide appropriate supervision when Patient 1 was becoming more violent towards peers. Patients 2, 3 and 4 were struck by Patient 1 in the face, forehead, and ear. Patient 2 sustained an injury to his mouth causing "blood oozing from patient's mouth", after being hit by Patient 1. The facility reported the following incidents to the Department regarding Patient 1 physically assaulting Patient 2, 3 and 4. a. 9/5/13 - Patient 1 hitting Patient 2 in the mouth causing, "blood oozing from his mouth." b. 9/7/13 - Patient 1 was involved in physical altercation with Patient 3, hitting Patient 3 on the left side of his ear. c. 10/2/13 - Patient 1 suddenly stood up and started hitting Patient 4 around the face and head area. d. 10/10/13 - Patient 1 abruptly stood up and hit Patient 3 on the forehead.A visit was made to the facility on 10/15/13, at 9:30 AM, to investigate the above entity reported incidents involving Patient 1, striking Patients 2, 3, and 4, resulting in injuries. The clinical record for Patient 1 was reviewed on 10/15/13, at 10 AM. A treatment plan dated 8/6/13 indicated the patient was having "high risk of assault and homicide". The treatment plan also documented Patient 1 had a history of "violent crimes (assault, rape, arson) and a more recent history (May 2012) hitting staff twice on his right shoulder and right side of his face/ear." On 10/15/13 at 11:20 AM, the SRN (Supervising Registered Nurse) was interviewed. The SRN stated he was familiar with Patient 1's aggressive behavior. He stated the patient was becoming, "very assaultive." He stated the treatment team met on 10/11/13 and discussed about increasing the patient ' s supervision from every 30 minutes to every 15 minutes to assure safety of his peers. When asked if the supervision every 15 minutes was being conducted he stated, "It was not done." He stated the treatment team meeting conducted on 10/11/13 was not documented in the clinical record. He stated the treatment team meeting for the patient should have been documented in the record. A concurrent record review was conducted with the SRN on 10/15/13. A "Behavior Intervention Plan" dated 10/11/13, did not include plans to increase supervision for Patient 1. The behavior intervention plan was not updated until the fourth incident of striking out at a peer on 10/10/13. There was no change in the patient's behavior treatment plan after the incidents of physical assault towards the patient's peers on 9/5/13, 9/7/13, and 10/2/13. Review of Patient 2's record revealed an IDN (Interdisciplinary Notes) dated 9/5/13, indicated, "... Patient was noted in a hallway away from his usual whereabouts when staff noticed blood oozing from the Patient ' s mouth. Upon further investigation by several staff, Patient finally stated the "the black man hit (him), "referring to peer (Patient 1) involved in the altercation. The physical blows were not witnessed by staff or by any peers..." Review of Patient 3's record revealed an IDN dated, 9/7/13, indicated, "Patient (Patient 3) was sitting in his wheelchair in line for treatment when suddenly staff heard shouting and screaming in the hallway ... When asked what happened he (Patient 3) answered, I was just sitting in the wheelchair then suddenly he (Patient 1) hit me on the left side of my ear on my earphone."Another IDN for Patient 3 dated, 10/10/13, indicated, "[Patient 3] was walking down the hallway after attending group, a peer (Patient 1) abruptly stood up and swung at [Patient 3]. [Patient 3] reported that he was struck on the forehead by the peer (Patient 1) ... Patient 3 reported to staff that he sustained a blow to his forehead ..."Review of Patient 4's record revealed an IDN dated, 10/2/13 indicated, "Patient was watching TV in day hall. Peer (Patient 1) jumped up and started hitting patient (Patient 4) around face and head area. Patient put hands up to protect self, and then began swinging his arms in defense." The facility failed to ensure Patient 2, 3 and 4 was free from physical abuse from Patient 1. The facility failed to provide increased supervision after Patient 1 was noted to become more violent, resulting in Patient 1 striking out and causing injury to his peers.This failure had a direct relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010292 |
B |
19-Feb-14 |
WD2211 |
11014 |
T22 DIV 5 CH4 ART 4 73523 (a)(9) PATIENT RIGHTS(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and 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 establish and implement policies and procedures to ensure patients were protected from mental and physical abuse when Patient 1, who was known to have a violent history, engaged in multiple assaultive behavior on other patients and staff without provocation. The facility failed to: 1. Ensure that Patient 1, who had a history of repeated assaults, was continuously assessed, monitored, and an intervention and behavioral guidelines were developed as part of the treatment plan for his assaultive behavior.2. Ensure that the treatment plan for Patient 1's assaultive and impulsive behavior was evaluated and revised to address his needs.3. Ensure that the policy and procedure "Section: SAFE 1501 Assaultive Patients: Intervention Guidelines" was implemented to refer Patient 1 to a Positive Behavior Support Team.4. Ensure that Patient 1's progress, goals, effectiveness of the intervention, and his response was properly documented in the Interdisciplinary Notes to be used as a tool for further assessment and evaluation. During an interview on 11/13/13 at 10 a.m., the Standard Compliance Coordinator reviewed Patient 1's record and confirmed that Patient 1had documentation of numerous incidents for his aggressive behavior towards peers and staff. She stated that between 8/10/13 thru 8/22/13 Patient 1 was the aggressor in three patient to patient altercations while in Unit T13. Patient 1 was transferred from Unit T13 to Unit T6 on 9/17/13. Incident reports submitted by the facility noted that he was again involved in the following incidents: On 9/15/13, while Patient 2 sat in the courtyard, listening to music Patient 1 punched him on the face and head. On 9/16/13, Patient 1 punched Patient 3 in the face several times without provocation in the Unit T13 dining room during lunch. On 10/30/13, Patient 1 assaulted Patient 4 without provocation in Unit T6 hallway. Patient 4 sustained a one centimeter laceration to his lip. On 11/1/13, during dinner in the Unit T6 dining room, Patient 1 claimed that Patient 5 had looked at him and he thought he was going to be attacked. Patient 1 threw a tray at Patient 5 and punched him multiple times on the forehead. The clinical record for Patient 1 was reviewed on 11/13/13. The Physicians' Progress Notes documented by the psychiatrist in Unit T13, dated 8/14/13, indicated that Patient 1 was a 25 year old male admitted to the facility with diagnoses that included schizophrenia, paranoid type (mental disorder) and polysubstance dependence (addiction to different classes of drugs or substances). The record documented that Patient 1 had been charged with violations of murder, injuring an elder adult, and assault by force. The treatment plan documented to continue his current antipsychotic medications and continue current treatment groups and therapy. The Treatment Plan (TP) reviewed for three consecutive months, dated 8/1/13, 9/23/13, and 10/7/13 indicated that an objective and intervention description was formulated under Focus 3.1 Dangerousness and Impulsivity describing, "Patient 1 had a significant history of violent behavior." His Objective Description indicated, "3.1.1 [Patient 1] will learn three coping skills to deal with violent impulses in groups. Progress will be documented in PSR (Patient Seclusion and Restraint) mall notes." The Intervention Description indicated, ".3.1.1.2 INTERVENTION: Nursing staff will rehearse with [Patient 1] the three coping skills he has learned in groups." There were no other treatment plans or behavior plans documented in the TP to address and provide immediate interventions to Patient 1's assaultive behavior. There were no assessments, evaluations, and monitoring found in the document. The TP was not revised and remained the same for three consecutive months, while Patient 1 continued to engage in assaulting his peers on multiple occasions as documented between August and November of 2013. The DMH Nursing Weekly Progress Note (MH-C 9109) dated 8/21/13, 8/28/13, 10/20/13, 10/27/13, 11/3/13, and 11/10/13 indicated Patient 1 had either engaged in altercations, requested PRN (as needed medication), and was placed in seclusion or restraints; however Patient 1's active symptoms, effectiveness of interventions, teaching and response to teaching were not documented. The facility's Nursing Policy and Procedure (P&P) titled, "Section: SAFE 1501 Assaultive Patients: Intervention Guidelines" dated 6/18/12 indicated, "DOCUMENTATION...1. The RN documents assessments, observed behaviors, proactive/early interventions and the patient's response, in the IDN." During an interview on 11/13/13 at 1:20 p.m., the Unit T6 Senior Psychiatric Technician (SPT A) stated that Patient 1 had been in their unit for two to three months. SPT A stated he knew that Patient 1 had a history of assaultive behavior prior to his transfer to Unit T6. He also stated that Patient 1 had been involved in numerous assaults and aggressions towards peers while in the current unit. SPT A stated that there was no Positive Behavioral Support for Patient 1's aggressive behavior. He reviewed Patient 1's Treatment Plan for dangerousness and impulsivity and confirmed that there were no treatment plans for his assaultive and aggressive behavior. He also acknowledged that the three consecutive months of documentation on the Treatment Plans were the same and not revised, stating, "The treatment team should be developing treatment plans for his (Patient 1) aggressive behavior." During an interview on 11/13/13 at 1:40 p.m., Psychiatrist A of Unit T6 stated that he knew Patient 1 as one of his patients. He stated that he was the only psychiatrist in the unit covering 45 to 46 patients. Psychiatrist A stated that Patient 1 had a history of assaults and "killing people" without any reason. He stated Patient 1 assaulted two to three patients while in the admission unit and would assault anybody for no reason. Psychiatrist A stated that Patient 1 was transferred to his current unit on 9/17/13 because of his aggressive behavior. He stated that Patient 1 was transferred from the prior unit without properly informing the admitting psychiatrist, psychologist, and the Interdisciplinary Team in their unit. Psychiatrist A stated Patient 1 was provided treatment for his psychosis by means of antipsychotic medications, mood stabilizing medications, therapy and coping skills and that he was compliant with his medications. Psychiatrist A stated, "Medications will not wok 100% on an individual and medication effectiveness decreases over time." Psychiatrist A reviewed Patient 1's Treatment Plan for dangerousness and impulsivity and concluded that it was repetitive. He acknowledged that the three consecutive months of the documentation in the Treatment Plan was not revised. During an interview on 11/14/13 at 10:07 a.m., Psychologist A of Unit T13 stated that Patient 1 was part of her case load when he was still in Unit T13. Psychologist A stated that Patient 1 was psychotic, completely unpredictable, and had a violent history. She stated that Patient 1 was clearly a danger to others. Psychologist A also stated that she reviewed Patient 1's Treatment Plan and signed it when she attended the treatment plan conference. Psychologist A reviewed three consecutive months of Patient 1's Treatment Plan, and confirmed she had signed two of them (Treatment Plans dated 8/1/13 and 8/5/13). When asked why the documented treatment plan for dangerousness and impulsivity were not revised, Psychologist A stated, "What do you suggest we do?" Psychologist A did not respond when asked why there was no positive behavioral support plan for Patient 1, knowing that he had been engaged in assaulting peers multiple times. The facility's Administrative Directive titled, "Interdisciplinary team (IDT) Process - Number: 785" dated 3/19/13 documented "PROCEDURES...I. TEAM SCOPE OF RESPONSIBILITY...A. Assessment...The needs of the patient are assessed across multiple domains including physical, psychiatric, psychological, rehabilitation... Treatment Planning:...The team uses the information gathered through assessments to collaboratively identify and prioritize the patient's needs and develop the patient's Treatment plan...C. Progress and Review...The team also monitors and reassesses progress...III. TxP CONFERENCE PROCESS...B. Roles of the Team Members...3. Psychologist...responsible for assessing various aspects of the patient's psychological and behavioral functioning...identifies the need for and develops behavior guidelines..." The facility's Nursing Policy and Procedure (P&P) titled, "Section: SAFE 1501 Assaultive Patients: Intervention Guidelines" dated 6/18/12 indicated, "GENERAL...5.The Treatment Plan Team collaborates, utilizing the skills of the Unit Psychologist to identify early behavioral or situational antecedents in the patient's escalation cycle...PROCEDURE...2. When formulating an early intervention plan, enlist the help of the Unit Psychologist and On Duty Psychologist (OPD) to support staff in implementing early/proactive interventions...9. The RN (Registered Nurse), in collaboration with the Treatment Team, updates the Treatment Plan...including intervention plans identified by the Psychologist...13. The Psychologist refers the assaultive patient to the Positive Behavioral Support Team..."The facility failed to establish and implement policies and procedures to ensure patients were protected from mental and physical abuse when Patient 1, who was known to have a violent history, engaged in multiple assaultive behavior on other patients and staff without provocation. The facility failed to: 1. Ensure that Patient 1, who had a history of assault, was continuously assessed, monitored, and an intervention and behavioral guidelines were developed as part of the treatment plan for his assaultive behavior.2. Ensure that the treatment plan for Patient 1's assaultive and impulsive behavior was evaluated and revised to address his needs.3. Ensure that the policy and procedure "Section: SAFE 1501 Assaultive Patients: Intervention Guidelines" was implemented to refer Patient 1 to a Positive Behavior Support Team.4. Ensure that Patient 1's progress, goals, effectiveness of the intervention, and his response was properly documented in the Interdisciplinary Notes to be used as a tool for further assessment and evaluation. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010388 |
B |
07-Mar-14 |
U2WC11 |
8019 |
T22 DIV5 CH 4 ART 4 - 73523 (a) (9) 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. These 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 protect patients from mental and physical abuse, as evidenced by Patient 1's repeated assaults of peers and staff, placing patients at risk for serious injury and psychological trauma. An incident report dated 12/16/13, documented on 12/16/13, Patient 1 physically assaulted a staff member when he placed his hands around her neck and then grasped her breast. The staff member had been assigned to provide Patient 1 with one to one supervision. On 12/18/13, Patient 1's record was reviewed. Patient 1's treatment plan, with a conference date of 12/5/13, documented Patient 1 had a diagnosis of bipolar disorder (a mental condition with severe mood swings) with severe psychotic (mental illness) features. A document of incidents involving Patient 1, dated 12/18/12 through 12/18/13, noted the following aggressive acts toward staff or peers: 1) On 2/3/13: Patient 1 smashed a chair against a wall, ran after a male staff "in intent to attack with closed fist and throw several punches in the air with no contact," aggression toward HPO (hospital police officer), then punched glass of the seclusion room door with his hand until the glass broke. 2) On 2/14/13: Patient 1 pounded on the nursing station window with both fists then "charged at staff." 3) On 3/8/13: Patient 1 banged his fists on the nursing station window and back door window and became an imminent danger to others. 4) On 3/31/13: Patient 1 became aggressive toward staff and HPO; required restraint (physical immobilization.) 5) On 5/26/13: Patient 1 threw a trash can in a hallway; tried to assault staff and was placed in 5 point restraints (devices for physical immobilization). 6) On 6/11/13: Patient 1 attacked a peer who sat in the treatment room. 7) On 7/5/13: A peer reported to staff that Patient 1 "grabbed him around his body," and a roommate helped to release him. 8) On 8/21/13: Patient 1 punched a peer in the face, which provoked retaliation. 9) On 8/28/13: Patient 1 grabbed the breast of a female staff member and became aggressive when staff intervened. 10) On 10/11/13: Patient 1 became verbally aggressive and chased a staff member. 11) On 10/23/13: Patient 1 "feigned a lunge at staff" and shouted an obscenity. 12) On 10/23/13: Patient 1 chased and punched a peer. 13) On 11/22/13: Patient 1 stated he had thoughts about raping a female staff member. 14) On 12/15/13, Patient 1 became physically aggressive toward hospital police, which required prone containment (physical restraint for the purpose of effectively gaining quick control of a person who is aggressive or agitated or who is a danger to self or others). 15) On 12/16/13, Patient 1 "tried to strangulate female staff." During an interview on 12/18/13 at 10:10 a.m., Licensed Staff A stated that on 12/15/13, Patient 1 was placed in 5 point restraints after aggressively "charging" and swinging at hospital police. After being in restraints for about 3 hours, staff and the doctor talked to Patient 1, and determined he could be released from restraints and placed on every 15 minute observations.Licensed Staff A stated that on 12/16/13, Patient 1 stated he was deeply in love with a female staff, and he might hurt himself or staff members. Patient 1 was started on one to one supervision. Licensed Staff A stated: "(Patient 1)" is big, and even a male staff might not be able to contain him, especially considering (Patient 1's) history and what just happened the day before with HPO." Staff A stated male staff members were assigned as a nursing measure. Later on 12/16/13, a male staff member, assigned one to one supervision of Patient 1, went to lunch and a female staff member took over. Staff A stated Patient 1 tried to choke the female staff member and the female staff was traumatized and "in shock." Staff A stated: "To be honest, in my opinion, it would be unsafe for a staff to be even one to one. Two staff would be better." Licensed Staff A stated he worked an extra shift this day (12/18/13) because they needed more male staff on the unit. Staff A stated the female assault victim was short and thin, and he (Staff A) would be better able to defend himself against Patient 1.During an interview on 12/18/13, at 11 a.m., Psychiatrist Staff B stated Patient 1 was transferred to his present residential unit on 11/26/13, from another facility unit where he had received one to one supervision. Staff B stated on 11/27/13, Patient 1 verbalized he felt better, so his enhanced supervision level was discontinued, with a plan to assign a staff member each shift for the patient to contact in case of any difficulty. Staff B stated Patient 1 was very difficult to handle and had a history of staff, peer and hospital police assaults. On the morning of 12/16/13, Patient 1 had experienced auditory hallucinations (hearing voices or sounds that have no physical source) directing him to hurt himself. Staff B stated staff placed Patient 1 on CIO (Constant Insight Observation), which was safer to staff than CCO (Close Constant Observation), because CCO required staff to be at hands length. Staff B stated that on 12/16/13, after 1 p.m., Patient 1 woke up from a nap and put on his socks and shoes. Without warning, he lunged at and assaulted the female staff member providing the CIO supervision. Staff B stated the victim could not pull her alarm because she was trying to disengage Patient 1's hands from her throat, but "luckily, she was able to yell." Staff B reviewed a document in Patient 1's chart titled "BEHAVIOR GUIDELINES", with a plan date of 5/9/13. Staff B stated there may be a more recent document, but was not able to locate one in Patient 1's chart. Staff B stated Patient 1's behavior plan included an assigned contact person with whom he could speak, if he experienced aggressive feelings. A physician's progress note, dated 11/22/13, indicated Patient 1's assault risk as: "HIGH. Recent Hx (history) of assaulting staff member and history of many assaults." An inter-unit transfer summary physician's progress note, dated 11/26/13, indicated Patient 1 had not been making contact with his shift contact person. Patient 1's level of supervision was CIO, one to one. A physician progress note, "Psychiatry Acceptance Note," dated 11/26/13 (the date of unit transfer), indicated Patient 1 denied thoughts of hurting self or others. One to one supervision was decreased to every 15 minute checks. During an interview on 1/24/14, at 3 p.m., Staff D, a unit supervisor, stated he was aware of the 12/16/13 incident, where Patient 1 assaulted a female staff member. Staff D stated there had been an effort to assign male staff only to provide Patient 1's one to one supervision, based on the client's history of assaulting a female staff member in August, 2013. Staff D stated that, on 12/16/13, the female staff member who was assaulted, was assigned to provide Client 1's one to one supervision during a male staff member's break. Staff D stated that information regarding patient supervision levels was communicated verbally during shift change and by e-mails. The facility failed to protect patients from mental and physical abuse, as evidenced by Patient 1's repeated assaults of peers and staff, which placed patients at risk for serious injury and psychological trauma. This facility's failure to implement measures to prevent repeated assaults by Patient 1, who had a history of violence and multiple assaults, had a direct relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010402 |
B |
07-Mar-14 |
TJS611 |
9066 |
T22 DIV 5 CH4 ART 4 73523 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 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 the rights of each patient to be free of the harm of abuse when patterns of repetitive assaults by the same individual, Patient 1, continued to occur within patients' own living environments placing other patients at risk for serious injury and psychological trauma. 1. On 12/16/13, the Department received notification from the facility of an aggressive act (physical) between Patient 1 and Patient 2 that occurred on 12/14/13. Staff observed Patient 1 and Patient 2 involved in a physical altercation. Both patients received prn (as needed) medication and Patient 2 sustained visible redness to his right hand. Facility documentation indicated that Patient 2 stated that the peer swung at him and hit his right side of the face, ear and back of his head. 2. On 12/16/13, the Department received notification from the facility of an aggressive (physical) act between Patient 1 and Patient 3 that occurred on 12/14/13 where staff observed Patient 1 punching Patient 3 in the face. Facility documentation indicated that Patient 3 sustained bleeding from both nostrils, slight swelling and bruising to the bridge of his nose, multiple facial abrasions especially near his mouth and forehead, slight swelling and bruising under his right eye, and an abrasion on the lower lip. 3. On 12/18/13, the Department received notification from the facility of an aggressive (physical) act between Patient 1 and Patient 4 that occurred on 12/17/13. Staff responded to yelling in the hallway and found Patient 1 and Patient 4 posturing to assault each other. Patient 1 admitted to punching Patient 4. Both patients received prn medications and Patient 1 was placed on enhanced observation. Facility documentation indicated that the assault was not witnessed and Patient 1 admitted to punching Patient 4 one time in the back of the head. 4. On 12/19/13, the Department received notification from the facility of an aggressive (physical) act between Patient 1 and Patient 5 that occurred on 12/18/13. Staff responded to a commotion in the hallway and observed Patient 1 in a fighting stance in front of Patient 5. Patient 5 reported that Patient 1 had hit him and Patient 1 admitted to the assault. There were no injuries to either patient and Patient 1 received a prn. 5. On 12/23/13, the Department received notification from the facility of an aggressive (physical) act between Patient 1 and Patient 6 that occurred on 12/23/13. Patient 1 hit Patient 6 in the face. No injuries were noted. Patient 1 received a prn medication. 6. On 12/30/13, the Department received notification from the facility of an aggressive (physical) act between Patient 1 and Patient 7 on 12/27/13. Staff responded to yelling in the hallway and found Patient 1 being chased by Patient 7. Patient 7 stated that Patient 1 hit him. Facility documentation indicated that Patient 7 stated, "He just hit me at the back of my head while I was walking to my room! Keep him away from me!"7. On 1/06/14, the Department received notification from the facility that an aggressive (physical) between Patient 1 and Patient 8 occurred on 1/04/14. Staff responded to a scuffle and observed Patient 1 bear hugging Patient 8. Patient 1 continued to escalate and was placed in locked room seclusion and received a prn medication. Patient 8 had slight bleeding on his gum and was treated for minor first aid. Facility documentation indicated that Patient 8 claimed that he was hit on the left inner cheek. 8. On 1/9/14, the Department received notification from the facility of a second aggressive (physical) act between Patient 1 and Patient 5 that occurred on 1/8/14. Patient 1 assaulted Patient 5 in the dining hall. No injuries were noted for Patient 5. Patient 1 received a prn. Facility documentation indicated that Patient 1 was standing behind a peer in the line and suddenly hit him with his tray on the back of his head. Patient 5 stated, "I don't know why he hit me. This is second time he hit me." 9. On 1/9/14, the Department received notification from the facility that an aggressive (physical) act occurred between Patient 1 and Patient 9 on 1/8/14. Staff observed Patient 1 running out of the day room with clenched fists and then heard Patient 9 yell that Patient 1 physically assaulted him. No injuries were sustained and Patient 1 remained aggressive and was placed in locked room seclusion. The facility's IM (Incident Management) document indicated that Patient 9 stated, "You better watch that guy! Get him away from me! He hit me in the head!... I was in the day hall and writing on my paper he just came there and hit me for nothing. He hit me in the left side of my forehead." On 1/21/14, review of the facility's "Walking Restraint Request and Authorization Form," dated 12/19/13, indicated that Patient 1 had command auditory hallucinations directing him to assault others. He had repeatedly struck peers in the head with his fists from behind, without warning. Documentation indicated that, "in light of the rapid escalation in his behavior (four assaults in rapid succession after none in the past 1.5 months) ..., walking restraints are indicated to prevent ongoing assaults of peers on the unit. Previous interventions have included Q (every) 15 minute observations, ongoing medication changes, attempts to behaviorally align his stated goals with safe behavior, but have not been successful to date." The report noted that assaults occurred in the unit hallways and day halls, "generally when staff were not in the immediate vicinity." There were no clear antecedents for the assaults. A Physician's Progress Notes, dated 12/19/13, documented that, "I have discussed his risk of further violence with covering/Senior Psychologist and Psychiatrist. I have apprised them that it clinically prudent to have walking restraints authorized to allow time for adjusted meds to work." Patient 1's "Treatment Plan," dated 12/23/13, noted that Patient 1 was estimated to be at high risk for aggression. Under Focus #3.1, "Dangerousness and Impulsivity," Patient 1 presented with impulsive aggression with peers on multiple occasions since admission on 10/22/13. These events appeared to stem from attempts to obtain food and other items from peers. On 1/21/14, review of Patient 1's "Discharge Summary," dated 1/9/14, noted that Patient 1 had a "chaotic hospital course since his admission." Documentation indicated that in the middle of December Patient 1 was doing well but then his functional status deteriorated and he started assaulting his peers. There were at least nine assaults over the course of three weeks. Further documentation indicated that medication adjustments were done and there was a request made for walking restraints and seclusion room protocol to be adopted while medications were being adjusted. "Hospital Administration did not agree to this request and he was mostly kept on gross observation status for safety of others."During an interview with Staff A on 1/22/14 at 1:30 p.m., Staff A stated that Patient 1 assaults, "out of nowhere, all of a sudden." During an interview with Staff B on 1/22/14 at 1:45 p.m., Staff B stated that in December, "he [Patient 1] was hitting left and right" and was usually related to food when he was in the canteen line and dining room. Staff B stated that a coping strategy plan was implemented and he followed redirection when he was "amping up." Staff B further stated that the unit was a double unit and the census ranged from 58-60 patients. Staff B stated that they try to have nine (9) staff when there is a full census and in December there were "a lot of floats" (staff not regularly assigned to the unit).Facility staffing information, provided by the facility, indicated that, "Due to Q5/6's high acuity request for rover was made and granted for Dec. 24-Dec 30." The Administrative Directive #766, for "Enhanced Observation of Patients," effective 12/18/12, indicated that rovers are utilized to increase supervision of the unit milieu, to prevent high risk behaviors in the unit milieu based on the overall acuity of the setting. During a subsequent interview with Staff B on 1/23/14 at 12:11 p.m., Staff B stated that, "We were instructed to keep an eye on him." The facility's failure to ensure that patients were not subjected to repeated incidents of physical harm and the failure to minimize patient assaults had the potential to affect all patients' mental and physical well-being. These failures had a direct or immediate relationship to the health, safety, and security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150010909 |
B |
24-Mar-15 |
FGTT11 |
3373 |
REGULATION VIOLATION: T22 Div 5 CH 4 ART 4 73523(a)(9) - Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon. Patients shall have the right: (9) To be free from mental and physical abuse.Findings: The facility failed to ensure that Patient 1 had the right to be free from abuse when Patient 2 with a known history of sexual assault assaulted Patient 1 as he slept. Review of the facility reported incident indicated that on 2/28/14 at 10:30 a.m., Patient 1 (admitted to the facility on 10/3/13), reported to staff that he awoke to a new roommate; Patient 2, orally copulating him. Patient 1 immediately pushed him off and told him to stop. Patient 2 then stated "this is what I do...I love you." Review of the patient's record indicated Patient 2 hears voices telling him to have sex with children and adults, both sexes and using sex to wheel and deal. The day before this incident, on 2/27/14, Patient 2 was moved from another unit to be the roommate of Patient l due to his being "focused on his younger peers on the unit and has been attempting to groom one of them. Team (treatment team) is concerned about this resulting in the peer decompensating." Prior to this move, Patient 2 was moved from T-15 to T-8 on 6/4/13 for exhibiting inappropriate behavior. He was transferred to T-8 because he was not cognitively capable of completing Sexually Offender Treatment (SOT) groups. The treatment team felt he should be housed on T-15. The psychologist noted in the 12/10/13 Treatment Team Notes that "He [Patient 2] would be better served by placement at a hospital that provides SOT on a full time 24/7 basis. He continues to groom young men on T-8 and is unwilling / unable to internalize or accept that he is doing so when confronted."ΓΊ Psychiatric recommendations on 2/27/14 included also a trial of raising the dose of Zoloft (an antidepressant) and to consider a trial of Lupron (a hormone therapy) if patient symptoms do not respond to Zoloft. "Patient remains at high risk for exhibiting sexually inappropriate behavior towards children and young men." During an interview on 9/8/14 at 4:30p.m., the Program Director stated that prior to Patient 2's transfer to T-7 the team did a risk assessment and considered that the age of the new roommate was such that he did not fit the age profile of the offender's victims. Patient 2 was first admitted to the facility in 2001. A psychiatric case history report dated 11/21/14 indicated that he has displayed a pattern of sexually inappropriate/harmful behavior and infringing on the rights of others throughout his hospitalization. Patient 2 has a long history of sexually deviant behavior dating back to 1975. In summary, a patient with a long and well known history of sexually inappropriate and harmful behavior infringing on the rights of others, sexually assaulted his roommate the first night after he was moved from another unit which resulted in Patient 1 being victimized. This failure had a direct or immediate relationship to resident health, safety and security. |
| 150001227 |
Department of State Hospitals - Napa |
150010910 |
B |
24-Mar-15 |
CWFU11 |
3753 |
CLASS B CITATION -- PATIENT RIGHTS REGULATION VIOLATION: T22 Div 5 CH 4 ART 4 73523(a)(9) (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 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. FINDINGS: The facility failed to ensure that Patient 1 was free from psychological abuse when a Licensed Staff (Staff A) abruptly entered an on-going meeting with Patient 1 and threatened "repercussions" if anyone made accusations against him. This behavior by Staff A had the potential, of instilling fear of reprisal in Patient A and the potential to prevent other patients from reporting allegations of abuse. Review of the facility reported incident on 3/4/14 indicated that on 3/1/14 Patient 1 reported that Staff A touched his shoulder on two occasions. Later, on 3/1/14 during a meeting to discuss this allegation, Staff A interrupted the team conference with Patient 1 and threatened retaliation to those who made false accusations against him. Review of the record for Patient 1 included a Treatment Plan dated 1/28/14. The plan indicated under the section "strengths" the following: "...has demonstrated his ability to cooperate with staff and treatment. He is receptive to discussing medication options.....is able to make his needs and concerns known to staff." On 3/1/14 an Interdisciplinary Note (IDN) indicated the following: On 3/1/14 at approximately 3:45 p.m.,Patient 1 reported to this writer that two male peers were tapping on his shoulder while talking to him. Writer investigated this complaint immediately. A mini team conference was conducted on 3/1/14 by the nursing team including shift lead,clinical nurse, and Patient 1. The patient was calm and cooperative, alert and oriented in all areas and denied any hallucinations or other injurious behavior. There was no injury reported. He expressed peers or staff being too friendly with him. "He stated: I am Asian and do not like people accusing me of being staff's favorite. I do not want anybody putting hands on me." According to a report of an allegation of abuse (SOC 314) dated 3/1/14 during a team conference regarding this issue, Staff A entered the meeting room and was asked to leave by the shift lead (Staff B). Staff A declined to leave and stated "if anybody is making accusations against me, there will be repercussions." Patient 1 then stated: "that sounds like a threat". A memo dated 4/23/14 written by the Unit Supervisor, indicated that Staff A was "escorted from the unit on 3/1/14 by the NSHPD (Napa State Hospital Police) due to aggressive behavior toward staff and patients, and an SOC 341 (state form for an allegation of abuse report) was filed regarding the incident." The facility investigation dated 5/15/14 indicated: "There is a preponderance of evidence to sustain allegations of misconduct and patient abuse by Staff A." During an interview on 7/30/14 at noon, Patient 1 stated he was glad that the staff no longer worked on his unit. Patient l stated "he was sort of a tough guy and just didn't seem like the kind of person who should be working here." In summary, when Staff A entered the meeting room where Patient 1 was expressing his concerns regarding unwanted physical contact, and Staff A angrily threatened all to not make false allegations against him, Patient 1 indeed felt threatened. This failure had a direct or immediate relationship to resident health, safety and security. |
| 150001245 |
Department of State Hospitals - Atascadero |
150011071 |
B |
14-Apr-15 |
WQ7W11 |
11851 |
REGULATION VIOLATION: T22 Div 5 CH 4 ART 4 73523(a) Patient's Rights and Welfare and Institutions Code 5325.1(c)(d)T22 Div 5 CH 4 ART 4 73523(a) (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 public upon request. Patients shall have the right:(25)Other rights as specified in Welfare and Institutions Code Sections 5325 and 5325.1 for persons admitted for psychiatric evaluations or treatment.AND Welfare and Institutions Code 5325.1(c)(d) 5325.1. Persons with mental illness have the same legal rights and responsibilities guaranteed all other persons by the Federal Constitution and laws and the Constitution and laws of the State of California, unless specifically limited by federal or state law or regulations. No otherwise qualified person by reason of having been involuntarily detained for evaluation or treatment under provisions of this part or having been admitted as a voluntary patient to any health facility, as defined in Section 1250 of the Health and Safety Code, in which psychiatric evaluation or treatment is offered 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 mental illness shall have rights including, but not limited to, the following: (c) A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect. Medication shall not be used as punishment, for the convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program.(d) A right to prompt medical care and treatment.FINDINGS: The facility failed to comply with the above regulations by failing to ensure the right of Patient 1 to be free from neglect and receive prompt medical care and treatment.Patient 1 was a 41 year old male with diagnoses including paranoid schizophrenia, panic attacks and pseudoseizures (non-epileptic, stress or emotional related seizure activity). Patient 1 fell to the floor on 12/4/13, and twice on 12/22/13, and twice on 1/7/14.During one of these falls Patient 1 suffered a fracture to his left femoral head. The femoral head is the highest part of the thigh bone (femur). It is supported by the neck of the femur. Each hip bone is connected to the corresponding femur, which is part of the lower limb, through a large ball and socket joint, the hip joint.Throughout the time period (12/4/13 - 1/7/14) Patient 1 complained of pain and was observed limping with an abnormal gait.An x-ray was ordered on 12/31/14, but not acknowledged or acted upon by the facility which resulted in a potential life threatening complication of avascular necrosis to the femoral head requiring a total hip replacement.Avascular necrosis of the hip is a painful condition that occurs when the blood supply to the bone in the head of the femur is disrupted and gradually collapses. Avascular necrosis can ultimately lead to destruction of the hip joint and disabling arthritis. (reference American Academy of Orthopedic Surgeons @ orthoinfo.aaos.org) Review of an Interdisciplinary Note (IDN) dated 12/4/13 at 3:05 p.m., noted per Patient 1's report "I feel dizzy and almost tripped on the floor but the staff got me." Patient denies hitting his head, escorted to Urgent Care Room in wheelchair.Patient 1 was then transferred from the Intermediate Care Facility, Unit 29 to Medical Unit 1 which is the Acute Psychiatric level of the facility for possible seizure like activity and to regain compliance with an anticoagulant drug (a drug that reduces the ability of the blood to form clots) for a history of deep vein thrombosis. Patient 1 had refused the drug for three days.Review of an Urgent Care Room (UCR) report dated 12/22/13 at 12:30 p.m., revealed while on Unit 1, Patient 1 tripped and fell in the hallway at 11:15 a.m., and again in the courtyard at 12:30 p.m. The UCR assessment by the physician noted Patient 1's complaint of a sore head at the left temple and pain in left hip but he was able to bear weight with slight limp, no X-ray needed. The diagnosis was "fall with contusion secondary to multiple PRN's, (as needed drugs), discussed with patient to space out PRN's, the treatment was an ice pack to the head and hip."Interdisciplinary Notes (IDN) dated 12/31/13 at 10:10 p.m. showed Patient 1 walking with an unsteady gait. IDN dated 12/31/13 at 7:15 a.m. showed Patient 1 had complained of difficulty while ambulating (walking).A physician order dated 12/31/13 at 9 a.m., revealed Patient 1 was to be transferred back to Unit 29 and to receive Tylenol 650 mg every four hours for left hip pain not to exceed four doses in 24 hours. If Patient 1 complained of severe left hip pain staff were to give Tramadol 100mg (narcotic-like pain reliever used to treat moderate to severe pain) every six hours not to exceed three doses in 24 hours. An order was given to x-ray the left hip.On 12/31/13, Patient 1 was transferred back to Unit 29. The transfer admission note dated 12/31/13 at 1:35 p.m. indicated "patient is walking slowly due to a history of fall on 12/27/13 on left hip, no swelling or bruising left hip area." There was no IDN describing a fall occurring on 12/27/13.The physician order for left hip x-ray was recapitulated on to the Unit 29 physician orders on 12/31/13 at 1:30 p.m., the order was noted by a licensed staff member of Unit 29 signifying they were aware of the order and would ensure its timely delivery of care, service and follow through.Review of the x-ray report revealed it had been completed on 12/31/13 at 9:47 a.m., and dictated on 1/2/14 at 3:59 p.m. by an offsite contract Radiologist with findings "suspicious for fracture of the left femoral head and decreased femoral head offsite bilaterally, associated with cam-type impingement." However, the results of the X-ray were not acknowledged or acted upon by the facility and Patient 1 continued to walk without the benefit of an evaluation for the suspicion of a left femoral head fracture.Review of the physician orders dated 1/1/14 at 9:50 a.m., revealed a wheelchair was ordered for long distances for fall risk and "dropped foot" for 45 days due to staff reports that Patient 1 complained of hip pain and had a wheelchair while on Unit 1. There was no additional information or evaluation documented concerning a "dropped foot." Drop foot, is a general term for difficulty lifting the front part of the foot. This is a sign of an underlying neurological, muscular or anatomical problem and can be associated with a fracture of the hip.An IDN dated 1/2/14 at 9:30 p.m. showed Patient 1 still complained of left hip pain and was advised to walk slowly to avoid falling; Patient 1 took a dose of Tramadol and complaints of pain decreased. IDN's dated 1/4/14 at 2 p.m. showed Patient 1 complained of left hip pain, stayed in his room most of the shift resting in bed and used wheelchair to go to the dining room which is located off the home unit.IDN and special incident report review revealed on 1/7/14, at 6 p.m. Patient 1 was standing in a line to receive medications when he got "anxious," tripped and fell again. Patient 1 again complained of left hip pain, was assisted up and sat in a wheelchair by staff.On 1/7/14 at 6:20 p.m. Patient 1 was in the examination room with staff for an assessment, stood up from the wheelchair and immediately fell to the floor crying out "left hip hurt, ouch, ouch, ouch." The physician transferred Patient 1 back to Medical Unit 1 on bed-rest and ordered an X-ray. There is no written indication the first X-ray was requested or reviewed. Review of an X-ray report dated 1/8/14 showed, "left femoral neck fracture with increased varus, to the prior X-ray study from 12/31/13. A varus is the inward bending of a bone or joint.Walking on a fractured hip may cause the two sides of the fracture to displace, or move apart, so they may no longer line up correctly. A displaced fracture also increases the risk of damage to the blood supply to the femoral head. The "Transfer Sheet" dated 1/8/14, showed Patient 1 was transferred to the community hospital emergency room with a note that indicated "recent fall with hip fracture." At the community hospital Patient 1 was admitted and the assessment showed he had a left hip external rotation deformity of 90 degrees and weakness of the leg, ankle and toes.An "Operative Report" dated 1/9/14, revealed Patient 1 was taken to surgery for percutaneous pin fixation. Pinning involves the manipulation, with X-ray guidance, of the fracture into an acceptable position, and the immediate insertion of metal pins through the skin, into one bone fragment and across the fracture line into the other bone fragment. The pins are normally left in position for four to six weeks, and are removed when the fracture has healed. However, the surgeon found the fracture to have more comminution at the femoral neck (bone broken into small fragments) and the fracture was determined not to be recent but "three weeks old." Surgery was discontinued.A magnetic resonance imaging (MRI) was completed and showed "bilateral avascular necrosis in the superior aspects of the femoral heads. Following the MRI a Computerized Tomography (CT scan) was done showing a "markedly displaced, angulated left femoral with a fracture line extended into medial calcar toward lesser trochanter." Review of an "Operative Report" dated 1/14/14 revealed Patient 1 underwent a second more invasive surgery on 1/14/14 and required a left total hip replacement. In a total hip replacement the surgeon removes the damaged sections of the hip and replaces them with parts usually constructed of metal and plastic. During an interview with the Standards Compliance RN on 4/2/14 at 9 a.m., she indicated Patient 1's x-ray was completed at the facility on 12/31/13, burned onto a disc and a courier took it to an offsite contract Radiologist for reading and a written report. The courier should have returned the report to the facility Radiology Department, who should have notified staff on Unit 29, where the patient resided for attention.The facility timeline review investigation report (no date) revealed Patient 1's x-rays were completed 12/31/13 and placed in a courier bag, which was not picked up or delivered to the offsite Radiologist until two days later on 1/2/14. The contract Radiologist read the x-ray films and dictated the report on 1/2/14 but there was no evidence if the results of the x-ray were delivered or received by the facility prior to 1/7/14. There was no follow-up by the prescribing physician of the X-ray on 12/31/13 to ensure it had been completed or what the results were.A review of the contract with the offsite Radiologist revealed the facility contact for radiology urgent report notification had been retired for several months and not updated.During an interview with the Acting Medical Director on 4/2/14 at 2:30 p.m., he acknowledged concerns identified in ensuring prompt medical care and treatment that was delivered to Patient 1.The facilities failure to act on an x-ray ordered on 12/31/13 showing a suspicious fracture of the left femoral resulted in a delay of medical care and treatment resulting in pain and suffering for Patient 1 and contributed to a potentially life threatening complication of avascular necrosis to the femoral head requiring a total hip replacement.These facility failures had a direct or immediate relationship to the health, safety, or security. |
| 150001245 |
Department of State Hospitals - Atascadero |
150011118 |
AA |
16-Feb-16 |
XSX111 |
14629 |
T22 DIV5 CH4 ART4 73521 Patient Care Policy Committee Written patient care policies shall be established and followed in the care of patients governing the following services: physician, dental, nursing, dietetic, pharmaceutical and an activity program and such diagnostic, social, psychological, and therapy services as may be provided. Such policies shall be developed by a committee whose membership shall consist of at least one physician, the administrator, the supervisor of health services and such other professional personnel as may be appropriate. These policies shall be reviewed and revised by the committee at least annually and minutes of the committee meetings shall be maintained on file indicating the names of members present, the subject matter discussed and action taken. T22 DIV5 CH4 ART4 -73523(a) 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. These 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 comply with the above regulations by: 1. Failing to ensure the rights of Patient 2 to be free from mental and physical abuse. Patient 1's acuity was a III (acuity is a definition of the patient classification system to serve as guidelines for allocation of staff), meaning he required 'frequent or intense staff intervention." Patient 1 was unsupervised and strangled Patient 2 to death while he was sleeping in his bed. 2. Failing to implement policies and procedures that required licensed staff to provide for patient safety by directly observing the patients and areas occupied by them at least three times each hour at irregular intervals not exceeding every 20 minutes during observation rounds. 3. Failing to implement policies and procedures that required licensed staff to adjust the patient acuity throughout the shift if the nursing care needs changed for the patient. These failures, either jointly or separately, resulted in the physical assault and death by strangulation of Patient 2, by Patient 1. Patient 1 was a 34 year old male admitted to the facility on XXXXXXX, as a dual commitment of mentally disordered offender and a sexually violent predator. His diagnoses included paranoid schizophrenia and antisocial personality disorder. Patient 1's history included assault which was likely to produce great bodily injury with intent to commit rape and sodomy. Patient 1 was 6 feet 8 inches tall and weighed 250 pounds. Review of Patient 1's Interdisciplinary team's focus of hospitalization and treatment form (dated 4/2/14) indicated that Patient 1's focus was psychiatric stabilization and anger awareness. Patient 1 was assessed to be a danger to others and was to be educated in anger awareness with enrollment in an Aggression Reduction group. Patient 1 did not attend the group. Patient 1 was also enrolled in groups for Mental Health Wellness and Healthy Living but refused most group participation. Psychiatrist 1 stated during an interview on 10/31/14 at 1:30 pm, that he was aware that Patient 1 had become more delusional since Patient 1's Olanzapine (an atypical antipsychotic medication) had been discontinued on 5/21/14 due to increased liver enzymes (an adverse side effect of Olanzapine). Review of the facility's Special Incident Report print out (no date) revealed Patient 1 had been involved in physical aggression and assault towards other patients eight times since admission on XXXXXXX and his attack upon Patient 2 on 5/28/14. In May 2014, Patient 1 had been on one to one staff observation for suicidal ideation for a total of 55.9 hours between 3/11/14 and 5/28/14. Patient 1 had been in full bed restraints for 8.25 hours, seclusion for 10.7 hours and other non-ambulatory restraints for 2.4 hours during the same time period. Review of interdisciplinary notes (IDN) of the week prior to Patient 1's assault of Patient 2, revealed a pattern of precursors for potential violence and increased need for staff supervision, as follows: On 5/23/14, Patient 1's peer reported to staff that Patient 1 tried to pay him to kill him (Patient 1). On 5/25/14, Patient 1 told staff that God was hurting him. On 5/25/14, Patient 1 paced and sang "am gonna kill all Christians." On 5/26/14, Patient 1 expressed to staff expectations that the court would let him go home the next day and he also expressed typical delusional content about Satan and that God makes him hurt. On 5/26/14 Patient 1 was given Ativan (medication used to treat anxiety disorders) for pacing and restlessness. On 5/26/14 Patient 1 was accused by his dorm mate of alleged assault. Patient 1's dorm mate stated that Patient 1 struck him in the right rib cage area. Review of an Interdisciplinary Note dated 5/28/14 at 11:15 a.m. revealed the following: 5/28/14 11:15 a.m.: Psychiatric RN note summary: "(Patient 1) requested staff presence as he needed to talk to someone. He had this to report, 'My earth name is [Patient 1], but it's not my real name. I am an angel of God. I have three names Chans, Ever and Antichrist. Chans is my power. Ever makes me everything like God. Antichrist makes me live forever and ever. I'm an angel of God. I was one of Gods fallen angels. I have to write something in stone. A grey stone. I have to engrave a grey stone. I have to do that at Patton. I have to write Lucifer got his power from God. The war is over. I asked God to give Lucifer his power because Lucifer is now with God...'. 'When I'm all done at Patton here on earth, I have to suicide myself and believe in God and the dead inside my body... I'm going to take the mark of the beast here...'. patient wanted this written in his chart, denies thoughts of harm to self or suicide at present. He further confirmed he does not intend to harm himself until he gets to Patton State Hospital." There was no written indication the registered nurse asked Patient 1 if he had intent to harm someone other than himself. During an interview with RN 1 on 10/16/14 at 11 a.m., RN 1 was asked if notification was made to the physician after Patient 1's communication with staff. RN 1 stated "No", because Patient 1 was already on "psychiatric sick call" for the alleged assault of a peer the night before. RN 1 was asked if Patient 1's acuity was changed from a III (3 ) to a higher level to ensure more frequent observation and supervision, she stated "No." RN 1 stated Patient 1 should have been an acuity IV (see definition below) but "program management pressure staff to keep the acuity levels low to avoid mandatory staffing." Review of the Nursing Procedure Manual policy and procedure titled, "Acuity Staffing Report" (Patient Classification Rating Form) No. 214.2, dated 10/9/13 revealed the following: "Acuity III = Patient is unable to meet identified behavior, but is still able to function in the unit milieu without restrictions. This patient requires frequent or intense staff intervention because he refuses or is unable to perform the correct behavior on his own. Because of the intervention(s) provided by nursing the patient is still able to function in the unit milieu without restrictions placed on him. The patient may be on 15 minute checks." "Acuity IV = Patient is unable to meet identified behavior without the addition of safety reinforcement: At this point, nursing service interventions alone are no longer able to keep this patient stable. Extensive nursing interventions and / or a reinforcement has been placed on the patient." "Acuity V = Patient is unable to meet identified behavior without the addition of 1:1 precautions due to unstable behavior." "A rating of V may be implemented for the following interventions: A 1:1 / Level of Sight (LOS) observation for unstable psychiatric conditions." The "Acuity Staffing Report" policy and procedure also required licensed staff to adjust the patient acuity throughout the shift if the nursing care needs changed for the patient. The policy and procedure showed, "Though the acuity tool is initiated at the beginning of each shift, the form will be adjusted throughout the shift if the nursing care needs change for a patient." During an interview with the attending psychiatrist (Psychiatrist 1), on 10/31/14 at 1:30 p.m., he indicated the registered nurse did not inform him of the conversation on 5/28/14 at 11:15 a.m. Psychiatrist 1 stated he was redirected from seeing Patient 1 in "psychiatric sick call", to complete a discharge summary for a patient leaving the facility. The psychiatrist stated when he had completed the discharge summary he went to Patient 1's dorm to speak to him and discovered Patient 1 on top of Patient 2, manually strangulating him. Review of staffing sheets for the unit dated 5/28/14 revealed the a.m. shift patient acuity on 5/28/14 determined 5.46 staff were allocated and 5 staff were delivered. Nursing Coordinator 1 indicated an additional staff would have not been delivered unless the acuity was at least 5.50. Review of the report from Office of Special Investigators (OSI) dated 6/11/14 (summary of investigations) revealed the registered nurse told the special investigator on 6/9/14 at 12:05 p.m., " Patient 1 should have been at least an Acuity 4 (IV) the entire time he resided on the unit. Patient 1 was transferred to the unit on XXXXXXX. Patient 1 was an Acuity 3 on 5/28/14 and program management wanted Patient 1 lowered to an Acuity 2." According to the OSI 6/11/14 report, "... on 5/28/14 at approximately 2 p.m., the psychiatrist went to Patient 1's dorm room to speak to him about an alleged assault he was accused of the night previous, opened the dorm door and saw Patient 1 on top of Patient 2 on a bed with his arms wrapped around his neck. Patient 2 was lying face down in his bed with Patient 1's stomach to Patient 2's back. The psychiatrist yelled for Patient 1 to get off Patient 2, and yelled to a custodian in the hallway to activate his emergency alarm. The psychiatrist went to the unit office and directed them to activate an emergency medical service alarm and then returned to the dorm room." "When the psychiatrist and senior psychiatric technician entered the dorm, Patient 2 was unresponsive, cyanotic (blue or purple coloration of the skin) and pulseless (without heart beat or pulse). CPR was initiated at 2:10 p.m., EMT's arrived at 2:12 p.m., with automated external defibrillator applied at 2:15 p.m. showing no shock was advised (pulseless) and transported to the facility urgent care room. Despite treatment of IV epinephrine and glucose, Patient 2 continued to be non-responsive and without respirations or pulse. Patient 2 was pronounced dead at 3 p.m. on XXXXXXX14." Patient 1 confessed to strangling Patient 2 and was arrested and booked into county jail for violation of CA Penal Code 187 (Murder). Review of the Certificate of Death dated XXXXXXX14 revealed Patient 2's manner of death was ruled a homicide on XXXXXXX14 with time of death 1500 hours. The cause of death was asphyxiation (minutes) due to manual strangulation (minutes). During the autopsy Patient 2 was found to have multiple fractured ribs which could or could not have occurred during the assault or unsuccessful attempts at resuscitation. Review of Administrative Directive No. 810 titled "Unit Security," dated May 28, 2014 revealed under "Observation Rounds," Staff will provide for safety by directly observing the patients and areas occupied by them. Unit staff shall make observations rounds of all areas occupied by the patients at least three (3) times per hour at irregular intervals. Intervals between rounds shall not exceed 20 minutes. This does not preclude staff from making rounds more frequently based upon safety or security need on the unit. Each round must be logged in the Day Book with staff initials and the time of the round. Review of Unit 26 Day book documentation of observation rounds revealed Staff A conducted the observation rounds starting at 1245, 1300, 1315, and 1330. The next entry was initiated by Staff A but there was no time the round was completed. The Security Round at 2 p.m. was blank. Review of the OSI report (page 8 of 26) showed that "On 6/6/2014 at 1230 Officer X spoke to Staff A in order to confirm when she had conducted the last security round and if she recalled seeing either Patient 1 or 2 during that security round. Staff A said she "did a security round at approximately 1345 hours and did not recall seeing either patient at that time. The last time Staff A recalled seeing Patient 2 was during lunch at approximately 1200 hours." There is no mention of when the last time Patient 1 was seen. (Interview could not be completed with Staff A as she was off of work.) The facility failed to fully implement their patient acuity system to ensure staff provided frequent or intense staff intervention to Patient 1 based on his acuity III, and/or failed to raise Patient 1's acuity to V as described in the policy and procedure: "Patient is unable to meet identified behavior without the addition of 1:1 safety precautions due to unstable behavior," with "1:1 / Level of Sight (LOS) observation." Implementation of this level would have been based on his unstable psychiatric condition, the reduction of his antipsychotic medication on 5/21/14, and delusional comments made to the registered nurse on 5/28/14 at 11:15 a.m., as well as other aggressive incidents occurring since the time of admission. The facility failed to ensure licensed staff provided for patient safety by directly observing them during safety observation rounds as evidenced by Staff A 's interview with OSI that she could not remember seeing Patient 1 or Patient 2 during observation rounds conducted in the hour previous to the strangulation of Patient 2. The facility failed to ensure the rights of Patient 2 to be free from mental and physical abuse by Patient 1 who was psychotically unstable and unsupervised by staff and strangled Patient 2 to death with his hands. These failures resulted in the physical assault and strangulation to death of Patient 2. These failures presented either (1) imminent danger that death or serious harm to the patient would result therefrom, or (2) a substantial probability that death or serious physical harm to the patient would result therefrom, and was the direct proximate cause of death to the patient. |
| 150001228 |
Department of State Hospitals - Napa |
150011297 |
B |
13-Oct-15 |
W6FQ11 |
6605 |
REGULATION VIOLATION: F 314 483.25(c) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that (1)A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.The above regulation was violated when the facility failed to identify and implement interventions to prevent pressure sores after a resident was assessed at risk for the development of pressure sores. This failure resulted in the resident's development of a Stage 4 pressure sore on the left ankle and the resident developed a subsequent Stage 3 on the left buttock two months later.Resident 1, admitted to the facility without pressure sores on 1/23/09, was a 68 year old with multiple medical and mental health problems. The resident had symptoms of psychosis, disorganized thinking, internal preoccupation, delusions, striking out, verbally threatening, resistive to care, as well as high blood pressure, obesity, incontinence and chronic lung disease.On 11/25/14 review of the resident's Annual Minimum Data Set (MDS) assessment tool, dated 1/23/14 indicated that the resident had no history of pressure ulcers and was identified at risk for the development of pressure ulcers. The MDS indicated that the resident was totally dependent for activities of daily living including bed mobility and transfer to a wheel chair and always incontinent. The resident cognition was impaired including short and long term memory problems.The Care Assessment Area (CAA) of the MDS indicated that based on the resident's total dependence for ADL's and always incontinent (bowel and bladder) he was at risk for pressure ulcers. This is addressed in the treatment plan under Focus 6.12 Incontinence and addressed in care plan. The MDS under Section M Skin and Ulcer treatments indicated the use of pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, application of ointments/medications other than to feet. There was however no plan of care found in the record.The record was reviewed on 11/25/14 with Licensed RN Staff A and on 12/16/14 with Licensed RN Staff B. No plans of care were found related to the resident's risk for pressure ulcers in the resident's record prior to the resident's development of the pressure ulcer on the left ankle identified on 6/11/14, with necrosis (dead tissue).A document titled "Rehabilitation Support Plan" dated 2/4/14 indicated that the resident also was totally dependent for transfers and bed mobility and had "a foot box screwed on footplates to prevent his feet from sliding out." "No evidence of skin breakdown." A Registered Nurse monthly summary dated 4/23/14 (3/27/14-4/23/14) indicated that Resident 1 needed assistance to elevate leg when in the wheel chair. Resident 1 did not wear shoes, only loose socks. Assessment of Resident 1's pedal pulses, toes, and foot color was performed daily. No pain noted.The monthly assessment dated 5/23/14 noted the resident had redness on the left and right heel with small scabs. The record reflected a nursing entry dated 6/10/14 at 11:30 a.m.: "Noted scab on left malleolus (outer ankle bone) measuring 1.7 centimeters (cm.) by 1 cm. No active bleeding. No signs of infection. Patient unable to state what happened. Able to move both feet without difficulties. Communicated to M.D." A document titled: "Daily Skin Integrity Flow Sheet" dated 6/11/14 (NSH #154) described the stage of the wound as Unable To Determine (UTD). A physician entry dated 6/11/14 at 9:30 a.m. indicated the physician assessed the resident's left ankle area as "early cellulitis" with orders for antibiotic, dressing, a wound care consult. A nursing plan of care was initiated for cellulitis and included a referral for a dietary consult. On 6/17/14 the Registered Nurse wound care consultant, documented the wound as a Pressure Ulcer UTD 2cm by 1.7 on the left outer ankle, with 100% yellow slough (dead tissue in the process of separating from healthy skin) and redness around the area. Treatment was initiated. Physician orders reflected a 6/19/14 order for foam boots to both feet for prevention of pressure ulcers and on 6/29/14 an order for an air cell mattress for pressure ulcer prevention. A plan of care for this new pressure sore was not initiated with these new orders and interventions identified. A plan of care dated 8/15/14 noted a pressure ulcer, unable to determine stage (UTD) on the resident's left buttock region that measured .9 cm. by 2.5 cm with 100% slough (dead tissue).The record indicated that Resident 1 received topical and surgical debridement of the left ankle pressure ulcer between 6/17/14 and 9/16/14. The wound care nurse documented on 9/16/14 that the resident had a Stage 4 pressure ulcer on the left outer ankle and a newly identified Stage 3 on the resident's left buttock. During an interview on 11/26/14 at 1:15 p.m. Licensed RN Staff A stated that all residents in the nursing facility are using pressure guard mattresses and sheep skin boots as preventative measures. There was no documentation that Resident 1 wore sheep skin boots in bed as there was no preventative plan of care for this resident who was high risk for pressure sores.During an interview on 12/16/14 Licensed Staff B stated that the pressure ulcer on the resident's left ankle should have been identified sooner when redness first appeared. The staff stated that there should have been a preventative plan of care in place with individualized interventions to prevent pressure sores. As of 11/20/14, the resident's treatment plan indicated that the resident's left buttock pressure sore had healed. The wound care nurse was still treating the Stage 4 pressure ulcer on the left ankle. In summary, Resident 1 a totally dependent resident for all care needs was assessed as at risk for the development of pressure ulcers. There were no plans of care developed to address this resident's risk prior to the resident's development of pressure sores. This lack of a preventative plan of care for this high risk resident not only resulted in the resident's development of one pressure ulcer but a second. The late identification of these pressure ulcers potentially caused longer healing time and the risk of additional complications.This failure had a direct or immediate relationship to resident health, safety and security. |
| 150001227 |
Department of State Hospitals - Napa |
150011322 |
B |
29-Jun-15 |
JOYY11 |
1336 |
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. The facility failed to ensure implementation of the health and safety code by failing to report all incidents of alleged abuse or suspected abuse immediately or within 24 hours to the Department when a patient made an allegation of staff abuse to the hospital police department and the facility failed to report the allegation to the Department.On 10/23/14 Patient 1 reported to the Department an allegation of staff abuse that had occurred on 8/8/14. During an interview on 11/25/14 at 1:30 p.m., the Director of Standards Compliance stated that the patient had in fact made the allegation directly to the hospital police, who then should have reported it to Standards Compliance but failed to do so. As a result Standards Compliance was unaware of the allegation and did not report it to the Department. The facility Administrative Directive 437 titled: "Abuse and Neglect Reporting Requirements" dated 4/15/14 section D number 5 indicated that "The Standards Compliance Director or designee will be notified within 24 hours." This failure had a direct or immediate relationship to resident health, safety and security. |
| 150001227 |
Department of State Hospitals - Napa |
150011442 |
B |
30-Oct-15 |
X1M811 |
4694 |
T22 DIV5 CH4 ART4 73523(a)(9)-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 comply with the above regulations when a staff member failed to follow the facility's policy regarding patients protected from harm and neglect. Licensed staff failed to do routine skin assessments on Patient 1's foot. Patient 1 was a diabetic with a long history of diabetic foot ulcers. This neglect resulted in an open wound under Patient 1's toenail on his right foot that was not provided treatment. The wound harbored a maggot that had lived in the wound for an undetermined amount of time. The facility failed to protect Patient 1 from neglect as follows: On 6/26/14, the facility notified the California Department of Public Health by written notice that staff had found Patient 1 with an open wound on his right foot with a maggot under his right toenail. Clinical record and document review starting on 4/17/15, indicated: Patient 1 was admitted to the facility with multiple diagnoses including diabetes. Patient 1 had a history of skin problems including diabetic foot ulcers (a devastating complication of diabetes resulting in ulcers with the potential of amputation in 85% of diabetic patients). A review of the facility IM (Incident Management) Report dated 6/27/14, indicated on 6/26/14 at 1:30 p.m., while performing treatment duties on Patient 1's left foot the Treatment Nurse (Staff A) observed pink discoloration on Patient 1's right sock. When the sock was removed by Staff A, a maggot fell to the floor. Review of the Physicians' Progress Notes - Monthly Summary, dated 6/17/14, revealed that Patient 1 had developed complications of diabetes ..... "He has peripheral neuropathy (a degenerative disease of the nervous system due to circulatory obstruction). He has skin breaks in the left ankle which he receives wound care. He is cooperative with his treatments and accepts assistance." A review of the Physicians' Progress Notes, dated 6/26/14, revealed that the physician documented ..... "Assessed right foot - appears to be infested with maggots - send to lab for identification." A review of Napa State Hospital Clinical Laboratory Report, dated 6/27/14, revealed ...... "Bug identification under toenail- insect - maggot." During an interview with Staff A on 5/7/15 at 11 a.m., Staff A stated, "I took the sock off and a small bug fell out from under the toenail area. I'm not sure what it was. I don't know if I always check both feet on a diabetic patient for any skin problems. I guess I do. Anyway, he is not compliant with his treatments. He will fight staff. I probably should have insisted to look at his other foot when I did his treatments. I didn't think that there was a problem with the right foot. Never heard anything about a problem. This is not my responsibility to know this anyway. I'm the wound care nurse."Review of RN Reassessment Notes, dated 6/24/14 to 6/28/14, revealed that Patient 1 was compliant with medications and treatments for his wound care. Despite the interview with Staff A, there was no documentation to support the fact that Patient 1 was noncompliant with his wound care and/or aggressive toward staff during his treatments. Review of the facility policy titled, "Abuse/Neglect and Reporting Requirements," number 437, dated 6/16/15 revealed ..... "It is the policy of the Department of State Hospitals (DHS) - Napa to provide a safe and humane environment to the patients. DSH - Napa will ensure that patients are protected from harm and will not tolerate any form of patient abuse and/or neglect." The facility failed to comply with the above regulations when a staff member failed to follow the facility's policy regarding patients protected from harm and neglect. Licensed staff failed to do routine skin assessments on Patient 1's foot. Patient 1 was a diabetic with a long history of diabetic foot ulcers. This neglect resulted in an open wound under Patient 1's toenail on his right foot that was not provided treatment. The wound harbored a maggot that had lived in the wound for an undetermined amount of time. The facility failed to protect Patient 1 from neglect. These facility failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150011631 |
B |
28-Oct-15 |
WFW011 |
4573 |
T-22, CH-4, ART-4, 73523(a)(9) (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 comply with the above regulation as follows: Based on record review and interview the facility failed to protect Patient 1 from abuse when Patient 2 pushed Patient 1 into a wall which caused him to hit his head hard enough to cause intracerebral bleeding and a subdural hematoma (blood in the brain cavity) requiring a craniotomy (draining blood from the brain cavity). Findings: Review of facility investigative report on 6/10/14 at 1:15 p.m., revealed that Patient 2 grabbed the arm of Patient 1 on 6/4/14 and threw him into the wall at approximately 3 p.m. Further review revealed that Patient 1 sustained a blunt head trauma with intracerebral bleed (bleeding into the brain) and subdural hematoma (blood on the brain) requiring a craniotomy (draining blood from the brain cavity) on 6/5/14. From the 6/4/14 incident and subsequent injury and surgery, Patient 1 developed left hemiparesis (left sided body weakness), aphasia (difficulty speaking), dysphagia (difficulty swallowing), and cognitive impairments. Review of Patient 1's medical record on 6/10/14 at 1:30 p.m., revealed that the patient was admitted to the facility on 7/23/98 and had diagnoses which include schizoaffective disorder (delusions and disorganized behavior) and cognitive disorder (disorder of perception, memory, and judgement).Review of Patient 2's medical record on 6/10/14 revealed that the patient was admitted to facility on 12/22/92 and had diagnoses which include schizophrenia (delusions and disorganized behavior), undifferentiated type, and antisocial personality disorder (disregard for the rights of others). Review of Patient 1's Treatment Plan, under Focus # 3.2 "Dangerousness and Impulsivity" revealed that Patient 2 had a history of assault, battery, and a pattern of aggressive, oppositional or demanding behaviors towards staff and peers. Review of facility investigative report on 6/10/14 revealed that at 3 p.m. on 6/4/14 a loud noise was heard in the nurses' station. Nursing staff went to see what caused the noise and found Patient 1 lying on his back on the floor. Patient 1 was then taken to the treatment room for a vital signs and observation. Further review revealed that at 4:30 p.m. Patient 1 began to show noticeable changes in his mental status and left sided weakness. Further review revealed that at approximately 5:40 p.m. Patient 1 was transferred by ambulance to an acute care hospital emergency room where the diagnoses of intracranial bleed and subdural hematoma was made. Review of facility documentation revealed an interview with Patient 3 who stated, "[Patient 2] just grabbed [Patient 1] as he walked by and threw him against the wall". Patient 3 further stated, "[Patient 1]'s head hit the wall at the same time his buttocks hit the ground. After hitting the wall, [Patient 1]'s head bounced off the wall". Further review of facility documentation revealed and interview with Patient 4 who stated, "[Patient 2] grabbed [Patient 1] by the arm and threw him against the wall". During interview with Staff A on 10/8/15, at 10 a.m., staff stated, "There was no behavior plan, no previous or no indication of behavior. It was not discovered that [Patient 2] was the person who threw [Patient 1] until later in the evening when other patients talked to the Police Officers. [Patient 2] was not put in Administrative Isolation until that time." Further review of Patient 2's medical record on 6/10/14 revealed that patient 2 was not placed into Administrative Isolation until 2200 hours (10 p.m.) on 6/4/14. Subsequently Patient 2 was arrested by Hospital Police officers and transported to the Napa County Jail at 2305 hours (1105 pm) on 6/4/14. The facility failed to protect Patient 1 from abuse when Patient 2 pushed Patient 1 into a wall which caused him to hit his head hard enough to cause intracerebral bleeding and a subdural hematoma (blood in the brain cavity) requiring a craniotomy (draining blood from the brain cavity). The facility's failure had a direct relationship to the health, safety, and security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150011644 |
B |
02-Nov-15 |
YN8611 |
6110 |
T22 DIV5 CH4 ART4 73523(a)(9)-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 violated the above regulation when Staff B witnessed Staff A yelling at and grabbing an item out of the hand of Patient 1 and Patient 1 complained of mistreatment by Staff A.On 5/28/15 the facility reported that on 5/27/15 Staff B witnessed and reported that Staff A yelled at Patient 1 and grabbed a bag out of his hand. On 5/28/15 Patient 1 initiated a complaint regarding this incident.During an interview on 6/04/15, at 9 a.m., Patient 1 stated he was trying to get towels from the linen room to clean up a spill and Staff A was yelling at him to leave for an appointment. He stated that Staff A handed him his chart bag. He stated he was holding a bag with shoes in his left hand. Staff A grabbed the bag and wrenched his right hand. Patient 1 stated Staff A accused him of refusing to go to his appointment. Patient 1 stated he reported the incident to the supervisor and the police. The patient stated that he had four surgeries on his right hand and problems with the right wrist and that it hurt after the staff grabbed the bag from him.During an interview on 6/4/15 at 9:30 a.m., Staff A denied "raising his voice" at Patient 1. Staff A stated that he was new to the unit, about 2 days. He had been assigned to escort 4 patients to clinic for appointments. There was a cart waiting because one of the patients had difficulty walking. Staff A stated that he was trying to get the clients together to leave as there was a cart waiting to take them to their appointments. Patient 1 told Staff A he had to use the restroom at which point Staff A told Patient 1 he couldn't take his record into the restroom. As Staff A was about to return the patient's record to the nursing station, he said, Patient 1 changed his mind.During an interview, on 6/4/15 at 2:30 p.m., Staff B stated she heard yelling in the hallway. When she went to see what was happening she saw Staff A yelling really loud and at the same time Staff A and Patient 1 were struggling back and forth with a white bag (bag used to take charts out of the unit.) "So I reported what I saw."Review of the record of Patient 1 revealed an Interdisciplinary Note (IDN) dated 5/26/15 at 8:45 a.m., written by Staff A: "Patient had podiatry appointment. -while writer was getting peers ready to leave unit patient was attempting to slow progress to leave unit. Escort staff was ready with CART, so quicker to appointment. Patient at time to leave. (sic) Then wanting to wait for peer. Not informed of peer's - not going to appointment. (Patient 1) then attempting to get clean linen to yet continue to delay leaving unit. Patient was then informed writer is leaving to appointment. Patient then moving slowly to door...Once on unit patient approaching SL (shift lead) about being treated like animal..."An IDN also dated 5/26/15 at 12:30 p.m. indicated that Patient 1 requested to be seen by the doctor. Patient 1 stated: "Staff grab (sic) this chart from me and I have an old surgery on my hand and wrist and its beginning to bruise." The IDN documented that visual assessment at the time did not reveal redness, swelling or bruising.Review of a Physician Progress Note dated 5/21/15 indicated that Patient 1 was seen by the physician and he reported doing well, enjoying his work and looking forward to applying to be on an open unit. The document indicated that the patient's psychiatric diagnosis was in full remission and included an additional diagnosis of right forearm fracture with chronic pain.Review of the facility investigation revealed that the facility substantiated the allegation of abuse. The investigation noted prior investigations over the past five years related to staff to patient conduct. Review of personnel information revealed that in 2011 Staff A received a counseling record for the use of excessive force with a patient, and unapproved physical interventions. In 2012, Staff A received a counseling record regarding placing his hand on a patient's shirt to remove the patient from an area. In 2014 a violation of psychological abuse was sustained. There was no record of specific action found for this violation.Attachments to Administrative Directives AD 755 titled: "Incident Management" and 437 titled: "Abuse and Reporting Requirements" include the following definitions:Abuse-Physical: "Any interaction or physical contact, motion, or action that is directed toward a Patient by someone other than another Patient, which may cause harm or pain. Examples include: shoving, hitting, slapping, pinching, shaking, kicking, punching, misuse of seclusion or restraint, misuse of medication or unnecessary roughness during the provision of care."The definition of verbal abuse: "Any language by someone other than another patient that may be threatening, demeaning, discriminatory, pejorative, derogatory, or aggressive." The definition of Psychological abuse: Any act by someone other than another patient that causes or could reasonably be expected to cause emotional distress to a patient. Examples include but are not limited to use of intimidation to achieve compliance, retaliation, purposely not intervening in a behavior that is demeaning to the patient, deliberately inflicting mental pain, anxiety, confusion, humiliation, harassment or coercion." In summary, the facility failed to ensure Patient 1's right to be free from mental and physical abuse when Staff A yelled at Patient 1, grabbed the bag out of the patient's hand and accused the patient of refusing to go to his appointment. This failure had a direct or immediate relationship to resident health, safety and security. |
| 630004081 |
Department of State Hospitals - Coalinga D/P ICF |
150011646 |
B |
28-Oct-15 |
YEMN11 |
2924 |
HSC 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 comply with the above regulation by failing to report an unusual occurrence within 24 hours to the California Department of Public Health (CDPH). This incident was reported to the Patient Right's Advocate Office (PRA) by Patient 1 on 4/4/13, of an incident occurring on 4/3/13 of possible abuse. This was reported to the facility Quality Improvement Office on 5/13/13 and was not reported to the CDPH until 5/15/13. The facility failed to comply with the above regulation as follows: Review of Patient 1's medical record on 5/30/13 documented that when direct care staff went to conduct a routine room search on 4/3/13, due to patient hoarding, Patient 1 was standing in the door with one hand on the door and one hand on a phone. He yelled at staff, let go of the door and fell on his buttocks. He got up by himself and sat on the bed. A Registered Nurse assessed the patient and all vital signs were within normal limits.During interview with Direct Care Staff A, on 5/30/13 at 2 p.m., she stated, "The door was open enough that I was able to slip into his room without touching the door or the patient. The patient let go of the door and lost his balance and fell onto his buttocks on the floor." Further review of Patient 1's record documented that Patient 1 filed a complaint of abuse against the staff on his unit with the Patient Rights Advocate's Office on 4/4/13. He stated that staff pushed him away from his room, knocked him down, and kicked him causing him to have a concussion. Staff ordered x-rays of the patient's hip and skull and all came back negative for injury. During interview with Quality Improvement Department (QID) Staff B, on 3/17/15 at 8:50 a.m., she stated that, "The Patient Right's Advocate Office (PRA) is not part of DSH-Coalinga and they are a private entity. QID is not aware of what patients file with PRA until PRA notifies them."Staff B, on 3/17/15 at 9:40 a.m., stated that form "SOC 341 (Report of Suspected Dependent Adult/Elder Abuse), dated 5/13/13, is what prompted notification of CDPH for an allegation of abuse, but notification was not made until 5/15/13." The SOC 341 form was sent to Standards Compliance on 5/13/13 by the PRA. Review of facility Administrative Directive No. 768, effective date February 10, 2015, Subject: Reportable Events to DSH and CDPH documents under V. Reporting Process, "D. The Reported Incident form will be transmitted via secure file transfer (SFT) to DSH-Sacramento and/or CDPH within 24 hours of the event being disclosed to QID." The facilities failure had direct relationship to the health, safety, and security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150011758 |
B |
06-Nov-15 |
MDJC11 |
5213 |
REGULATION VIOLATION T-22 DIV 5 CH 4 ART 3 73339(a) Dietetic Service - Sanitation All kitchen and kitchen areas, shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.The facility violated the above regulation when two patients on unit T-18 observed on-going sightings of cockroaches during meals in the K-4 dining and serving areas.On 7/15/15 Patient 1 complained of cockroaches in the dining room on K-4 and there was an insect in his cereal. During an interview, on 7/27/15 at 11:45 a.m., Patient 1 stated that the dining room was full of cockroaches. He stated he had spoken to staff about it and it was still a problem. The patient stated that he brought the cereal to the attention of the kitchen staff who asked if he wanted another bowl of cereal. The patient declined. He stated: "I lost my appetite."Patient 2 complained on 7/23/15 of cockroaches in the dining hall and in the food. On 7/27/15 at 10:45 a.m., observations in the K-4 kitchen area revealed one cockroach crawling up the tile wall behind clean dishes across from the dishwashing machine. There was also a cockroach, (not moving), under the garbage disposal area. During a concurrent interviews Dietary Food Services Staff, Staff A stated she had seen one the prior week near the garbage disposal and a few in the main area of the kitchen. Staff A stated that last Friday a Licensed Staff B reported he saw one during lunch in the dining room. The Food Service Supervisor stated that all sightings of pests are reported to the Food Service Supervisor II Staff C and recorded. Staff C stated that the last spraying for cockroaches was two weeks ago.During an interview, on 7/27/15 at 11:30 a.m., Licensed Staff B stated that on Friday 7/24/15 he was in the dining room on K-4 during lunch and a cockroach crawled across his clipboard that was on one of the dining tables. Staff stated he had seen others in prior months.Review of facility documents on 8/24/15, indicated that the facility had a contract with a pest control company that began in January 2015.On 9/23/15, review of " Pest Sighting Log " and pest control reports for K-4 and the main facility kitchen, indicated the following:On 1/9/15 k-4 there was roach activity found underneath refrigerators and around food prep, service areas, and ovens. (Sightings 1/7/15) 1/13/15 roach activity still being seen will retreat.2/16/15, Activity seen around kettle pots, stoves and prep areas, all areas throughout kitchen.2/27/15 roaches were found in the main kitchen and dry food storage areas. (sightings on k-4 2/27/15) 4/10/15 inspected and treated K-4 and the main kitchen roaches seen in both kitchens. (Sightings 4/10/15, and 4/16/15)4/24/15 roach activity seen on K-4, treated. (Sightings 4/29/15 and 5/5/15) 5/12/15 roach activity in the Main kitchen, treated.6/2/15 some roach activity seen in main kitchen will treat. (Sightings 5/28/15) 6/9/15 heavy roach activity seen in K-4 kitchen and dining areas, as well as dish areas.7/16/15 roach activity seen in K-4, treated(Sightings 7/9/15 and 7/27/15) 8/24/15 roaches on k-4 treated (reported sightings on 8/3/15, 8/14/15 and 8/24/15)) 9/23/15 roaches in main kitchen On 8/24/15 at 3 p.m., Standards Compliance Staff, Staff E reported from the Director of Dietetics that some of the food in the unit kitchens originates from the main kitchen. During an interview on 8/24/15 at 2 p.m., Patient 1 stated regarding the on-going issues with roaches: "We might be in a mental hospital but that doesn't mean we shouldn't have safe food and be given dignity." The patient continued that he had seen another roach last week on one of the dining room tables. "I showed it to the staff and they just keep saying they have a pest control company working on it. I'm concerned for my health." the patient stated. Observations in the K-4 kitchen on 8/24/15 at 10:00 a.m., revealed a sighting under the dishwashing sink. During concurrent interviews the Food Service Supervisor I, stated she had seen roaches in the serving area and tray line, but not lately. The staff stated that she does report sighting to her supervisor.On 9/10/15, Patient 2 complained that the roaches were still a problem.On 9/14/15 at 10:30 a.m., during an interview, Patient 1 stated that on 9/6/15 he saw a roach in the kitchen serving line crawling over buns. The patient stated the server then wrapped all the buns up and threw them away, but "who knows where the roach went?"According to the Center for Disease Control (CDC) the cockroach is considered: "an allergen source and an asthma trigger for residents. Although little evidence exists to link the cockroach to specific disease outbreaks, it has been demonstrated to carry Salmonella typhimurium, Entamoeba histolytica, and the poliomyelitis virus ..." In summary, the facility failed to ensure that all kitchen areas were protected from cockroach infestation, particularly in K-4 kitchen and dining areas. This failure over the past year had the potential to cause disease and has caused ongoing health concerns for the patients who use this dining room.This failure had a direct or immediate relationship to resident health, safety and security. |
| 150001227 |
Department of State Hospitals - Napa |
150011760 |
A |
06-Nov-15 |
K1IJ11 |
10177 |
REGULATION VIOLATION T-22 DIV 5 CH 4, ART 473523 (a) (9) 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 2's right to be free from verbal and physical abuse when Patient 1 repeatedly assaulted Patient 2 resulting in the emergent transfer of Patient 2 to the hospital for treatment of facial injuries including a broken jaw.On 5/1/15 the facility reported incident indicated, that on 4/30/15 at 4:37 p.m., as Patient 2 sat watching television, Patient 1 began punching him in the face multiple times and Patient 2 fell to the floor on his back. Patient 1 then continued to punch Patient 2 in his face and started kicking him in the face several times. The staff separated the patients. Patient 2 was lying on the floor bleeding profusely from his face and transferred emergently to the hospital. At the hospital Patient 2 received stitches to his facial injuries and was also diagnosed with a dental alveolar fracture (broken bone of the mouth, which contains the teeth) and a surgical consultation was pending.Staff A a social worker, who witnessed the incident, documented: "(Patient 2) was watching TV in the day-hall when (Patient 1) assaulted him without provocation, punching him several times in the head. (Patient 2) was not able to defend himself, he fell unconscious to the floor, however, (Patient 1) continued to punch him repeatedly. (Patient 2) started to bleed profusely from multiple wounds in his face and head. At one point he (Patient 2), tried to get up but he could not see and he started to have severe difficulties breathing, choking on his own blood. (Patient 1) continued to punch him relentlessly, screaming and yelling obscenities. I was behind (Patient 1) telling him to stop and trying to get (Patient 2) away from him, but (Patient 2) was trapped between the chairs and (Patient 1). At one point (Patient 1) stopped for a second, at that moment from the back I pushed him away from (Patient 2). I tried to step between them, trying to get (Patient 2) off of the floor. (Patient 1) charged me repeatedly with aggressive posturing and insults but did not touch me after all. Then two nurses arrived. We immediately started to contain the blood coming out of (Patient 2) but his wounds were multiple and very severe and the blood was coming out faster than what we could contain. His clothing and all the floor area around him was covered in blood. At this time I noticed his dentures were twisted and imbedded into his gums, he had major cuts in his chin, mouth nose right eye and the right side of his head. We continued attending to him until the paramedics arrived..."Review of the records of Patients 1 and 2 indicated that each was diagnosed with Schizophrenia. The aggressor, Patient 1 was 15 years younger and weighed 45 pounds more than Patient 2, the victim. Patient 1 had a history of aggression, most often in retaliation. On 1/6/15 he was spat on by a patient and turned and punched that peer repeated in the face. On 1/7/15 he was punched by a patient in the chest, he turned and punched the peer repeatedly in the chest. On 3/30/15 a patient hit him and he turned and punched the peer three times in the face knocking him to the floor. On 4/2/15 he struck this same peer in the bathroom.Patient 2 had a history of aggression, was considered cognitively limited and low functioning. Patient showed severe limitations in judgment memory and learning and also no insight on his diagnosis, nature of his hospitalization or need for treatment. Patient 2 was also blind in the right eye.The facility incident report indicated that a short time before this physical altercation Patient 1 alleged that Patient 2 swung at him and Patient 1 was able to evade the assault. Both patients were separated from each other and offered a medication for agitation. Patient 2 accepted the medication and Patient 1 did not. The Unit Supervisor documentation noted under "Precipitating Events" that Patient 1 had a "long history of assault which can be attributed to his labile (emotionally unstable) mood. He usually gets easily irritated and has the habit of getting even with his peers when they do him wrong". Under the section titled "Early Warning Signs:" "It was alleged that that there was an initial verbal and physical altercation between these two patients (sic) when they were in the small day room which continued when Patient 2 separated himself and went to the big day hall."During an interview on 5/13/15 at 11 a.m. the Unit supervisor stated that after the 3/30/15 incident involving retaliation of a peer twice by Patient 1 the peer was moved to another unit. On the day of this incident on 4/30/15 Patient 2 was with staff in the larger day hall when he was assaulted by Patient 1. He alleged that Patient 2 swung at him earlier in the small day hall. We kept yelling at him to stop he was about to run after the social worker when the hospital police arrived.According to the facility Administrative Directive titled: "Abuse/Neglect and Reporting Requirements" Number 437: "It is the policy of the Department of State Hospitals (DSH) - Napa to provide a safe and humane environment to the patients. DSH - Napa will ensure that patients are protected from harm, and will not tolerate any form of patient abuse and/or neglect." Section III Immediate Response: "Staff are to ensure the safety of the patient(s) by immediately assessing the patient for injury or psychological distress as a result of the allegation/observation and provide protective, medical, and/or psychological services, as warranted." Review of the Treatment Plan for Patient 1 dated 3/25/15 indicated the last "Assault/Homicide risk assessment was updated 3/27/14. At that time Patient 1 was: "assessed to be at moderate to high risk of aggression to others particularly when he is not taking his medications as prescribed. In the past year he has assaulted others on 10 occasions, frequently in retaliation to an assault or attempted assault against him." According to the Physician's (psychiatric) Monthly Summary dated 4/15/15 Patient 1 "had a couple of instances when he got into fights with a peer. First time he retaliated after being hit by a peer, but next day he cornered the respective peer in the bathroom and beat him up. He is compliant with medication and participates in groups."Review of the facility incident tracking documentation revealed that Patient 1 had been the aggressor in 6 previous incidents of aggressive physical acts to other individuals, between January 2015 and this assault on 4/30/15. The facility Administrative Directive titled: Risk Management Number 30 effective 1/20/15 indicated that the Program Review Committee (PRC) prioritizes which patients to be reviewed based on the patient's aggression history, level of injury, type of assault, enhanced observation, admission aggression assessments, and direct referrals from the Treatment Team. The committee members include the Program Director Senior Psychiatrist, Senior Psychologist Senior Social Work, Senior Rehabilitation Therapist, Health Services Specialist (Registered Nurse), Nursing Coordinator and Risk Manager. The PRC meets weekly. There were two Program Review Committee (PRC) "discussion notes." On 4/9/15, Patient 1 was reviewed for "2 or more incidents of Aggressive Acts to Peer and Self-Injurious Behavior." The discussion notes indicated that the Patient had had an aggressive act to the same [peer twice this week. He has shown very delusional and aggressive behavior recently. He believes the FBI is after him, and he becomes more paranoid when other peers get close to him for any reason. He doesn't attend or participate in groups due to his paranoia. Per his treatment team, this is his normal behavior cycle. Physician A, his psychiatrist has informed patient of medication options that might ease his anxiety and/or paranoia, but has disagreed and is refusing to talk further about it. Medication regimen has been reviewed and no changes have been made recently..." Under the section "Recommendation:" "PRC agrees with current plan." The second PRC, Patient 1 was reviewed for "Aggressive Act to Another Individual." "PRC 5/14/15: Patient had been arrested and then the patient came back due to not being able to accept him (they had no room)." This document indicated that upon arrival back on the unit Patient 1 was started on two anti-psychotic medications. "He is asking when he can go live out on his own...he has promised his psychiatrist that from now on he will be good. Team reports the patient does hold grudges and will focus on peers who have been former targets. When the patient apologizes, he is able to recall everything he is sorry for.""Recommendations: PRC agrees with current Plan." According to a document titled: "Behavioral PRN/STAT Note" contained in the record of Patient 2 on 4/30/15 at 4:30 p.m. "Patient threatened and postured to assault, swung his hand to his peer, (Patient 1) tensed muscles and eyes glaring. Staff redirected him back to his room but he chose to stay in the day hall and was physically assaulted by his peer. At 4:35 p.m. olanzapine 2.5mg by mouth. 5:35 p.m. Patient was physically assaulted by his peer whom he threatened by swinging his hand, injuries sustained transported to hospital."In summary, the facility failed to protect Patient 2 from physical and mental abuse by Patient 1 when earlier the same day, Patient 2 swung at Patient 1. Patient 1 had a known history of retaliation and refused a calming medication offered at that time.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 Patient 2. |
| 150001227 |
Department of State Hospitals - Napa |
150011970 |
B |
25-Jan-16 |
J7EM11 |
5021 |
T-22 Div 5 Ch 4 Art 3 73311(a) Nursing Service - General Nursing Service shall include, but not be limited to, the following: (a) Identification of problems and development of an individual plan of care for each patient based upon initial and continuing assessment of the patient's needs by the nursing staff and other health care professionals. The plan shall be reviewed and revised as needed but not less often than quarterly.The facility violated the above regulation when Patient 1 struck Patient 2 in retaliation for being touched by Patient 2. This intrusive behavior of Patient 2, touching/tapping others on the face or head, was known but not assessed and incorporated into the patient's care plans, as a behavior that often led to his being assaulted by others. This incident resulted in Patient 2 sustaining a nasal fracture. The facility reported incident indicated on 5/6/15 at 6:52 p.m., staff witnessed Patient 1 being punched in the face approximately 10-15 times, in front of the nurse's station. Staff immediately intervened. During a concurrent interview, Patient 1 told staff that he struck Patient 2, because Patient 2 had hit him on the left cheek. Patient 2 was crying immediately following the incident. The patient "informed staff that he tried to pat his peer, (Patient 1) on the head, while walking in the hallway. His peer got upset and hit him on the eyes, nose and mouth. Patient 2 was wearing his soft helmet at the time of the incident." Patient 2 was initially assessed with redness around both eyes; slight swelling under the right eye, bruising on the right upper cheek, scant bleeding from the nostrils with septum slightly deviated towards the right, and cut on the upper lip. An x-ray on 5/7/15 indicated there was a non-displaced fracture at the distal aspect of the nasal bone, the age of which was difficult to determine. The facility incident report, dated 5/6/15 at 7:10 p.m. indicated Patient 1 had 7 incidents of assaults on peers since 4/1/15. Patient 2 "has a behavior of 'tapping' peers on the cheek/face; this is the second time he has done this to (Patient 1) with the similar result." Patient 2 was encouraged to avoid Patient 1 and not to tap or touch others.The incident report included a section titled: "Program Review." The section showed, "Actions to prevent reoccurrence: Continue to monitor." A review of incidents prior to 5/6/15 between these two patients revealed an incident dated 4/18/15. In the incident, Patient 1 assaulted Patient 2 resulting in Patient 2 requiring first aid. Review of the record of Patient 2, revealed a Physician's Progress Note, dated 5/6/15. The note indicated Patient 2 was assaulted, had facial trauma, and was sent for x-ray and ear, nose and throat consultation Review of the treatment plan for Patient 2, dated 5/27/15, revealed there was no documentation of a focus, regarding or including this behavior. A document, dated 11/15/13, titled, "Behavior Intervention Plan" for Patient 2, did not identify the intrusive behavior of touching/tapping others. The "Physicians' Progress Notes Monthly Summary," dated 6/18/15, included the following: "He continues to hit and touch peers...He has a behavioral intervention plan for reducing the risk of assaultive-ness to others but it seems like it is not working and his assaults occur without any antecedent." During an interview, on 11/3/15 at 11: 45 a.m., the Unit Supervisor stated touching/tapping others was one of his behaviors at the time. When queried about why the behavior was not in the behavior plan, nor treatment plans, the Unit Supervisor stated she would tell the patient's Social Worker and his Psychologist about that. The facility document titled: "Risk Management Program Review Committee (PRC)" dated 2/26/15, indicated in the discussion notes, the plan to increase Patient 1's medication as per the Psychopharmacological Resource Network (PRN) recommendations. The Program Review Committee (PRC) for Patient 2, dated 4/16/15, indicated that he had 26 aggressive acts in the past year, and had assaulted 10 patients. Patient 2 was described as extremely paranoid and delusional. "He has had charges filed, but they have not been followed through with the District Attorney... After he assaults, he immediately becomes calm. His peers are fearful of him." Patient 2 had also assaulted staff. The patient's medications were reviewed and further recommendations regarding medications were made. The record of Patient 2, indicated that he was high risk for assaultive behavior and moderate risk for victimization. The record of Patient 1 indicated he was high risk for assault. In summary, the facility failed to protect Patient 2 from harm, when there was no plan in place to attempt to modify a known intrusive behavior of touching and tapping others. As a result of this behavior on 5/6/15, Patient 1 assaulted Patient 2 causing facial injuries including a broken nose. This failure had a direct or immediate relationship to resident health, safety and security. |
| 630004081 |
Department of State Hospitals - Coalinga D/P ICF |
150012033 |
AA |
23-Sep-16 |
S9CP11 |
10314 |
Citation 15-1411-12033 Intake 405769 T22, DIV5, CH4, ART3 - 73331 Dietetic Services - Therapeutic Diets Therapeutic diets shall be provided as prescribed by the attending physician and shall be planned, prepared and served with supervision and/or consultation from the dietitian persons responsible. The facility failed to ensure that Patient 1 was provided with the therapeutic diet (A diet meal plan that controls the intake of certain foods and is part of a treatment of a medical condition normally prescribed by a physician and planned by a dietician. A modification of a regular diet), prescribed by the attending physician when dietary staff provided Patient 1 with a regular textured diet instead of the prescribed mechanical soft diet for dysphagia and high risk choking. This failure resulted in Patient 1's death caused by asphyxia due to choking on the meat that was served with the non-prescribed regular textured diet. Review of Patient 1's clinical record revealed Patient 1 was a 51 year old who was admitted to the facility on September 10, 2009. Diagnoses included dysphasia (difficulty in swallowing) and involuntary movement disorder. Patient 1 was prescribed mechanical soft diet for dysphagia and high risk for choking. Review of Patient 1's physician dietary orders revealed that on June 6, 2014, Patient 1's primary physician prescribed Patient 1 to receive a mechanical soft diet. Staff was to provide drinking straws to Patient 1 to assist Patient 1 with his liquid intake secondary to his diagnosis of dysphagia. Patient 1's treatment Plan dated June 10, 2014 contained documentation that Patient 1 had history of choking and poor eating behaviors (i.e. eating or swallowing rapidly, oversized mouthfuls, failure to thoroughly chew food). Review of Patient 1's care plan dated June 2, 2014 revealed an entry for impaired swallowing secondary to dysphagia as evidenced by choking, coughing, or gagging; history of choking when eating too fast. Review of Patient 1's Speech Pathology assessments from November 2013 through July 2014 revealed that Patient 1 frequently exhibited evidence of laryngeal penetration (when food or liquid enters the laryngeal passage, but does not go below the level of the vocal cords) which was manifested by cough. This coughing occurred approximately once per meal. On July 13, 2014 at approximately 5:35 P.M., Food Service Staff (FST) 1 served Patient 1 a regular diet instead of the prescribed mechanical soft diet. The regular diet consisted of a whole piece of chicken, scalloped potatoes, green salad with tomato and wheat bread. While Patient 1 was eating he began to choke. Staff attempted the Heimlich maneuver, but was unsuccessful in dislodging the piece of chicken in Patient 1's airway. Cardiopulmonary Resuscitation (CPR) was initiated, paramedics were called, and Patient 1 was transferred to the Emergency Room (ER). A round of advanced cardiovascular life support medication was administered. Patient 1 remained asystole (cardiac standstill or arrest; absence of heartbeat.) and was pronounced dead on July 13, 2014 at 6:31 P.M. On May 26, 2015 at 10:50 A.M. Director of Dietetics stated Patient 1 had always been on a therapeutic diet for the treatment of dysphagia and high risk for choking. The physician prescribed Patient 1 a variation of diets that included full liquid, dental soft and mechanical soft. For a patient with dysphagia and history of choking, a mechanical soft diet would also be considered a dysphasia diet consisting of mechanically altered food which would enable the patient to chew and swallow with much less risk for choking. Director of Dietetics stated it was dietary staffs' responsibility to ensure that each patient was served a diet that was consistent with the physicians order. She stated when she became aware Patient 1 was served the wrong diet she interviewed her dietary staff. Director of Dietetics stated FST 1 informed her that on July 13, 2014, FST 1 served Patient 1 a dinner meal of a regular diet instead of the prescribed mechanical soft diet. The regular diet Patient 1 received included a whole piece of chicken. On May 28 2015 at 1:00 P.M., during an interview, Speech Pathologist stated Patient 1 had a long history of dysphasia, was noncompliant with safe feeding strategies and had several episodes of choking on food items. Speech Pathologist stated he had spoken to Patient 1 and staff on several occasions regarding the severity of Patient 1's diagnosis of dysphagia and the danger of choking on regular food items. He had spoken with staff regarding the importance of supervising Patient 1 during meals; to remind Patient 1 to eat slowly and to remind Patient 1 to clear his throat before taking the next bite. Speech Pathologist stated Patient 1 was too impulsive and that Patient 1 would never have been able to fully grasp safe feeding strategies. On May 28, 2015 at 2:00 P.M., during an interview, Patient 1's primary physician stated Patient 1 had a diagnosis of dysphagia with a very high risk for choking and that Patient 1 has had several choking episodes in the past. Patient 1 also had tremors that would often increase while performing motor activities such as feeding himself, secondary to his diagnoses of involuntary movement disorder. MD 1 further stated Patient 1 had tendencies of eating too fast and putting more food into his mouth before he had swallowed what was already there. Patient 1 has had multiple Speech Pathologist evaluations that have performed swallowing evaluations and consultations with a consistent recommendation to continue a therapeutic diet for dysphagia and high risk for choking. Review of the facility's investigative report revealed that on July 13, 2014, the facility's investigative staff (Special Investigator 1) interviewed FST 1. During this interview, FST 1 told SI1 that "[Patient 1] came to the diet window and mumbled a name with an "M." He looked into the food cart, looking for a diet meal with an "M" last name; however he [FST 1] was unable to locate one. After telling [Patient 1] there was no diet meal for him, [Patient 1] requested and was provided a normal meal (meals served to patients not on a diet program)." FST 1 stated "There is a diet list, and one can verify the patient's diet from that diet list." Special Investigator 1 asked FST 1 "If that's the case, and when [Patient 1] asked for his diet tray and the tray wasn't there; is it policy for him to have verified with the diet list. [FST 1] stated no, if a tray isn't there for a patient, there is no need to verify with the diet list." On July 17, 2014, Director of Dietetics was interviewed by Special Investigator 1, who asked Director of Dietetics, "What type of training Food Service Technicians receives or policy and procedures Food Service Technicians follow regarding when a patient requests their (patients) diet tray, and the tray is not there." Director of Dietetics stated that "tech is trained, if it's a renal diet or something specific, to notify their (food service techs) supervisor, so the supervisor can notify the kitchen to have something prepared".... Special Investigator 1 asked Director of Dietetics "If techs are supposed to verify with the diet list when a patient requests their patients diet meal if the tray is not there." Director of Dietetics stated "The tech is taught and supposed to." A thorough review was conducted and Supervising Special Investigator concluded the following: "Nutritional Services not implementing the current written physician order regarding [Patient 1] diet.... [FST1] not verifying with the diet list when [Patient 1] requested his diet meal even though, according to [Director of Dietetics] techs are taught to.... Lack of policy or procedures in place in regards to LOC [Level of Care] staff verifying patients did receive their diet meal while at the PDR [Patient Dining Room] serving window." Review of documentation from the community emergency room revealed the following that on July 13, 2014 at 6:15 P.M. Patient 1 arrived at the community emergency room via ambulance. Patient 1 arrived in asystole (without heartbeat), intubated with Laryngeal Mask Airway (LMA) and Advanced Cardiac Life Support (ACLS) in progress; skin was ashen, mottled and cool to touch; muscle tone was flaccid and pupils were fixed and dilated. ER staff continued ACLS and a round of advanced cardiovascular life supportive medications were administered (Epinephrine). Patient 1 was pronounced dead on July 13, 2014 at 6:31 P.M. Review of the Fresno County Coroner's report, case # 14-07.098, indicated an autopsy was performed on Patient 1. The Coroner's investigative report revealed "[Patient 1] died as a result of injuries sustained when he choked on food while eating, on July 13, 2014, at 1731 hours, at [facility]." The report indicated that the food found in Patient 1's esophagus and stomach appeared to be pieces of a white meat consistent with chicken. Review of the facility's policy and procedure titled "Texture Modification of House Diet," dated September 9, 2009. "Dysphasia level 2 - Foods are mechanically altered by blending, chopping, grinding or mashing so that they are easy to chew or swallow. Liquids may need to be thickened." Review of the facility's policy and procedure titled "Therapeutic Diets", dated May 25, 2005. "Therapeutic diets shall be provided as prescribed by the attending physician and shall be planned, prepared and served with supervision and/or consultation from the dietitian." Review of the facility's policy and procedure titled "Meal Service" dated June 13, 2007. "Nutritional Service personnel will refer to the diet list at every meal service in order to make sure therapeutic, and dysphagia diets are correctly served." The facility failed to ensure that Patient 1 was provided with the therapeutic diet prescribed by his physician for dysphagia and high risk choking. Dietary staff served Patient 1 a regular diet that included a whole piece of chicken and Patient 1 choked while he was eating the chicken. This failure resulted in Patient 1's death caused by asphyxia due to choking on meat. The above violation presented an imminent danger to the patient and was a direct proximate cause of the death of the patient, therefore constitutes a Class AA Citation. |
| 150001227 |
Department of State Hospitals - Napa |
150012365 |
B |
1-Jul-16 |
H4F711 |
4888 |
T22 DIV5 CH4 ART4 - 73523(a) (9) Patients' Rights Patients' Rights 73523 (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 Client 1's right to be free from mental /psychological abuse when a psychiatric technician (Staff A) was observed being verbally/psychologically abusive to Client 1 on 10/15/15. The Department received notification on 10/16/15 that Client 1 alleged that a staff member, Staff A, had been making her life difficult and was verbally abusing her. To obtain additional information regarding the allegation, the Standards Compliance Director was interviewed, via telephone, on 10/20/15. The Standards Compliance Director stated that staff observed Staff A waving her finger over the client, saying something to the effect of, "What's wrong with you?" Record review on 11/18/15 indicated Client 1 had diagnoses that included schizophrenia, paranoid type. A "Treatment Planning Conference," dated 11/3/15, indicated Client 1 had multiple assaults/altercations with peers resulting in the use of walking restraints. The Rehabilitation Therapist, Staff B, interviewed on 2/10/16 at 8 a.m., stated, "I was in my office and I heard a raised voice." Staff B stated she looked out of the peep hole and saw Client 1 sitting against the wall by the door in the day hall with her head down. Staff B stated Staff A was standing over Client 1, in what appeared to be a threatening manner. Staff B said Staff A sounded aggressive but she did not hear specifics. Staff B stated, "It sounded like she had an issue with Client 1." Staff B stated Staff A was "towering" over Client 1 and Client 1 looked like she was "cowering" with her head down and appeared intimidated. Psychiatric technician, Staff C, was interviewed on 3/24/16 at 4:50 p.m. Staff C stated Client 1 had an altercation with a peer and was afraid of going into walking restraints again however, "they" decided not to put her back into restraints. Staff C stated Staff A asked Staff C to accompany her (Staff A) to Client 1's room. Staff C stated Staff A was going to tell Client 1 that she was not going back into walking restraints. Client 1 was lying down and may have been asleep. Staff A told Client 1, "I need to tell you something." There was no response. From the door, Staff A said, I have something to tell you, wake up. Client 1 sat up and said, "what do you want, why are you bothering me?" Staff C stated Staff A said, "I was going to tell you good news but I'm not telling you anymore." Client 1 got out of bed and went to the nursing station and asked, "What was the good news?" Staff C stated Client 1 was fixated on it for the rest of the shift. Staff C stated Staff A said, "You had a chance. You don't need to know." Staff C stated, "I don't think Staff A should have acted like that because Client 1 fixates. She is borderline, she can flip." Staff C stated, "[Staff A] can be pretty rough and can be rude sometimes." During an interview with Staff A on 1/6/15 at 4:10 p.m., Staff A denied waving her finger over Client 1 and denied saying, "What's wrong with you?" Staff A stated, "Client 1 had a rough history and I don't interact any more than I have to. I don't say anything mean, just 'yes' or 'no'." Staff A stated, "Deep down inside, I am afraid of her." Staff A stated she recalled Client 1 had been upset in the dining room and started to throw a chair and staff brought her back to the unit. Staff A stated that she told Client 1, "be careful, you don't want to go into walkers (walking restraints). It is Sunday and when the team meets on Monday or Tuesday we'll find out." Staff A stated she then went to the door of Client 1's room and she told Client 1, "Sit straight, I've got good news. You don't have to go into walkers." On 11/20/15 at 8:55 a.m., Client 1 was interviewed regarding the allegation. Client 1 stated she could not remember but said, "She was really mean." Therefore, the facility failed to ensure a client's right to be free from psychological and verbal abuse as witnessed by two staff members. Staff observed Client 1 cowering during an interaction with Staff A. Staff A was overheard speaking to Client 1 in a raised voice and after repeated requests by Client 1 to learn of the, "good news" Staff A would not tell her and replied, "You had your chance." The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 150001227 |
Department of State Hospitals - Napa |
150012373 |
B |
6-Jul-16 |
5Y7G11 |
1957 |
HSC 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 comply with the above regulation and report an allegation of abuse within 24 hours. This failure resulted in a delay of California Department of Public Health (CDPH) oversight and investigation into the event and allowed the alleged abuser continued contact with patients, increasing potential risk of further patient abuse. On 10/21/15, review of facility notification of the incident to the CDPH, signed 2/27/15, showed that Disability Rights of California and State Hospital Police became aware on 12/12/14 of Patient 1's allegation of verbal abuse by staff on 10/1/14. The facility communication to CDPH was not in accordance with HSC 1418.91 (a). According to facility Administrative Directive 437, "Abuse/Neglect and Reporting Requirements," effective 4/15/14, "Staff shall report all incidents of Suspected Elder or Dependent/Child Abuse, upon discovery..." During interview with Standards Compliance Staff 1 (SCS 1), on 1/21/16 at 1:50 p.m., SCS 1 stated that communication of State Hospital Police with the Standards Compliance office had been corrected in the Plan of Correction for Citation 15-0786-0011322-S. When referring to the case presently under review, SCS 1 stated, "This was late reporting." In summary, State Hospital Police failed to communicate to facility Standards Compliance staff their knowledge of an allegation of verbal abuse by staff to a patient. Standards Compliance was designated by the facility with the task of timely reporting of such allegations to CDPH, but was unable due to the failed communication. The facility's failure had a direct relationship to the health, safety and security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150012374 |
B |
6-Jul-16 |
X4F911 |
1800 |
ERI CA00437757 Citation 15-12374 HSC 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 comply with the above regulation and report an allegation of abuse within 24 hours. This failure resulted in a delay of California Department of Public Health (CDPH) oversight and investigation into the event and allowed the alleged abuser continued contact with patients. On 10/20/15 State Hospital Police Incident Report 15030265 was reviewed regarding Staff 1's report of an abuse allegation. It revealed that alleged abuse, by staff to Patient 1, occurred 2/23/15, but was not reported to the State Hospital Police until 3/4/15. On 10/20/15, CDPH intake number CA00437757 was reviewed. It indicated that the alleged abuse which took place 2/23/15, was not reported to CDPH until 3/5/16. According to facility Administrative Directive 437, "Abuse/Neglect and Reporting Requirements," dated 4/15/14, "Staff shall report all incidents of Suspected Elder or Dependent/Child Abuse, upon discovery..." An interview with Standards Compliance Staff 1 (SCS 1), on 1/21/16 at 1:50 p.m., revealed the following. When referring to the case presently under review, SCS 1 was asked if this was late reporting. She nodded her head up and down. In summary, facility Staff 1 delayed reporting of what she believed was abuse, and thereby delayed investigation and removal of a suspected abuser from client contact, increasing potential risk of further patient abuse. The facility's failure had a direct relationship to the health, safety and security of patients. |
| 150001227 |
Department of State Hospitals - Napa |
150012384 |
B |
18-Aug-16 |
8U7P11 |
4168 |
T22 DIV5 CH4 ART4-73523(a) (9) Patients' Rights 73523(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 comply with the above regulation when a Psychiatric Technician (Staff A) was observed being verbally/psychologically abusive to Client 1 on 4/2/16. The Department received notification on 4/4/16 that Client 1 alleged a licensed staff member (Staff A) had been verbally abusive over the weekend to Client 1. Record review on 4/22/16, indicated Client 1 had diagnoses that included schizophrenia and antisocial personality disorder. A "Treatment Planning Conference," dated 1/19/16, indicated Client 1 had several incidences of inappropriate language and behavior with staff and female peers. On 4/22/16 at 3:05 p.m., Client 1 was interviewed regarding the allegation. Client 1 stated that he was walking by the medication room. Client 1 stated Staff A called him a "dirty old man, devil worshipper, devil" and told him he was "going to hell". Staff A was described as very aggressive, and as having said "mean and harmful things to me." The client stated this had been ongoing. He said "You don't talk to a patient like that," She (Staff A) "brought me to tears, cried for hours, I didn't deserve that." During interview of Client 2 on 4/22/16 at 3:15 p.m., the client stated she witnessed Staff A speaking inappropriately to Client 1. Client 2 described overhearing Staff A call Client 1 a devil worshipper, devil, demon, and heard Staff A tell Client 1 he was "going to hell." During interview of Client 3 on 4/22/16 at 4:35 p.m., Client 3 stated he overheard Staff A call Client 1 a devil worshipper, laughing with other staff members, and also had heard Staff A say he was going to hell. Client 3 stated "I have never heard anything like that," and stated Staff A was childish and inappropriate. Client 3 said this was Staff A's normal behavior, and attitude and described Staff A as often argumentative. Client 3 said he had reported this behavior before several times to Staff B a couple of months ago. During an interview on 4/22/16 at 4:45 p.m., Client 4 stated he overheard Staff A call Client 1 a demon. Client 4 stated "it was out of the blue." Later, throughout the day, the client heard Staff A talking about the incident to the other staff members. Client 4 stated, "she (Staff A) was very childish and inappropriate." According to Client 4, the incident occurred by the medication room where the residents were lined up to receive their medications. During an interview on 4/27/16 at 11:00 a.m., Staff A stated Client 1 was taunting Staff A. Staff A told him (Client 1), if he continued, she would write him up. He backed up but continued to call her names. Staff A denied calling him a devil worshipper or devil or any names and said that Client 5 was present at the time the allegation of verbal abuse was to have occurred. During an interview on 4/27/16 at 1:41 p.m., Client 5 stated Staff A kept calling Client 1 Satan and stated, Staff A had been "ranting and raving about him (Client 1)." The first time the client had seen this behavior with Staff A, Client 5 was getting medications at the time of the incident-witnessed event. During an interview on 4/27/16 at 2:59 p.m., Supervisory staff (Staff B) stated that Client 1 had told him that "you got to talk to the staff." Staff B stated that Client 1 said Staff A was calling Client 1 a devil worshipper while he was getting his meds. Staff B stated, Staff A had a hard time getting along with patients. Staff A had prior incidences with other residents with "miscommunication." The abusive verbal language used caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 150001227 |
Department of State Hospitals - Napa |
150012503 |
B |
16-Aug-16 |
IIYB11 |
3877 |
T-22, DIV 5, CH-4, ART-3, 73311(a) Nursing Services-General Nursing Services shall include, but not limited to, the following: (a) Identification of problems and development of an individual plan of care for each patient based upon initial and continuing assessment of the patient's needs by nursing staff and other health care professionals. The plan shall be reviewed and revised as needed but not less often than quarterly. The facility failed to comply with the above regulation by failing to review and revise Patient 1's plan of care to ensure that Staff A was safe from attack and injury from Patient 1. Review of facility documentation on 6/4/14 revealed that on 5/24/14 Patient 1 physically assaulted Staff A in a unit stairwell. Patient 1 pushed Staff A to the floor grabbed the staff member's breast and asked her to take off her pants. Review of Patient 1's medical record on 6/4/14 documented that Patient 1 was 39 years old with diagnoses which included schizoaffective disorder, post-traumatic stress disorder, and borderline intellectual functioning. Patient 1 was admitted to the facility on 7/29/2003. Documented in Patient 1's treatment plan under Focus #3.1, Dangerousness and Impulsivity, "Throughout his hospitalization he has exhibited sexually inappropriate and/or sexually aggressive behavior towards staff as well as peers." And, "He does not demonstrate any understanding as to why his behaviors are inappropriate." Further review of Patient 1's medical record and treatment plan, dated 5/29/14, documented that Patient 1 has numerous incidents of inappropriate behavior of a sexual nature toward staff, as follows: on 1/9/14 Patient 1 was sexually inappropriate to two male staff; on 2/27/14 Patient 1 was verbally aggressive and violent toward a male staff; on 2/4/14 Patient 1 exposed himself to a male staff; on 2/21/14 Patient 1 made contact with a male staff to declare his love to him; on 2/24/14 and 2/25/14 Patient 1 exhibited stalking behavior to a male staff; on 4/26/14 Patient 1 attempted to grab a male staff's genitalia twice; on 5/19/2014 attempted to grab a male staff's genitalia; and, on 5/24/14 attacked and injured a female staff member in a unit stairwell. Patient 1 was place in locked room seclusion following this incident for the protection of patients and staff. Review of Patient 1's "Behavior Intervention Plan" dated 2/26/2014, in Patient 1's medical record, on 6/7/2014, for Sexual Behaviors and Stalking Behavior showed no changes in the plan even though Patient 1 had further incidents of inappropriate behavior towards staff. Facility staff was unable to provide written documentation that Patient 1's "Behavior Intervention Plan" had been updated following the incidents on 4/26/14 and 5/19/14. During interview on 6/3/2014 with Staff B, staff stated, "Patient (Patient 1) was focusing more on male staff. [Patient 1] doesn't understand the boundaries of relationships to staff. He (Patient 1) was not on 1:1 observation. Patient hid in the stairway, waiting for her. ... He grabbed her shirt and was trying to remove her pants." Review of facility IDNs (Interdisciplinary Notes), Behavioral PRN (as needed)/ STAT (immediately) note dated 5/19/2014, documented that Patient 2 had attempted to grab a male staff's genitalia. Patient 2 is quoted as saying "They said they are going to extend my stay here! So why should I care anymore if I do something bad? I'll just continue doing this." Review of facility IDNs dated 5/24/2014, documented that at 2231 hours (10:31 pm) Patient 1 was arrested and taken to jail. The facility's failure to review and revise Patient 1's plan of care placed patients and staff on the unit in jeopardy for potential further physical abuse and harm. The facility's failure to comply with the above regulation had a direct or immediate relationship to patient health, safety and security. |
| 150001227 |
Department of State Hospitals - Napa |
150012825 |
B |
22-Dec-16 |
I0Q511 |
5324 |
T22 DIV 5, CH 4 ART 4 73523 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 each patient's right to be free from abuse, when Patient 1 assaulted Patient 2 resulting in physical harm to Patient 2 and fear for his safety. The facility reported incident, dated 1/18/16, indicated that on 1/18/16, Patient 1 assaulted Patient 2 in the hallway. Patient 2 sustained swelling around his mouth, lacerations on his upper and lower inner lip and the avulsion (a forcible detachment or tearing away) of three upper teeth, which were recovered in the hallway. Gauze and ice pack were applied and the patient was evaluated for dental trauma. Patient 1 sustained an abrasion to the third knuckle of his right hand. Review of the facility Incident Management (IM) document, dated 1/18/16, indicated that on 1/18/16 at 12:30 p.m., Patient 2, came to the nursing station with a bloody, swollen mouth. The patient stated he was walking down the hallway going to the bathroom and suddenly he was struck in the mouth. Patient 2 pointed out the aggressor as Patient 1. Nursing assessment of Patient 2 revealed three missing teeth in the upper front area, with bleeding and swelling and a laceration to the upper and lower inner lip. The missing teeth were found in the hallway. Patient 2 was seen by the dentist on 1/18/16 at 4:15 p.m. for re-implantation of the teeth. Patient 2 stated he was walking down the hallway and Patient 1 said to him "what's up (expletive deleted)" and hit him once. The IM indicated when Patient 1 returned to the unit from lunch, the nurse assessed the patient. Patient 1 had a red and swollen third finger knuckle on his right hand. The patient stated: "I hit him one time...It was him or me. The reason I didn't report it is because he was with staff and I went to the cafeteria." Patient 1 received medication for calming, was moved to a different hallway and monitored every 15 minutes. The Unit Supervisor also indicated on the document, both patients respond to internal stimuli, pace hallways and talk to themselves. Patient 1 received medication for calming, was moved to a different hallway and monitored every 15 minutes. The incident management document indicated there was a mini team conference on 1/19/16 during which Patient 2 expressed fear for his safety. Patient 2 transferred to another unit on 1/19/16 at 3:30 p.m. An Interdisciplinary Note (IDN) dated 1/12/16, indicated Patient 1 was internally preoccupied, pacing in halls and talking to himself. An Interdisciplinary Note (IDN) for Patient 2, dated 1/19/16 at 9 a.m., indicated the patient had re-implantation of three maxillary anterior teeth on 1/18/16 at 4:15 p.m. The treatment plan for Patient 1, dated 1/19/16, indicated he was admitted on 7/30/15 with a diagnosis of Schizophrenia. During a team conference dated 1/19/16 regarding the incident of assault on 1/18/16, Patient 1 stated: "...he came to my face. I know he wants to fight with me." The Psychologist documented "He continues to display symptoms of major mental illness including severe paranoid delusions, disorganized speech, disorganized behavior, labile affect and irritable mood. He regularly is regularly (sic) offered PRN (as needed) medications to manage agitation, as he paces the hallways, yelling and laughing to himself. He frequently makes paranoid, delusional statements about people being out to get him..." The team recommended pursuing an Involuntary Medication Order (IMO) which the patient agreed to. The patient treatment plan identified the problem of "Dangerousness and Impulsivity" and described the problem of involvement in physical altercations with peers on both the admission unit and the long term unit where he currently resides. Both episodes appeared to be psychotically driven. Review of a monthly Psychiatric Progress Note, dated 12/30/15, documented: "[Patient 1] is delusional and refuses to consider clozapine (an antipsychotic medication mainly used for Schizophrenia) when I tried to discuss it. He states he wants to stay on the medication he is taking. He does not understand his illness stating the medication is poison to his brain. He does not have an IMO (Involuntary Medication Order)..." During an interview, on 11/9/16 at 11:50 a.m., the Unit Supervisor stated that Patient 1 had not assaulted since this incident. The patient has had medication changes and was also in a single room which was quieter. The facility failed to protect Patient 2's right to be free from mental and physical abuse, when without provocation the patient was assaulted resulting in the loss of three front teeth necessitating re-implantation. This failure had a direct or immediate relationship to resident health, safety and security, and caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 150001227 |
Department of State Hospitals - Napa |
150012989 |
B |
7-Mar-17 |
O9SY11 |
7830 |
T22-DIV 5 CH 4 ART 4 - 73523 (a)(9) Patient Rights
(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the Patient. The policies shall be accessible to the public upon request. Patients shall have the right:
(9) To be free from mental and physical abuse.
The facility failed to protect the right of Patient 1 to be free from abuse, when Staff A responded to Patient 1 with a raised voice and profanity, as Staff A simultaneously pulled Patient 1 by her arm to a seclusion room threatening to "teach her some manners."
The facility reported incident, signed 4/14/16, indicated that on 4/12/16, after receiving her medication Patient 1 was asked by Staff A (the shift lead), to check her mouth to ensure she had swallowed the medication. Patient 1 responded to Staff A with the statement "you're (expletive deleted) rude." Staff A, allegedly then grabbed the arm of Patient 1 forcefully and dragged her to an open seclusion room. Staff B and other patients alleged that Staff A stated to Patient 1, "I'm sick and tired of your (expletive deleted) mouth. You need to learn some manners." During investigation of the above, Staff A was placed on no patient contact.
During an interview, on 4/19/16 at 3 p.m., Staff B stated that on 4/12/16 at approximately 7:30 p.m., during the medication pass, Patient 1 began to walk away after taking the medication. Staff A stated, "Wait, we need to check your mouth (Patient 1's last name)." Staff A grabbed the patient's arm with both hands. The patient asked where Staff A was taking her. Staff A then stated to the patient "I'm sick and tired of your (expletive deleted) mouth. You're going to learn some manners." Staff B stated the Staff A (the shift lead), was harsh and sometimes demeaning, but this was the first time it was this bad. Staff B stated that Staff A told him to unlock the side room. The patient stayed in there. It was unlocked per Staff B and Staff A just walked back like nothing had happened. The patient came out after a while. Staff B stated he reported the incident the following morning to his Unit Supervisor (Staff C) because he feared that Staff A would retaliate and Patient 1 seemed alright.
The record of Patient 1 indicated she was admitted to the facility on 4/4/16, eight days prior to this incident. There was no documentation on 4/12/16 related to this incident.
The facility investigation indicated that during an interview on 4/13/16, Patient 1 told the hospital Police Officer that after she had taken her medication, Staff A asked her to open her mouth. The patient stated the way she (Staff A) asked was very rude. The patient complied with the request and stated she (Patient 1) said some words to her (Staff A), and turned and walked away. Staff A grabbed her left arm with both hands. The patient stated that Staff A told her she was going to teach her some manners. Staff A took her to the Seclusion Room, and told her to stay there. The patient stayed in the seclusion room for about fifteen minutes.
During an interview on 4/25/16 at 1:40 p.m., regarding the allegation, Staff A stated she was short staffed that evening. She was watching the medication pass. Patient 1 had been given the cup and she began spitting in it, and she kept a spoon in her mouth. Staff A told Patient 1 to let her check Patient 1's mouth, but the patient kept walking away. Patient 1 began talking back at her. Then Staff A stated she put her right hand on the patient's upper arm and left hand on the patient's forearm and led her to the side room. Once in the side room Staff A stated she asked for the patient to give her the spoon and the patient threw it on the floor. Staff told Patient 1 to stay in the side room for fifteen minutes. Staff A stated the patient came out after fifteen minutes and was fine... Regarding the use of profanity toward the patient, Staff A stated "I did not say I'm sick of your (expletive deleted) mouth."
During an interview, on 5/11/16 at 11:30 a.m., Patient 1 stated Staff A told her to open her mouth, and then grabbed her arm. The patient also stated that Staff A was intimidating and not very nice.
Review of the personnel record of Staff A on 4/19/16 indicated the Licensed Staff was a Senior Psychiatric Technician and had worked at this facility for twelve years. At the time of this incident she was the shift lead.
The facility investigation indicated that the U.S. (Staff C) believed that Staff A's behavior on 4/12/16 was abusive and it was inappropriate for Staff A to place her hands on the patient and drag her to the
Seclusion Room. During a follow up interview, on 2/23/17 at 2:35 p.m., Staff C stated Staff A had been transferred from another unit, approximately one and one half months prior to this incident. An interview with another medical professional indicated Staff A was easily angered and shouted at patients. Staff A was observed yelling at a patient for not wearing shoes, and did not appear to interact effectively with negative or difficult patients. The investigation also indicated that Staff A admitted she did not offer Patient 1 time in open room seclusion and that the patient did not display threatening or dangerous behavior prior to room seclusion.
Review of the facility Administrative Directive titled: "Abuse/Neglect and Reporting Requirements" number 437 dated 6/2/15, indicated it was the policy of the hospital to provide a safe and humane environment to the patient. Department of State Hospitals (DSH) Napa was to ensure that patients were protected from harm, and would not tolerate any form of patient abuse and/or neglect. Attachment A defined physical and verbal abuse as follows:
Alleged physical abuse is defined as any interaction or physical contact motion or action that is directed toward a patient which may cause harm or pain. Examples include shoving, hitting, slapping pinching, shaking, kicking, punching, misuse of seclusion or restrain, misuse of medication or unnecessary roughness during the provision of care. Alleged verbal abuse is defined as any language by someone that may be threatening, demeaning, discriminatory, pejorative, derogatory, or aggressive.
Review of the facility Administrative Directive titled: "Behavioral Seclusion or Restraint" Number 761 dated 3/3/15 (in place at the time of this incident), indicated under the Policy section: "Emergency intervention of seclusion, restraint or restraint hold shall be utilized only when all verbal and less restrictive intervention have failed." "Seclusion or restraint shall not be used as aversive treatment, punishment, retaliation, or for the convenience of staff...Staff shall not threaten the use of seclusion or restraint in an attempt to gain compliance from a patient...."
Section 1) a) definitions "Seclusion: Any involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion does not apply to "time-out" strategies wherein a patient agrees to remain in an unlocked room or area and maintains the choice to leave."
In summary, the facility failed to protect Patient 1 from abuse by Staff A (Licensed shift lead), when Staff A grabbed the patient's arm from behind, after the patient had complied with staff request to check her mouth. Staff A while yelling at the patient and with the use of profanity in an angry tone, continued with hands on to pull the patient into a seclusion room, which the patient had no opportunity to agree to.
This failure had a direct or immediate relationship to resident health, safety and security. |
| 170001857 |
Department of State Hospitals - Patton D/P ICF |
170009254 |
B |
01-Oct-12 |
PFQB11 |
5848 |
T22 DIV5 CH4 ART4-73523(a)(9) 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.T22 DIV5 CH4 ART4-73521 Patient Care Policy Committee Written patient care policies shall be established and followed in the care of the patients governing the following services: physician, dental, nursing, dietetic, pharmaceutical and an activity program and such diagnostic, social, psychological and therapy services as may be provided. Such policies shall be developed by a committee whose membership shall consist of at least one physician, the administrator, the supervisor of health services and such other professional personnel as may be appropriate. These policies shall be reviewed and revised by the committee at least annually and minutes of the committee meetings shall be maintained on file indicating the names of members present, the subject matter discussed and action taken. The following findings reflect an investigation of Entity Reported Incident #CA00264915. The Department determined the facility failed to: 1. Ensure that Patient A was not subjected to physical abuse, when he was assaulted twice within 24 hours by Patient B.2. Implement established policy and procedure to provide safe care. 3. Ensure that a staff member was not subjected to harm when he was attacked by Patient B using several coins wrapped in a sheet. These failures contributed to a physical altercation between Patient A and B, which occurred twice within 24 hour period, and an assault on a staff member (Staff 1) conducting 1:1 level of supervision to Patient B.Findings: On 11/2/11 at 11:00 a.m., a review of the investigation report dated 3/29/11, indicated that on 3/28/11 at 9:45 p.m., while in bed, Patient A was attacked by Patient B using batteries wrapped in a pillow case. Patient A sustained injury to the left ear. Both patients were placed on 1:1 level of observation for protection and were separated. Patient A remained in the bedroom and Patient B was taken to the observation room.Further review of the report revealed that on 3/29/11 at 8:00 a.m., staff escorted Patient B to the incentive store to collect amenities. At 3:00 p.m., staff escorted Patient B to his bedroom, upon his request, to obtain his toothbrush. Upon entering the bedroom, Patient B attacked Patient A, who was lying on his own bed. He hit Patient A with closed fist and made three hand contact on Patient A's face and head before the 1:1 staff members were able to restrain him. Patient A sustained a laceration above the left eyebrow, nose, upper and lower lip and hematoma to the right eye/cheek area. The left eyebrow laceration was closed with five sutures. The psychiatrist assessed Patient B and ordered 2:1 level of observation and transferred to the sister unit for temporary housing.While on Unit 24/25 side room, under 2:1 observation, a physician's progress note dated 3/29/11 at 10:20 p.m., indicated, "This [Patient B] put a lot of coins ($15) inside the sheet and hit one staff with it at the head. The staff suffered laceration to the right frontal scalp area." On 11/22/11 at 10:00 a.m., during review of Patient B's clinical record, the following were noted. He was admitted to the facility on 1/22/10, with diagnosis of schizophrenia, paranoid type. He is described as physically aggressive and assaultive to staff and peers with little or no provocation. Patient B had numerous significant assaultive episodes namely: on 2/21/10, while on 1:1 observation, he attacked a staff, alleging that staff took his eye glasses; on 2/24/10, attacked a staff while being escorted to an eye appointment; on 3/15/10, attacked a visitor in the visiting center with a shank; on 1/17/11, attacked a staff severely by punching him on the head several times with a closed fist; on 3/23/11, he hit the physician on duty during a physical evaluation. Clinical documentation revealed that Patient B had been on 5 point restraints on several occasions due to this dangerous behavior.On 3/23/12 at 2 p.m., during an interview with the Unit Supervisor, he stated that Patient A and B were to be separated for 24 hours due to altercation and should not have been brought back to his room where Patient A was housed. Patient B had requested canteen money before the altercation. The canteen money of $15.00 (in coins) was delivered to the home unit (Unit 21) at 6 p.m. A registry staff from the home unit brought the coins to Patient B for safe keeping. Patient B used these coins to hit Staff 1 on his head. Review of the facility's policy titled "CONTINUOUS SUPERVISION of INDIVIDUALS, dated 2/2011, indicated, POLICY: 2. Personnel assigned to any individual to be on continuous observation for any reason shall be held accountable for the individual's safety and care. PROCEDURES: Belongings searched by nursing personnel for potential dangerous objects. NURSING ACTION: 2) Ensure individual's safety - Search individual (for any kind of contraband) and immediate environment for contraband or any hazardous item(s) and remove them as appropriate."The failure of the facility to implement its policy on Continuous Supervision of Individuals resulted in Patient A to be attacked twice within 24 hour period by Patient B. The above failure also resulted in an assault to Staff 1 when Patient B hit him with several coins wrapped in a sheet. The above violations had a direct or immediate relationship to the health, safety, or security of clients. |
| 170001857 |
Department of State Hospitals - Patton D/P ICF |
170009256 |
B |
27-Mar-14 |
6ME311 |
6214 |
Title 22 73317 ( a) Nursing Service-Policies and procedures (a) Written policies and procedures developed by the supervisor of health services and approved by the patient care policy committee shall be available to all nursing personnel. Such policies and procedures shall include: During the investigation of an unusual occurrence conducted on 1/6/12, the facility was determined to have failed to ensure that a patient was free from harm due to the facility's failure to follow their policy and procedure related to Suicide Prevention. On 1/5/12, Patient 1 committed suicide.Review of Patient 1's clinical record on 1/6/12, revealed that Patient 1 was a 55 year old single male, admitted to the facility on 6/22/05, with diagnosis that included schizoaffective disorder. Patient 1 had a long history of psychiatric hospitalizations since 1985 when he began to experience severe depression. He had an extensive history of suicide attempts and a history of starvation.The Suicide Risk Assessment dated 1/9/08 revealed that Patient 1 announced to staff/peers that he knew he would be going to court on 1/10/08 and if he were made to go to court he would kill himself. He was assessed at that time as a high risk for suicide and was placed on 1:1 observation for his safety.Review of Patient 1's medical record revealed that during 2011, Patient 1 exhibited suicidal behavior on 3/7/11; voiced suicidal thought on 5/10/11 and had been placed on 1 to 1 observation for his safety. During his Integrated Nursing Assessment dated 6/18/11, Patient 1 stated to staff that he felt as if he had no future, and that he wanted to be deported to Vietnam. His stated goal was to go to Vietnam. His assessment at this time included the findings of dangerousness and impulsivity.A review of the Social Work Monthly Progress Note dated 1/4/12 revealed "[Patient 1] stated that he does not want to go to court under any circumstances." The report further indicated "During the last month this individual has been seen talking to himself in a bizarre fashion." The Interdisciplinary Notes dated 1/5/12 at 8:30 a.m., indicated that at approximately 7:30 a.m., a roommate of Patient 1 was yelling "Hurry my roommate is trying to hang himself." Staff members responded to the scene and observed Patient A hanging from a piece of cloth tied around his neck and attached to the door hinge.A review of the facility's Hospital Police Department Crime/Incident Report dated 1/5/12, revealed that the patient was transported to the acute care hospital where he was pronounced dead on 1/5/12 at 8:34 a.m. The synopsis of the facility's Hospital Police Department Crime/Incident Report dated 1/5/12 indicated "Victim tied a strand of cloth taken from bed sheet around his neck. Victim tied the other end of the strand of cloth to the doors "closing mechanism arm." Victim hung himself. Victim died from sustained injuries." A review of the Coroner's report, indicated that the autopsy dated 1/6/12, revealed that the cause of death was "Hanging, minutes. The manner of death was "Suicide." A review of the Death Summary Report dated 1/13/12, indicated that Patient 1 has a history of chronic suicidality. The report showed some of the factors that could have contributed to the patient's distress. The report included that the patient always wanted to be deported to Vietnam. The report further indicated that one of the patients reported to the psychologist that Patient 1 got a letter from the Vietnamese embassy stating that he could not be deported. Patient 1 was upset about this and he received the letter one week prior to his suicide. The report further revealed that "No staff members were notified about this."In an interview with Physician A conducted on 2/1/12 at 10:30 a.m., she stated that she was not the doctor for the patient until August 2011. During interview, Physician A said that the patient's death was probably due to the agitation expressed due a court issue. She stated that he may have thought he had to go to court. She further stated that 2 years prior, the patient had a fight with an Hospital Police Officer (HPO) because he was made to go to court. In an interview with the Social Worker on 2/1/12 at 2 p.m., she revealed that on 1/5/12, the day of the patient's suicide, Patient 1 went to breakfast, and returned to the unit at 7:20 a.m. Patient 1 saw his name on the board for an appointment,( a board used by staff to log any scheduled for patients for the day/week) he asked staff what it was for, and was told an outside evaluator was going to come and evaluate him. He wiped his name off of the board (which was not unusual for him, anytime he saw his name on the board-he wiped it off)...at 7:40 a.m.On 2/1/12 at 2:45 p.m., an interview was conducted with Registered Nurse A, (RN A), the Case Manager assigned to Patient 1. She stated that on the day of his suicide, the patient was mad that someone had put his name on the communication board for a court evaluation appointment that morning of the incident.Review of the Nursing Policy and Procedure #815 dated June 2009 on Suicide Prevention and indicated "Allow the individual to verbalize suicidal thoughts. Failure to communicate with the individual may lead to interpretation of your silence as consent or uncaring attitude. Encourage appropriate methods of expressing emotions. Give validation to the individuals experience and help the individual to explore healthy ways to cope with their problems." Interventions on page 815.6 included "Teach/monitor disease process, signs and symptoms relapse prevention plan, effects of medication, importance of periodic lab and follow up." On 1/5/12, staff failed to follow their policy and procedure related to Suicide Prevention, by their failure to recognize the patient's reaction towards court and legal issues, an identified stressor to the patient. There was lack of documented evidence in the medical record to reflect that staff allowed the patient to verbalize his thoughts about court issues and failed to help him explore ways to cope with his problems.On 1/5/12, Patient 1 committed suicide.These failures had a direct or immediate relationship to the health, safety, or security of patients." |
| 170001857 |
Department of State Hospitals - Patton D/P ICF |
170012827 |
A |
15-Mar-17 |
DP2411 |
7387 |
REGULATION VIOLATION:
T-22 DIV 5 CH 4, ART 3 73315(g) Nursing Services - Patient Services
(g) Treatment for minor illness or routine treatments for minor disorders when ordered by the licensed health care practitioner acting within the scope of his or her professional licensure shall be administered by nursing personnel.
The facility failed to ensure that a medication ordered for athlete's foot was administered by nursing personnel for Patient 1 when nursing staff allowed Patient 1 to self-administer the medication to his left foot. The nursing staffs' failure to visualize and assess Patient 1's foot caused a delay in treatment, when the patient's athlete's foot condition progressed to cellulitis (a bacterial infection just below the skin surface) which resulted in the amputation of the patient's left foot on 9/23/15.
During a review of the clinical record, the admission face sheet indicated Patient 1 was admitted to the facility on XXXXXXX00 with diagnoses that included a history of right foot amputation.
A review of a physician progress note, dated 8/18/15, indicated Patient 1 was seen for complaints of a rash between the toes of his left foot, with diagnoses of tinea pedis (athlete's foot).
A review of a Change of Status note, dated 8/18/15, indicated the following documentation: Chief complaint rash to toes. Patient has related medical condition of Tinea Pedis and history of post amputation to right leg with prosthetic (an artificial leg). Assessment indicated a scaly and discolored rash to toe web on left foot.
Review of a physician order dated 8/18/15 indicated the following: Ketoconazole 2% cream (a topical antifungal medication that prevent fungus from growing on the skin) twice a day, between toes, for eight weeks.
A review of a quarterly RN (Registered Nurse) progress note, dated 8/4/15 and monthly RN progress note, dated 9/9/15, indicated the following open "health maintenance conditions with status, medications and effectiveness, included documentation regarding improving infection between toes of left foot, with the administration of Ketoconazole 2% cream, twice a day.
A review of the medication administration records (MAR) dated 8/18/15 through 9/18/15 indicated Patient 1 had been administered the Ketoconazole 2% cream twice a day.
A review of an Interdisciplinary Note, dated, 9/20/15, at 9:00 AM, indicated the following documentation by Psychiatric Technician (PT) 1: "Noticed patient wearing a flip flop on his foot. The back of his heel appeared bright red, very abnormally so. When the patient was asked about his heel he replied, 'Oh, I popped a couple of blisters. I was wearing a sock that caused the blisters.' The patient said his foot had been looking kind of strange for a couple of days and didn't think it was a big deal. He stated that he had foot problems before and he didn't want to bother anyone so he wore a sock over it so no one would notice it. His foot looks swollen, purple, raw and weeping."
Review of an RN assessment note, dated, 9/20/15 indicated the following documentation: Left foot cellulitis. The foot is swollen, red, hot and tight despite drainage this morning. Oozing serosanguinous (yellowish with small amounts of blood) drainage is present. The leg is also hot with phlebitis (inflammation of the veins) up 3/4 of left leg. Patient now has chills and shivers. Feels hot to touch.
Review of case management notes indicated the following: 9/20/15 Patient transported to Acute care hospital for further evaluation and treatment of left foot cellulitis and 9/23/15, Final Diagnosis: Left foot benign foot with severe acute suppurative (producing pus) and gangrenous necrosis (dead tissue) of posterior tibia vessels. Status post left below the knee amputation due to expanding cellulitis to thigh.
During a phone interview with RN 1, who was the morning medication nurse, on 3/23/16 at 2:50 PM, she stated, "I can't speak for all treatment nurses, but I think everyone did this. I gave the patient the medication in a cup, along with gloves and he went to his room to administer the medication." RN 1 verified Patient 1's foot rash was not always assessed after self-administration of medication and stated, "He should have come back to the treatment room to be assessed, but that didn't always happen."
During further interview, RN 1 stated, "I should have been checking his foot, but it is nearly impossible to complete what I have to accomplish during the 1 and 1/2 hour time frame of treatments and medication pass including: 15 -18 vital signs, 10 finger sticks, five insulin administrations, 22 treatments (creams, topical, etc.) and 4-6 blood draws. The patient does not have to have an assessment to self-administer medications unless he has an open condition for it."
During a concurrent interview with RN 2, who was the medication nurse for the evening shift, she confirmed that she had given the patient the medication in a cup in order for him to self-administer and had not assessed his foot each time the medication was given.
During review of Patient 1's Treatment Plans, dated, 8/15/15 and 9/18/15, there was no indication the patient had been assessed and approved to self-administer medications or treatments.
During an interview with Patient 1 on 3/24/16 at 4:00 PM, he stated, "The nurse gave me gloves and a cup to apply my own medication. They never really saw my foot after the treatment was ordered. My foot was changing colors and started to get swollen so I covered it with a sock. I was afraid I wouldn't be allowed to continue my job in landscaping. I told my nurse [case manager] about two weeks before I was sent to the hospital. He said he didn't need to see it because he had already seen it."
During an interview with Physician 1, on 3/25/16, at 9:05 AM, he confirmed the nurses had given the patient medication and gloves to self-administer the medication in his room. When he was asked if the athlete's foot could progress to cellulitis and develop to the swollen, purple, weepy condition that was documented, in a matter of days, he replied, "No. It probably developed over the course of a couple of weeks. We may need to change the practice of self-administration of topical medication to include assessment of the patient in the treatment room."
Physician 1 confirmed Patient 1 was a reliable reporter.
A review of a policy and procedure titled, "Administration of Medication", revised, 10/15, indicated:
"Only licensed nursing staff shall administer medications, except for those who have been approved to self-administer specific, limited medications and or treatments as part of their Treatment Plan."
Therefore, the facility failed to ensure that a medication ordered for athlete's foot was administered by nursing personnel for Patient 1 when nursing staff allowed Patient 1 to self-administer the medication to his left foot. This failure resulted in Patient 1's foot to not be visualized and assessed by nursing staff, causing a delay in treatment when Patient 1's athletes' foot condition progressed to cellulitis (a spreading of a bacterial infection just below the skin surface) which resulted in the amputation of the patient's left foot on 9/23/15.
This facility failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 170001857 |
Department of State Hospitals - Patton D/P ICF |
170012828 |
B |
9-Mar-17 |
P7I511 |
13242 |
REGULATION VIOLATION:
T-22 DIV 5 CH 4, ART 3 73311(a) Nursing Services
Nursing service shall include, but not be limited to, the following:
(a) Identification of problems and development of an individual plan of care for each patient based upon initial and continuing assessment of the patient's needs by the nursing staff and other health care professionals. The plan shall be reviewed and revised as needed but not less often than quarterly.
The facility failed to identify and perform continuing and accurate assessments of Patient 1's right foot wound.
The facility's failure to perform continuing and accurate assessments resulted in Patient 1 developing a necrotic (localized death of living tissue), foul smelling wound on the plantar (sole of the foot) portion of his right foot requiring emergency transport to the acute care hospital, surgery, intravenous ( within the vein) antibiotics, further wound care and post-surgical physical rehabilitation.
An unannounced visit was made to the facility on February 12, 2016, at 9 AM to investigate an entity reported incident involving Patient 1.
Review of Patient 1's medical record revealed that he is a 52 year old male, admitted to the facility on XXXXXXX 14, with diagnoses including, but not limited to, right foot chronic callus, hypothyroidism and a history of substance abuse.
A review of a document titled, "Consultation and Referral Report" dated December 26, 2014 indicated Patient 1 had a history of Tinea Pedis (Athletes Foot) and a callus at right foot plantar surface, that bleeds/form blister with mild cellulitis (serious bacterial skin infection). This document indicated Patient 1 was initially seen by Podiatry on January 5, 2015, and diagnosed with Ulcer Grade II, Right Metatarsal Head (where the second toe attaches to the foot). Further record review of the "Physician/Psychiatrist Progress Notes" indicated the ulcer recurred and was treated on May 19, 2015, July 21, 2015, and July 28, 2015. A review of the Medication and Treatment Record, for the months of June through December [2015] indicated there was also an order for an antifungal powder to be applied between Patient 1's toes daily for treatment of Athletes Foot.
During an interview with the Podiatrist (DPM) on May 4, 2016 at 10:45 AM, he stated Patient 1 had a history of chronic callus formation on his right foot, at the 2nd metatarsal head ( where the second toe attaches to the foot) requiring intermittent callus removal. He also stated the patient had previously developed ulcers at the site of the callus. The calluses formed due to an abnormality in Patient1's gait. DPM confirmed a monthly order for the application of an anti-fungal powder between the toes of both feet of Patient 1. DPM stated the anti-fungal powder is used as a preventative measure. During a review of the Medication and Treatment Records, for the months of June 2015 to January 4, 2016, Patient 1 had been administered Tolnaftate (anti-fungal 1%) powder topically every morning between the toes.
A review of Interdisciplinary Notes, dated 12/08/15 at 4:30 PM indicated Patient 1 complained of right foot pain in the morning. He was seen and examined by the Primary Care Physician (MD 1) at approximately 10 AM on 12/8/15. Diagnosis of a right foot wound infection. Orders included referrals to Podiatry and Surgery, STAT (immediate) x-ray of right foot and Doxycycline 100 mg (antibiotic) orally twice a day x 14 days. Patient 1 was placed on 1:1 observation and non-weight bearing status. Further review of Interdisciplinary Notes for 12/08/15 at 4:30 PM until 12/09/15 at 1 PM, reflected no indication of any nursing evaluation or assessment of the right foot wound. In an interview with MD 1 on 4/1/16 at 11 AM, she described the wound as "deep, foul smelling and covered with necrotic tissue". She reported measurements of 3.0 x 3.5 cm (centimeters). Wound was described as deep, but there was no measurement of depth. MD 1 described it as "0.5 cm or more". MD 1 stated that Patient 1 developed these calluses and ulcers due to a gait abnormality, caused by trauma due to jumping from a building. On 12/9/15 at 9:15 AM, Patient 1 was re-evaluated by MD 1. A decision was made at that time to transfer Patient 1 to an outside facility for emergency services to evaluate/treat possible osteomyelitis. (An infectious usually painful inflammatory disease of bone, often of bacterial origin, that may result in the death of bone tissue.)
Patient 1 was transferred and admitted to an Acute Care Hospital on XXXXXXX15 at 2:10 PM via ambulance. A review of the "Physician Notes: Transfer to Outside Facility for Emergency or Other Services" dated 12/9/15 indicated: Reason for Transfer as a deep right foot wound, rule out Osteo. Subjective findings included: Right foot (sole) deep necrotic wound, first reported 12/8, but duration unknown. This form also indicated Patient 1 will likely need IV (in the vein) antibiotics and surgical evaluation. Page 2 indicated Patient 1 had an elevated WBC (white blood cell) count on 12/1/15, of 13.0.
Upon obtaining consent from Patient 1's conservator, surgery was performed on his right foot. The operative report from the acute care hospital, indicated Patient 1 was placed under general anesthesia for Debridement (surgical removal), curettement (surgical scraping and cleaning) of the third metatarsal bone of a necrotic ulcer of the right foot, plantar aspect. The wound was left open, irrigated and packed with a dressing.
Physician Progress Notes dated 12/12/15, indicated "Wound is still foul smelling and draining pus". Patient 1 was started on two IV antibiotics. Orders for wound care with Bactroban (antibiotic ointment) and dressing changes 2 times per day were started.
Physician Progress Notes dated 12/13/15, indicated the addition of a third antibiotic, and continuous infusion of IV fluids.
Further review of the Progress Notes indicated Patient 1 required an extended course of IV antibiotics, placement of a Peripherally Inserted Central Catheter (PICC) and dressing changes. Patient 1 was transferred to a skilled nursing facility on XXXXXXX15.
A review of the facility's policy titled, Nursing Process Overview, dated November 2014, page xi.1 indicates:
POLICY: Nursing Services shall provide individualized, goal directed nursing care to all Patients through the use of the nursing process (assessment, nursing diagnosis, planning, implementation, and evaluation). Page xi. 3 indicates: DATA COLLECTION, Observation is continuous throughout the nurse-patient relationship. Every time nursing service staff is with the Patient, the nurse should be gathering data through the skills of observation. Examination can include the taking of vital signs, chest, heart sounds, or the observing for skin problems while paying particular attention to any physical complaints of the patient.
A review of the Nursing Care Plan for Patient 1, dated July 2, 2015 indicated a nursing diagnosis/condition of a right foot callus. Re-evaluation date was October 27, 2015. Nursing interventions listed, included to assess for complications, such as infection or poor healing, and to assess skin; evaluate the healing process. Observe wounds, and note characteristics of wound size, appearance and drainage. The Nursing Care Plan dated October 24, 2015, indicated the same interventions with a re-evaluation date of January 24, 2016.
An interview with Registered Nurse 1 (RN 1), on April 1, 2016 at 11:15 AM; she stated "there are no routine assessments, only if the patients complain". She also stated "currently, only diabetic patients receive monthly skin assessments. PTA's (psychiatric technician assistants) will report abnormalities, if observed during showers". RN 1 confirmed Patient 1 had a previous history of a similar ulcer formation.
An interview was conducted with Registered Nurse 2 (RN 2) on May 3, 2016 at 10:10 AM. She stated she has performed treatments and wound care to Patient 1's feet many times in the last few months. A review of the Medication and Treatment Records from June 5, 2015 through January 4, 2016, indicates RN 2 performed the daily application of the anti-fungal powder to Patient 1's feet on June 16, July 2, August 14, 15, 22, 28; October 13; November 13, 15 & 26 and December 4, 5, 6 and 7. When asked where she documented her observations, after applying the treatments, she stated, "The RN Case Managers perform monthly assessments". She further stated the Interdisciplinary Notes are to document changes in a patients care. When asked how she would determine if the treatment provided is working, she responded, "the doctor will write new orders". She stated she had not looked at the bottom of Patient 1's feet, because the order was to apply powder between the toes. Patient 1 kept his feet flat on the floor while she applied the treatment. RN 2 did confirm that Patient 1 had a previous history of a similar ulcer formation.
An interview was conducted with the Registered Nurse Case Manager, (RNCM) for Patient 1, on May 16, 2016 at 5:05 PM. He stated that it is his responsibility to see and perform monthly assessments on all patients assigned to him. The assessment should be a review of past and present, physical, psychiatric and surgical concerns for the patient. "We chart on all identified medical problems". He also stated treatment nurses should be assessing the treated area with each treatment, to determine if the treatment is working. During this interview, he also stated the Psychiatric Technicians perform weekly assessments, addressing medical and psychiatric issues of assigned patients.
During further interview, RNCM stated "while performing the December Monthly assessment, I didn't look at the bottom of his foot. I don't know if I got distracted or if it was all the paperwork I knew I had to finish, but I missed it. It was in the same place as before. I was devastated. I missed it and all the other nurses missed it".
The December Monthly Assessment is dated 12/22/15, with a reporting period identified as from: 11/22/15 to: 12/20/15. Patient 1 did not return to the facility until XXXXXXX 15.
During a follow up interview, on May 27, 2015 at 2:35 PM, the RNCM stated "I didn't perform a physical assessment on him on that day. It's the wrong assessment date. The assessment dates are automatically set based on the last assessment".
An interview was conducted with the Unit Supervisor (US) for Unit 06, on 2/23/17 at 12:00 PM. She stated psychiatric technicians (PT) document weekly notes on patients assigned to them. The RN Case Managers document monthly assessments and they write the care plans. The documentation should address all open medical and psychiatric problems that were previously identified. The PT should use the care plan as a guide to completing their weekly documentation. The documentation should include information about the current status of the problem, looking back over the dates in the reporting period time frame. A concurrent review of the PT Weekly Notes, dated 11/9/15, 11/13/15, 11/21/15 and 12/6/15 indicated, "Focus/TC 6.15 Right Foot Callus Describe: He does not have any c/o pain on his foot and when staff checked it's like dark, dry and flaky". The same entry is documented on all four reviewed weekly notes. The notes are all exactly the same. The US stated, "they should not all say the exact same thing. I don't know why they do and there should be a clearly defined reporting period". The interventions in the care plan were not addressed at all. The US confirmed there was no PT weekly note for the week of 11/29/15 - 12/5/15.
During a continued review of the RN Case Manager monthly notes, the US stated, "it looks like we have the same problem". The notes aren't comprehensive and don't give a clear picture of the status of Patient 1's foot. The interventions identified in the care plan were not addressed. "The documentation should be providing a discussion of the current status of the problem". The RN Progress Note for Assessment and Evaluation, dated 10/21/15 and 11/22/15, indicated documentation on an open condition, Right foot callus, "On 7/21/15, Patient 1 had a procedure for R foot ulcer with callus. It has completely healed with small amount of callus left." US confirmed this entry does not address the current status of Patient 1's foot, and the interventions identified in the care plan were not addressed. US also stated that the Treatment nurses are RN's and should be looking at and documenting any changes in the patient's wound or treated area. A review of the Interdisciplinary Notes dated from 10/14/15 to 12/7/15, indicated no entries about the status of Patient 1's foot. US confirmed there were no entries, and stated there should be something there because he has had this problem for some time.
Therefore, the facility's failure to perform continuing and accurate assessments of Patient 1's right foot, led to the development of a necrotic, foul smelling wound requiring hospitalization, surgery, IV antibiotics and an extended course of post hospitalization rehabilitation.
The facility's violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 220000053 |
DEVONSHIRE OAKS NURSING CENTER |
220012152 |
B |
29-Mar-16 |
6SE011 |
7513 |
1424(f)(1) Health & Safety Code (f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. This RULE is not met as evidenced by: Based on interview and record review, the facility willfully falsified documentation regarding one of one sample resident (Resident 1). Resident 1 had a left arm fracture of unknown origin. The facility falsely documented they tried to apply padding to Resident 1's side rail and Resident 1 refused the intervention. Failure to accurately and truthfully document care may negatively impact accident prevention and healing of Resident 1's fracture. Findings: Review of Resident 1's face sheet, dated 10/1/15, indicated she was admitted to the facility on 2/2/13 with multiple diagnoses including muscle weakness, difficulty walking, and paralysis of the right side due to a stroke.Review of a document titled "Interdisciplinary Team Meeting Note/Care Conference", dated 11/28/15, indicated Resident 1 was diagnosed with dementia (brain disorder with memory problems, personality changes, and impaired reasoning). Review of an "Investigation Report", dated 12/30/15, indicated a Certified Nursing Assistant (CNA) 1 "...was ...(providing care) to...(Resident 1). She's complaining of pain on her... (left) arm. I check(ed) on it. I noticed the shoulder was swollen. So I report(ed) it to the charge nurse, and the charge nurse order(ed) the X-ray. Then sent...(Resident 1) to the hospital." Review of Resident 1's X-ray, dated 12/30/15, indicated a slanted fracture of the left upper arm bone.During an interview on 1/27/16 at 3:35 PM, Charge Nurse 2 stated "We think she(Resident 1) hit her shoulder on (her) side rail..." thus fracturing her arm.During an observation, accompanied by Charge Nurse 1, on 1/27/16 at 3:50 PM, Resident 1 was observed in bed, awake and both 1/4 side rails were not padded. During a concurrent interview, Charge Nurse 1 was unable to explain what intervention(s) the facility was implementing to prevent Resident 1 from re-injuring herself. Charge Nurse 1 was asked to search Resident 1's chart and other areas regarding any documentation involving this injury. The search found no documented evidence of any interventions regarding Resident 1's side rails in Resident 1's active chart. No physician orders regarding the side rails, no care plans regarding the side rails. Charge Nurse 1 later found a manila folder containing numerous documents. Observation of the contents of the manila folder with Charge Nurse 1 indicated there was only one document titled "Interdisciplinary Team (IDT) Meeting Note/Care Conference", dated 12/30/15 at 3:00 PM. Review of the two-page document titled "Interdisciplinary Team Meeting Note/Care Conference", dated 12/30/15 at 3:00 PM, indicated there were no information regarding padding of Resident 1's side rails nor her reaction to her side rails being padded.During an interview on 2/2/16 at 9:50 AM, the DON stated "...(on 12/30/15) around 2:45 PM, we tried to put ... (padding on her side rail) right after she returned from the ....(Emergency Room), she refused it, tried to grab it." The DON stated this incident was documented and proceeded to provide another two-page document titled "Interdisciplinary Team Meeting Note/Care Conference", dated 12/30/15 at 3:00 PM. The DON searched Resident 1's records and acknowledged this incident regarding padding the side rail and subsequent refusal was not documented in Resident's chart nor was this refusal care planned.The facility has now provided two IDT notes to the Surveyor. Both IDT notes were dated 12/30/15 at the same exact time, 3:00 PM. Comparison of both IDT notes indicated the second two-page document titled "Interdisciplinary Team Meeting Note/Care Conference", dated 12/30/15 at 3:00 PM, provided by the DON on 2/2/16 at 9:50 AM had additional text added to page two of the document. The text added was "IDT recommended to apply padded side rails to resident's bed but resident refused, trying to pull it out and yelling to remove it. ...(Staff explained) to resident the risk and benefits of refusing the padded side rails but resident stated 'I don't care, I don't like it.' " During an interview on 2/2/16 at 3:40 PM, the DON stated IDT notes were usually two pages. The first page contained information regarding the resident and a space for team members to sign. The meeting summary was then documented on part of the first page and may continue onto a second page. The DON stated if there was additional information, staff were to start documenting on a blank third page.The DON was shown both IDT notes, both dated 12/30/15 at 3:00 PM. The DON was made aware both IDT notes were almost identical except the IDT notes provided on 1/27/16 contained no information regarding padding of Resident 1's side rails. The DON admitted she re-wrote the IDT notes (provided to the Surveyor on 2/2/16). The DON stated she did not know what happened to the original IDT notes provided to the Surveyor on 1/27/16. The DON could not explain why she had to re-write the IDT notes instead of writing and correctly dating a late entry/addendum to the original IDT notes.During an interview on 2/2/16 at 4:20 PM, Social Service (SS) stated she recalled signing the IDT notes dated 12/30/15 only once. When presented with both IDT notes, SS added it was "Not common for me to sign two ...(IDT notes)."During an interview on 2/2/16 at 4:25 PM, Charge Nurse 1 stated she recalled signing the IDT notes dated 12/30/15 only once. When presented with both IDT notes, Charge Nurse 1 added she has "Never done that (sign an IDT note twice). During an interview on 2/2/16 at 4:30 PM, the Administrator stated he recalled signing the IDT notes dated 12/30/15. The Administrator added "After the (IDT) meeting we would sign (the IDT notes). ..." When presented with both IDT notes, the Administrator stated the first pages (with all the signatures) looked the same, the second pages look different.During an interview on 2/2/16 at 3:50 PM, the DON was provided with the chronology of this investigation. 1. The Surveyor visited the facility on 1/27/16. Charge Nurse 2 stated Resident most likely fractured her arm on her side rails. A search of Resident 1's records found no physician orders or care plan or other documented evidence regarding interventions involving the side rails. The facility provided the Surveyor with IDT notes dated 12/30/15 at 3:00 PM. This IDT notes contained no information regarding padding of the side rails. 2. The Surveyor interviewed the DON on 2/2/16 and the DON stated there was documentation the facility tried to pad the side rails. 3. On 2/2/16 the DON provided another almost identical IDT note, also dated 12/30/15 at 3:00 PM. Except now the IDT note provided on 2/2/16 contained information the facility tried to pad Resident 1's side rails and Resident 1 refused.4. Interviews with the Administrator, SS, Charge Nurse 1 indicated they all signed Resident 1's 12/30/15 IDT notes once. The Administrator even stated both signature pages (first pages of both IDT notes) appeared identical. The DON acknowledged she re-wrote and altered the contents of the IDT notes at a later date. She did not get any team members to re-sign the altered IDT note. The DON tried to submit the altered IDT notes as being written on 1/30/15 at 3:00 PM. The above facts indicated there was a willful effort to falsify documentation in Resident 1's records. |
| 240000252 |
Desert Manor |
240009227 |
B |
12-Apr-12 |
DKBW11 |
4571 |
REGULATION VIOLATION: Title 22 72315 Nursing Service - Patient Care and 72523 Patient Care Policies and Procedures 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. AND 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 ensure that Patient A was treated with dignity and respect and not subjected to abuse. On December 12, 2010, two certified nursing assistants (CNA's) were observed verbally abusing Patient A; this resulted in the patient becoming upset and crying. The facility failed to implement their policy and procedure pertaining to abuse prevention.On February 8, 2011, the facility investigative report was reviewed. The document showed that on December 12, 2010 at approximately 1:00 PM, the team leader (TL) overheard CNA 1 and CNA 2 verbally abusing Patient A.On February 8, 2011 at 9:15 AM an interview was conducted with the Director of Nursing (DON). The DON stated that CNA 1 and CNA 2 used inappropriate language with Patient A. The DON stated that at the conclusion of the facility's investigation, both CNA's were terminated and reported to the CNA Board. The DON stated that the incident occurred around 1:00 PM and she was not notified until 2:30 PM. The DON stated that the charge nurse did not follow the facility's abuse protocol. On February 8, 2011, Patient A's medical record was reviewed. Patient A was admitted to the facility on February 15, 2008 and readmitted on April 23, 2010. Patient A's diagnoses included dementia (a condition in which there is a gradual loss of brain function; it is a decline in cognitive/intellectual functioning. The main symptoms are usually loss of memory, confusion, problems with speech and understanding, changes in personality and behavior and an increased reliance on others for the activities of daily living), renal failure (inability of the kidneys to excrete wastes and to help maintain the electrolyte balance) and seizures (uncontrolled electrical activity in the brain, which may produce a physical convulsion, minor physical signs, thought disturbances, or a combination of symptoms). The Minimum Data Set (MDS, a comprehensive assessment of the resident) completed on January 17, 2011, documented that Patient A had long and short term memory loss and her cognitive skills for daily decision making were severely impaired. On February 8, 2011 at 9:30 AM, an attempt to interview Patient A was unsuccessful. Patient A was in the hallway in a wheel chair, drinking a cup of coffee and could not recall her name. On February 10, at 8:40 AM, an interview was conducted with the TL via the telephone. The TL stated that on the afternoon of December 12, 2011 at approximately 1:00 PM, CNA 1 and CNA 2 were in Patient A's room. The TL stated that she overheard the following, "Since you are a pig, we will roast you on the barbeque grill and have a pig roast." The TL stated that the 2 CNA's were teasing Patient A. Patient A was crying and overheard to say, "Please have them go away, call the police and put them in jail." The TL stated that she told the 2 CNA's to leave Resident A's room and they did. The TL further stated that she immediately reported the incident to the charge nurse. The TL stated that the shift for CNA 1 and CNA 2 ended at 2:00 PM, at which time they clocked out and left the building.The facility's policy titled "Abuse prevention program" version dated March 16, 2009, included the following under the heading "verbal abuse:" "Any (oral, written or gestured language) that willfully includes disparaging and derogatory terms to residents or their families or within their hearing range." Under the heading "Facility reporting," the following was documented. "The charge nurse must in turn immediately report this to the Administrator or the Director of Nurses." Under the heading "Protection of resident during investigation," the following was documented. "Immediate suspension from duty of an accused employee..."Based on the information obtained, the facility did not follow the abuse policy and ensured that the incident was immediately reported to the Administrator or the DON. In addition, the facility failed to immediately suspend CNA 1 and CNA 2, as stipulated in the policy.These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000252 |
Desert Manor |
240012330 |
A |
15-Jun-16 |
None |
12931 |
REGULATION VIOLATION: 72301 Required Services. (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 prevent a fall in one of three sampled residents, (Patient 1). Specifically, the facility failed to implement the use of the pressure pad monitor (a device that causes an alarm to sound from a person?s movement in order to alert staff when the resident moves) for Patient 1. This failure resulted in Patient 1 falling and sustaining injuries which included a hematoma (a swollen area with blood underneath the surface) to the forehead, and skin tear to the forehead, which required transfer to a general acute care hospital (GACH). Findings: An unannounced visit was made to the facility on October 2, 2014, to investigate an entity reported incident related to quality of care and treatment. During an interview with the Director of Nurses (DON) on October 2, 2014 at 9:35 AM, in the presence of the Administrator, the DON stated Resident 1 was "acting confused" on August 1, 2014. According to the DON, on the next day of August 2, 2014, Resident 1 fell twice at the facility. The DON further advised that the Certified Nurse Assistant (CNA 1) failed to apply the "bed alarm" on Patient 1's bed, as ordered by the physician, resulting in Patient 1?s second fall. The DON reported that CNA 1 no longer works for the facility. A review of the ?EMPLOYEE SEPARATION NOTICE,? with an effective date of August 5, 2014, revealed, that CNA 1 ?has been written up multiple times and was put on a ?final? [notice on] 03/23/14 (March 23, 2014) for safety issues and carelessness issues, and attendance. [On August 2, 2014] 08/2/14 a resident sustained multiple injuries after having a fall in which the resident had an order for a body alarm & no such alarm was placed on the resident. [On August 3, 2014] 08/03/14 (CNA 1) no call/no showed for her shift resulting in unnecessary overtime for other employees so not to leave the floor short staffed.? During a facility tour on October 2, 2014 at 10:28 AM, Patient 1 was observed propelling herself in a wheelchair in the hallway. A lap buddy (a thick flat cushion that fits over a person's lap and under the armrests of a wheelchair to prevent unassisted rising) and an anti-tipper (small bent bars placed at the back of the wheelchair to prevent from tipping backwards) were noted on the wheelchair. Patient 1 was observed to be alert and verbally responsive. A review of the clinical record of Patient 1 was conducted on October 2, 2014. The clinical record noted that Patient 1 was admitted on December 9, 2013, with several diagnoses, which included Alzheimer's disease (a condition with a progressive mental deterioration and marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 1?s care plan dated December 9, 2013, was conducted on October 2, 2014. The care plan set forth the following notation: "Risk for falls due to: confusion?12/10/13 (December 10, 2013) Bed Pad Monitor ?fall score 8.? Additionally, Patient 1?s care plan set forth under ?Approaches/Action? the following: ?personal alarm in bed.? A review of the physician's order dated January 20, 2014 was conducted on October 2, 2014. The physician?s order indicated: "PRESSURE PAD MONITOR ON BED Q (EVERY) SHIFT FOR POOR BODY SAFETY AWARENESS." A review of the Nurses Progress Note dated August 1, 2014 at 4:20 PM, revealed , ?Resident noted to have increased confusion, ambulating independently, steady, wandering in hall, unable to keep calm, stating, ?[I] can?t find my mother?? A review of Patient 1?s nurses progress notes revealed that earlier on the same day, August 2, 2014 at 2 :45 PM (day shift - previous shift), ?Nurse walking down hallway looked into Rm. (room) 102 and saw (Patient 1) on floor. Nurse went in and started assessment. (Patient 1) confused and making no sence (sense) when asked what happened. After assessing no change with condition and range-of-motion nurse helped (Resident 1) unto bed.? This resulted to a skin tear on Patient 1?s forehead. The physician was notified and orders were received to start neurological checks (assessment of level of consciousness, pupils, ability to grasp, move extremities and vital signs) for 72 hours, clean the skin tear on the forehead with normal saline, apply steri-strips, antibiotic ointment and cover with dry dressing, for a STAT X-ray examination, and to call the physician for any complications.? A review of the Diagnostic Imaging Report of the skull dated August 2, 2014, revealed, ?CONCLUSION: Unremarkable skull.? During an interview with CNA 2 on October 2, 2014 at 11:25 AM, CNA 2 stated after Patient 1 was found on the floor on August 2, 2014 at 2:45 PM, CNA 2 and another CNA assisted Patient 2 back to her bed. CNA 2 confirmed they had applied the bed alarm on Patient 1?s bed and had left Resident 1 on it shortly before their shift ended. CNA 2 further indicated that the purpose of bed alarm was to alert the staff whenever Patient 1 attempted to get out of her bed, which she did approximately three to four times during that shift. CNA 2 described Patient 1 as being ?very weak that day and seemed to be out of it; was acting funny.? Patient 1's nurses progress notes dated August 2, 2014, was reviewed on October 2, 2014. The progress notes dated August 2, 2014 at 8:00 PM, documented the following occurrences: ?Nurse notified by CNA that res. (resident) was lying on the floor with bleeding noted from forehead area. Upon nurse's arrival res. (resident) found lying on floor, next to bed, in supine position (laying with face up)...res (resident) noted to have increase to size of previous raised area to forehead, has a small laceration to base of raised area. Res. (Resident) has moderate amount of bleeding to base of laceration.? The progress notes dated August 2, 2014, further revealed that at 8:02 PM, the physician ordered for Patient 1 to be transferred to the general acute care hospital (GACH) emergency room via ambulance, for evaluation. The facility's Resident Admission Form dated XXXXXXX at 2:45 PM, was reviewed on October 2, 2014. The Resident Admission Form set forth the following: "Pt (patient) (with) bruising to forehead, around eyes, cheeks and on L (left) side neck, also has S/T (skin tear) with raised hematoma to center forehead from a fall on 8.2.14 (August 2, 2014).? During an interview with the Director of Staff Development (DSD) on October 2, 2014 at 11:55 AM, the DSD stated, CNA 1 had confirmed that she had made a mistake when the bed alarm was not put on Patient 1's bed. A review of the facility?s Investigative Summary Report dated August 11, 2014, revealed under Investigative Summary, ?(Patient1) has a diagnosis of Alzheimer?s (condition affecting memory ability). The CNA (CNA 1) caring for (Patient 1) failed to place the pressure bed pad alarm, [on the bed] which is on (Patient 1?s) daily plan of care. The CNA (CNA 1) was then terminated as a result.? A document entitled, "CONCERN FORM," was reviewed on October 2, 2014. The document was signed by a Licensed Vocational Nurse, (LVN 1) on August 2, 2014, and set forth the following: "(Patient 1) had a fall earlier today. She was already on neuro VS (neuro vital signs - assessment of the brain activity); Res [Resident- Patient 1] was sitting in a w/c (wheelchair) for safety, (CNA 1) placed (Patient 1) in bed, did not check res. [resident-Patient 1], [who] had no bed pad alarm on the bed. Res. [resident-Patient 1] has an order for alarm as a result of her negligence res. (Patient 1) fell and had to go to the emergency room." During a phone interview with LVN 1 on October 2, 2014 at 12:00 PM, LVN 1 confirmed the information on the "CONCERN FORM," dated August 2, 2014, was accurate, and further stated that CNA 1 did not place a pressure pad alarm on Patient 1's bed. During an interview with the DON on October 2nd, 2014 at 12:15 PM, and a concurrent review of Patient 1?s Point of Care (POC) for the period of August 1 through August 30, 2014, (a document which contains, for example, resident-specific physician orders, communications, and changes in resident orders, that CNA staff would access), revealed a physician's order for Patient 1, dated January 20, 2014, for "PRESSURE PAD MONITOR ON BED Q (EVERY) SHIFT FOR POOR BODY SAFETY AWARENESS." The DON confirmed that on August 2, 2014, CNA 1 initialed next to the physician order, which indicated CNA acknowledged that she knew about the order. The DON stated, CNA 1, "neglected to put the bed alarm on the resident," and stated CNA 1 did not follow the physician's order. The DON was asked on October 2, 2014, for a copy of the facility's policy and procedure on the use of the pressure bed alarm. However, the DON stated there was no specific policy adopted by the facility on use of the pressure bed alarm. A review of the facility's policy and procedure entitled, "Communication Systems," VERSION: July 2013, set forth the purpose of the facility?s police and procedure was as follows: ?PURPOSE: To identify methods of communication between direct care staff and members of the interdisciplinary team. POLICY: It is the policy of the facility that all staff members are required to communicate significant information related to the needs and care of residents utilizing the designated systems available to them. The policy set forth the following provisions: under "Communication Book (Point of care - POC Communication book) (Recommended)...10. All nursing staff should check the communication book on their shift (recommend to use at each change of shift report) for new information and to initial that they have read it. During an interview on October 2, 2014 at 12:25 PM, with the Director of Staff Development (DSD) and a concurrent review of the in-service contents for March 7, 2014, regarding "Dignity/Res (Resident) Rights / Body alarms/tab alarms/(wheelchair) cleaning" was conducted. The ?Objectives of Session? revealed, ?Nursing staff will be aware of issues regarding dignity/rights/alarm usage.? The recipients of this inservice were the CNAs. In addition, a concurrent review of the in-service contents for August 4, 2014, regarding ?Body alarms, positioning, bed alarms following POC? was conducted. The ?Objectives of Session? revealed, ?CNA?s will know the importance of following POC(point of care) & using alarms when ordered.? The recipients of this inservice were the CNAs. The DSD confirmed there was no documented evidence that CNA 1 attended the March 7, 2014 or the August 4, 2014, in-service. A review of the facility?s Policy and Procedure titled ?Fall Management Program,? VERSION: 05/13 (May 2013), set forth under PROCEDURE, ?1. All direct care staff are to receive periodic training on resident safety and fall prevention?? A review of the ?Education/Counseling Notice? signed by CNA 1, dated January 12, 2014, revealed a written counseling for violations regarding ?Carelessness? and ?Safety Issue.? The description of the violation revealed, a resident ?fell due to no S/R (self-releasing) seatbelt on w/c (wheelchair) as ordered. Seat belt found underneath cushion seat of w/c. [CNA 1 was} instructed to put S/R seat belt on resident and body alarm by assisting aid. Instructions witnessed by nurse. (CNA 1), stated she understood. Fall resulted to injury to resident.? The Education/Counseling Notice set forth the Plan of Correction was as follows, ?To be discussed with DON. (CNA 1) is to go over Plan of care (POC communication book) at the beginning of each shift. No Doubles (shift) x 30 days. No 12 hr. (hour) shift x 2 wks. (weeks). Any other disciplinary actions can result in termination.? A review of and Education/Counseling Notice signed by CNA 1, dated August 4, 2014, revealed a ?Final Termination? counselling for violations regarding Carelessness, Safety Issue, and Not following through on orders of resident.? The description of the violation revealed, CNA 1 was responsible for Patient 1, ?who had an order for a bed alarm, CNA 1 put the resident [Patient 1] to bed without checking to see if the resident [Patient 1] had an alarm as so ordered, the resident [Patient 1] fell out of her bed resulting in injury.? The Education/Counseling Notice set forth the Plan of Correction was as follows: CNA 1 ?will put residents [patients?] safety as priority. Failure to comply with any of company policies will result in additional disciplinary action up to and including termination.? Under Employee Comments, it noted, ?I was clocked out & on lunch when she (Patient 1) tried to get out of bed. Despite POC (POC Communication book) order for alarm, there was no alarm present.? 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. |
| 240000252 |
Desert Manor |
240012742 |
B |
10-Nov-16 |
3JLG11 |
4937 |
Regulation Violation 72527 (a) (6) Patients? Rights (6) To be transferred or discharged only for medical reasons, or the patients welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patients? health record. 725219 (b) (1) (2) Patient Transfer (b) When a patient is transferred to another facility, the following shall be entered in the patient health record. (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patients guardian or authorized representative except in an emergency or as provided in Section 72527(a) (5). The facility failed to: 1. Document the reason for Patient 13?s transfer to another facility; and 2. Provide Patient 13?s public guardian (a person appointed by law to act in his place when a person is unable to) a 30 day written notice prior to the transfer. 1. During a review of the clinical record for Patient 13, the admission record indicated, the patient was admitted to the facility on February 18, 2016, with diagnoses that included unspecified psychosis (mental illness-a loss of contact with reality), and dementia (a decline in memory or other thinking skills severe enough to reduce a person?s ability to perform every day activities). Patient 13 had a public guardian. A review of the physician's history and physical noted that Patient 13 was not capable of understanding or making decisions. A review of Patient 13?s Physician?s Discharge Summary dated July 1, 2016, did not indicate any reasons for transferring the patient to another facility. The Physician?s progress notes dated from April 23, 2016 to June 25, 2016, did not have documentation to show the reason for Patient 13?s transfer. A record review of the nurse's notes from June 25, 2016 to July 1, 2016, indicated no documented reasons for transferring Patient 13 to another facility. During an interview with the Director of Nursing (DON) on September 29, 2016 at 2:28 PM, the DON stated that we were transferring people over there (to another facility), and they were transferring people over here (current facility). The DON stated, ?We were exchanging patients, trying to find patients that would not leave the facility.? During an interview with the DON on September 29, 2016 at 3:35 PM, she provided Patient 13's physician discharge summary and stated that there was nothing on the summary to show why he was being transferred to another facility. 2. During a clinical record review on September 28, 2016 at 8:11 AM, Patient 13 had a ?Notice of Proposed Transfer/Discharge?, with a notification date of June 30, 2016. There was no documentation to show that Patient 13?s public guardian was provided with the required copy of the Notice of Proposed Transfer/Discharge from the facility 30 days prior to Patient 13?s transfer to another facility. The Notice of Proposed Transfer/Discharge gives the patient (public guardian) time to ensure that the transfer/discharge is appropriate and is in the best interest of the patient. Further review of the Notice of Proposed Transfer/Discharge form indicated the form was signed by a facility representative on July 1, 2016. The public guardian for Patient 13 did not sign the document. Patient 13 was transferred to another facility on July 1, 2016. During an interview with the Director of Nurses (DON) on September 29, 2016 at 2:28 PM, she confirmed that the notice had not been sent to the public guardian before Patient 13 was transferred to another facility. The undated facility policy and procedure titled, "Transfer and Discharge Policy and Procedure", indicated, " ...Procedure: Upon transfer or discharge of a resident, the following documentation will be made in the resident?s clinical record. The physician will document the needs which cannot be met by the facility or when the resident has improved sufficiently and no longer needs the services of the facility, or when the resident?s actions endanger the health and safety of himself and/or others?? The undated facility policy and procedure titled, ?Transfer and Discharge Policy and Procedure", indicated ?...Procedure:? (B) Before a transfer or discharge is made, notice will be given in writing to the resident and, if known, a family member or legal representative thirty (30) days before transfer/discharge of the reasons for the transfer/discharge from the facility. The notice of proposed transfer/discharge notice will be given?.? The facility failed to document the reason for Patient 13?s transfer to another facility and failed to provide a thirty (30) day notice to the patient?s public guardian prior to transferring Patient 13 to another facility. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 250000857 |
DESERT REGIONAL MEDICAL CENTER D/P SNF |
250009425 |
B |
19-Nov-12 |
19FI11 |
5526 |
Desert Regional Medical Center D/P SNF - CA00281664; Citation 72311(a)(2) Nursing service shall include, but not be limited to, the following: Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.On September 14, 2011, at 8:50 a.m., an unannounced visit was made to the facility to investigate an entity reported incident. During the investigation, it was determined that the facility failed to: 1. Provide transfer and mobility aids and assistance when Patient A was in the bathroom, in accordance with Patient A's plan of care; and 2. Implement the policy titled, "Fall Prevention Program and Post Fall Care (dated March 2010)," which indicated Patient A should have been provided transfer and mobility aids. Patient A, 78-year old female was admitted to the facility on August 25, 2011, which included the following diagnoses: 1. Pulmonary embolism (a blockage of a lung artery); 2. Anemia; and 3. Gastrointestinal bleed. The "Clinical Documentation-Admission/Shift Assessment," dated August 25, 2011, at 10:24 p.m., indicated Patient A's gait and transfer ability was impaired and the patient had a "Morse Fall Risk Score (an assessment of risk level)" of 110 (zero to 24= no risk; 25 to 44= low risk; 45 or greater= high risk). The "Clinical Documentation-Nursing Note" dated August 26, 2011, at 5:32 p.m., indicated, "...ambulates with PT (Physical Therapist)...bed alarm on..." The "SNF (Skilled Nursing Facility) Interdisciplinary Plan of Care," dated August 25, 2011, indicated Patient A was at risk for fall due to mild dementia (a serious loss of cognitive ability) and that Patient A would be provided transfer and mobility aids. The "Physical Therapy (PT) Initial Evaluation/Screening," dated August 26, 2011, indicated Patient A's current ambulation level was minimum assistance, using a front-wheeled walker and the patient required stand-by assistance.The facility policy titled, "Fall Prevention Program and Post Fall Care (dated March 2010), indicated, "The following high risk interventions are used in addition to the above measures on identified high risk patients...Provide transfer and mobility aids..." The "Clinical Documentation-Nursing Note" dated August 26, 2011, at 8:09 p.m., indicated, "1920 (7:20 p.m.) patient was assisted to the bathroom by CNA (Certified Nursing Assistant)...patient got out of the bathroom unassisted and slid on the floor per patient she landed on her knees sustained abrasion on her right knee, a small bruise on left knee, and c/o (complained of) minimal pain on her right ankle...2215 (10:15 p.m.) back from radiology..." The radiology report, "XR (X-ray) Ankle...Right," dated August 26, 2011, at 10:10 p.m., indicated, "Impression: Oblique fracture of the distal fibular shaft. Soft tissue swelling." On September 14, 2011, at 9 a.m., Room 2408 (Patient A's room) was inspected and observed that the bathroom had toilet amenities. The hand washing sink was located outside of the bathroom (inside Patient A's room), approximately five feet away from the toilet.On February 21, 2012, at 7:10 a.m. CNA 1 was interviewed and stated she was the CNA assigned to Patient A, when the patient fell on August 26, 2011. She stated she assisted the patient into the bathroom, closed the bathroom door, and then left the patient's room. Patient A was left in the bathroom, without any ambulating assistive device. CNA 1 stated she stepped out of Patient A's room. CNA 1 returned to the room (she could not recall the amount of time gone) and found Patient A on the floor, between the bathroom and the hand washing sink. CNA 1 stated, "(I) should have stayed in the room and waited for the patient (Patient A)..." On September 14, 2011, at 9:40 a.m., the interim Director of Nursing (DON) was interviewed and stated the CNA (CNA 1) assisted Patient A to the bathroom and left the room. The DON stated since Patient A had a bed alarm (a device to alert staff when the patient gets out of bed without assistance), the patient may have periods of forgetfulness and may not remember to ask for assistance while in the bathroom. The DON added that CNA 1 did not know she should have waited outside the bathroom. On February 21, 2012, at 12:10 p.m., Patient A's record was reviewed with the Director of Rehabilitation Services (DRS). The DRS stated according to the PT evaluation, dated August 26, 2011, Patient A required stand-by assistance, using a front-wheeled walker while ambulating. The DRS stated when Patient A was assisted to the bathroom, staff should have left the bathroom door cracked open, enough to monitor the patient. The DRS stated a staff member should have been readily available, while Patient A was in the bathroom. The facility failed to implement Patient A's plan of care and the facility policy, which indicated Patient A should have been provided transfer and mobility aids (assistance). Patient A ambulated from the bathroom to the hand washing sink, without staff assistance and an assistive device, resulting in a fall subsequently sustaining a right ankle fracture (distal fibular shaft), which required Patient A to wear a boot walker (a boot that provided splinting, protection, and cushion to an affected area) for walking. These violations had a direct relationship to the health, safety, or security of patients. |
| 250000857 |
DESERT REGIONAL MEDICAL CENTER D/P SNF |
250010458 |
A |
13-Feb-14 |
43DA11 |
9613 |
72311 (a)(1)(A) and 72311(a)(2):Nursing Service General (a) Nursing Service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient?s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commences at the time of admission of the patient and be completed within seven days after admission.(2)Implementing of each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan. On August 15, 2011, an unannounced visit was made to the facility to investigate a complaint allegation in which Patient A sustained a fall, resulting in a right femur fracture which required surgical intervention seven days after the patient had a total right hip arthroplasty (surgical replacement of the hip joint with an artificial joint).Based on interview and record review the facility failed to ensure Patient A's care needs were identified and assessed with appropriate interventions implemented by failing to;1. Ensure the bed alarm on Patient A's hospital bed, was activated, contributing to a fall for this high fall risk patient; 2. Ensure Patient A received a comprehensive pain assessment prior to, and after receiving pain medication; and,3. Ensure the "Interdisciplinary Plan of Care," for Patient A's insomnia was implemented, contributing to the patient's fall after receiving Percocet 5/325 mg. (a narcotic-pain medication) and Ambien 5 mg. (sleeping medication) at the same time. A review of Patient A's record was conducted on August 15, 2011. Patient A, 83 years old, was admitted to the facility on June 10, 2011, for rehabilitation after having a total right hip arthroplasty (hip replacement-surgical replacement of the hip joint with an artificial joint) on June 7, 2011.A review of Patient A's Morse Fall Risk Score (An assessment tool which determines a patient's risk for falls) indicated the patient was a high fall risk. The "Interdisciplinary Plan of Care," for Patient A, dated June 10, 2011, indicated the patient as an "Ultra High Risk, (for falls)." The interventions indicated to review medications especially hypnotics (medication for sleep), and analgesics (pain medication). A review of the "Interdisciplinary Plan Of Care," for Patient A indicated on June 10, 2011, a plan of care was initiated based on the patient's problem of, "Altered Mood r/t (related to) Anxiety, Insomnia." The interventions for this problem included, "Attempt diversional activities, relaxation techniques or interventions prn (as needed)."A review of the "Clinical Documentation Nursing Note," dated June 14, 2011, at 2:27 a.m., indicated Patient A was found on the floor. A review of the hip x-ray completed on June 14, 2011 at 7:51 a.m., noted Patient A sustained a fracture of the right femur, necessitating a transfer to the acute facility for surgical intervention.The record reflected on June 13, 2011, at 8:34 p.m., one tablet of Percocet 5/325 mg. was given to Patient A for "moderate pain," along with one tablet of Ambien 5 mg. (a hypnotic) used for, "Insomnia."A review of the "Interdisciplinary Plan Of Care," dated June 10, 2011, indicated the interventions for pain include, "Assess discomfort/pain using 0-10 scale...Assess effectiveness of intervention using 0-10 scale." The level of pain on a scale from one to ten (with ten being the highest level of pain), was not documented prior to, or after the patient received the Percocet 5/325 mg., on June 13, 2011, at 8:34 p.m. An interview was conducted with RN 1 on August 17, 2011, at 12:30 p.m., who stated she would not give medications to relieve pain and insomnia to an elderly patient at the same time. RN 1 further stated she would give the pain medication first, then use other interventions to help the patient go to sleep, and would reassess the patient after a while to see if the interventions worked or if medication for sleep is needed at that time. Further record review failed to show that interventions, such as diversional activities to assist the patient to relax in order to be able to sleep were implemented. A review of the right hip x-ray completed on June 14, 2011 at 7:51 a.m., indicated Patient A sustained a fracture of the right femur, necessitating a transfer to the acute facility for surgical intervention on the same hip for she had surgery seven days prior.A review of the facility policy and procedure, "Pain Management (Revised 6/11)," indicated the purpose, "To assure the adequate assessment and treatment of pain for patients throughout the continuum of care..."...The procedure indicates, "...a reassessment for the presence and intensity of pain shall be performed...following any intervention intended to lessen the patient's pain (administration of pain medications, application of cold packs, repositioning).. Such reassessment is a dynamic and ongoing process which shall take place within a clinically appropriate time frame...)." An interview was conducted with RN 1 on August 17, 2011, at 12:20 p.m., who stated, "If a patient is complaining of pain, you have to assess the pain, where it is. You have to see what precipitated the pain. After trying repositioning or giving the patient medication, the patient has to be reassessed in 30 minutes or so." A review of the Nursing Notes dated June 14, 2011, at 2:27 a.m., indicated, "Pt. (patient) was found sitting on the floor next to the bed, bed alarm on, it did not ring at this time." An interview was conducted with the Interim Director (ID) on August 15, 2011, at 1 p.m., who stated, "The bed alarm was not engaged at the time of Patient A's fall, the biomedical department checked to make sure it worked and it did. This omission was a user error." A review of the facility's policy and procedure, "Fall Prevention Program and Post Fall Care (Revised 4/09)" was reviewed on August 15, 2011. The procedure indicated, with identified high risk patients to utilize the bed alarm as needed. An interview was conducted with RN 1 on August 17, 2011, at noon, who stated, "If a patient falls, the registered nurse would have to assess the patient. This assessment would then be written as a narrative in the nurses notes." An interview was conducted with the Interim Nursing Director (IND), on August 15, 2011, at 12:30 p.m., who stated the RN is to do all assessments. The IND further stated there was no assessment of Patient A completed by an RN after the patient fell.An interview was conducted with the IND on August 17, 2011, at 1:30 p.m., who stated if a patient is on an anticoagulant, (blood thinner), this must be assessed and communicated to the physician. The record reflected Patient A was receiving Lovenox (a blood thinner) 0.4 milliliters by injection, subcutaneously (beneath the skin) daily, since June 8, 2011. A review of the facility policy and procedure, "Fall Prevention Program and Post Fall Care (Reviewed 3/10)," was conducted on August 15, 2011. The "Post Fall Actions, Observation, Documentation," indicated "Contact Physician for notification purposes and orders as needed Inform Physician of full findings. Ask the physician to order tests "stat" if the patient is receiving anti-coagulation...Neurological checks and more frequent vital signs should be instituted and documented...and considered for those patients with anticoagulation or clotting disorders...? A review of the "Clinical Documentation-Nursing Note," dated June 14, 2011, at 4 a.m., indicated, "(Physician) did not return the pager." Further record review indicated the nurse received a telephone order from the physician for a STAT x-ray of the pelvis and right hip at 5:30 a.m., three hours after Patient A was found on the floor. A review of a hip x-ray completed on June 14, 2011 at 7:51 a.m., indicated Patient A sustained a fracture of the right femur. Patient A was subsequently readmitted to the hospital for repair of the right femur fracture.A review of the facility policy, "Physician Notification," (Approved by the Medical Executive Committee on April 6, 2004,) indicated, "When problems in contacting an attending physician for orders regarding a patient's condition have arisen and when that delay has been determined to be potentially detrimental to a patient's well-being, the Medical Staff's chain of command is to be followed ... " An interview was conducted with the Interim Nursing Director (IND) of the facility on August 14, 2011. The IND stated Patient A's physician did not respond for three hours, the procedure is, if a patient's physician does not respond within fifteen minutes to one hour the house supervisor should be notified and the chief of the department should be notified. There was no documentation found to show that a registered nurse completed a post fall assessment, pain assessment, neurological checks, or notified the physician about Patient A receiving Lovenox. Therefore, the facility failed to ensure the ?Interdisciplinary Plan of Care,? for insomnia was implemented, a comprehensive pain assessment was implemented, the patient?s bed alarm was activated prior to sustaining a fall, and to ensure Patient A?s physician was notified promptly, and a post fall assessment completed when this post-surgical patient sustained a fall, fracturing her right femur. 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. |
| 250000732 |
DELPHINIUM HOUSE |
250010820 |
B |
19-Jun-14 |
YAM311 |
2624 |
W127 CFR 483.420(a)(5) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. During an entity reported incident investigation conducted on October 22, 2013, it was determined the facility failed to ensure Client A was free from physical abuse. Client A, a male 51 years of age, was admitted October 22, 1991, with diagnoses including Profound Mental Retardation (a serious mental disability). The record indicated Client A was non-verbal (unable to speak) and did not have the ability to make his needs known. During an interview with the Qualified Intellectual Developmental Professional/Administrator (QIDP), on October 22, 2013, at 11:30 a.m., she stated on October 11, 2013, she was notified by Client A's Day Program Director (DPD), program direct care staff (PDCS 1) witnessed a staff member take a "Swipe" at Client A. The QIDP stated the DPD reported the PDCS 1 stated she heard a sound, "That sounded like skin hitting on skin", at the time the incident had occurred. An interview was conducted with PDCS 1, on October 22, 2013, at 9:23 a.m. PDCS 1 stated on October 11, 2013, three PDCS (including herself) were on the bus taking clients on a field trip. PDCS 1 stated Client A was on the bus sitting across the aisle from PDCS 2. PDCS 1 stated, "I saw ... (PDCS 2's name) arm and hand make contact with... (Client A) person and heard like a (PDCS 1 demonstrated by smacking her hands together) sound." An interview was conducted with PDCS 3, on October 22, 2013, at 9:45 a.m. PDCS 3 stated on October 11, 2013, she and two other PDCS staff were on the bus taking clients on a field trip. PDCS 3 stated Client A was on the bus. PDCS 3 stated Client A was sitting across the aisle from PDCS 2. PDCS 3 stated, "I heard a slap, skin on skin sound. When I heard the sound, I looked at ... (PDCS 1's name) to see if I heard what I heard. I asked her, ?Did he hit him?? and she said "Yes"." During an interview with the day program's Quality Assurance Specialist (QAS), on October 22, 2013, she stated the results of the program investigation concluded the alleged abuse of Client A by a day program staff (PDCS 2) had occurred on October 11, 2013. The facility failed to ensure Client A was free from physical abuse while attending a day program outing. During the bus ride to a day program outing, Client A was physically abused by a Program Direct Care Staff. The above violation had a direct or immediate relation to Client A?s health, safety, or security. |
| 250000061 |
Desert Springs Healthcare & Wellness Centre |
250011022 |
B |
25-Sep-14 |
QHGJ11 |
4141 |
Class "B" Citation ?483.25(h) Accidents The facility must ensure that- (1)The resident environment remains free from accident hazards as possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Certified Nursing Assistant (CNA 1) used a Hoyer Lift (equipment to aid in transfer and prevent injury to resident and staff) to transfer a patient from wheelchair to bed on May 18, 2014. As a result, Resident 1, fell to the floor and sustained a fractured left wrist. CNA 1 failed to report Resident 1's fall to nursing staff. On May 19, 2014, Resident 1, complained of left wrist pain and the Charge Nurse (CN1) found Resident 1's left wrist to be slightly swollen and painful. The Medical Doctor (MD) was notified and an x-ray was ordered. The x-ray showed a left wrist fracture. There had not been a report of any fall or injury for Resident 1. Resident 1 was admitted to the facility on March 22, 2011. Admitting diagnoses included history of cerebral vascular accident (CVA- a stroke), with left sided weakness. His Minimum Data Set (MDS, an assessment tool), indicated that he was totally dependent for transfers from wheel chair to bed. He required two people to assist him when he transferred from wheelchair to bed. The care plan for Resident 1, titled, Activities of Daily Living, dated, March 1, 2013, indicated a Hoyer lift should be used for all transfers. On May 20, 2014, the Director of Nurses (DON), was notified of the injury to Resident 1. The DON interviewed staff working with Resident 1 in the days before May 19, 2014, when he complained of pain to his left wrist. None of the staff had noted any swelling of his left wrist and were not aware of any falls. CNA 1 was one of the staff who denied any knowledge of a fall when first interviewed. On May 20, 2014, the DON interviewed Resident 1. Resident 1 indicated, "a fat Mexican boy accidentally dropped him on the floor when he was transferring him." Resident 1 identified the Certified Nursing Assistant that dropped him as CNA 1. On May 20, 2014, the DON re-interviewed CNA 1. At this time, CNA 1 stated that on May 18, 2014, Resident 1 had a fall incident. CNA 1 stated he was attempting to transfer Resident 1 by himself. CNA 1 stated that he did not report the fall because he was afraid of being reprimanded, and he did not think Resident 1 had been injured. On May 29, 2014, an interview was conducted with Resident 1. Resident 1 stated CNA 1 always helped him back to bed by himself. Resident 1 stated that usually CNA 1 placed his wheelchair near the bed. However, this time he placed him by the window. CNA 1 lifted him up from the chair and then dropped him. Resident 1 stated CNA 1 picked him up from the floor and put him in bed without any help. When asked how his arm felt now, he stated, "Oh it hurts, it aches so." The facility CNA Job Description indicates under the section, "Duties and Responsibilities - Administrative Functions, "...Report all accidents and incidents you observe on the shift that they occur." The Corrective Action Memo, dated May 20, 2014, for CNA 1, indicated, "On 5/18/14 you failed to report to Charge Nurse pt (patient) had a fall, which caused injury to pt." On May 27, 2014, the facility terminated CNA 1 for "not reporting incident to charge nurse."The facility failed to ensure: 1. CNA 1 used a Hoyer Lift to transfer Resident 1 on May 18, 2014, per facility care plan interventions. 2. CNA 1 used two-person assistance when transferring Resident 1 on May 18, 2014, per the MDS assessment and facility care plan interventions. 3. CNA 1 immediately reported Resident 1's fall to the charge nurse on May 18, 2014. As a result, Resident 1 sustained a fall and fractured his left wrist on May 18, 2014, when CNA 1 transferred Resident 1 by himself and without the use of a Hoyer Lift.The above violations either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety, and security. |
| 250000061 |
Desert Springs Healthcare & Wellness Centre |
250011684 |
B |
27-Aug-15 |
EZUJ11 |
5901 |
Staff Treatment of Residents ?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. The facility failed to protect the rights of Patient A from the misappropriation of the resident's property by the Minimum Data Set Coordinator (MDSC) when Patient A's money was deliberately used without Patient A's consent. On December 5, 2014, the facility reported MDSC had been accused of stealing money from Patient A. Patient A was admitted on September 21, 2014, with diagnoses including dementia, muscle weakness, depression, failure to thrive, and anxiety. Patient A was alert but had confusion and memory loss. Patient A was 86 years old and had no family or friends.On December 11, 2015, at 5 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the facility had launched an investigation regarding the suspicious transactions at the bank concerning Patient A. The DSD stated MDSC had given them two checks made out to MDSC (herself) and signed by Patient A. Each check was for $10,000, and had not been cashed. MDSC also gave them receipts from Walmart and Kmart. DSD stated the Walmart receipts had items including a ladies watch and cosmetics that Patient A would not have used, as he had no family or friends. The DSD stated during the investigation they learned MDSC would pick up Patient A on Sundays, without telling anyone at the facility. She stated MDSC had helped Patient A set up his checking account and had access to his checks. The DSD stated after the investigation, MDSC was terminated on December 9, 2014. On December 11, 2015, a review of Patient A's medical record was conducted. The medical record had no physician order for the patient to go out on pass. On December 23, 2014, at 4:15 p.m., an interview was conducted with the Administrator. The Administrator stated the facility's social worker had received a call from Patient A's current caregiver. Patient A was discharged to a board and care facility on November 24, 2014. The caregiver reported several suspicious bank transactions occurring during the patient's stay at the facility from September 21, 2014, to November 24, 2014. The facility employee involved with the transactions had been the facility's Minimum Data Set Coordinator (MDSC). The Administrator stated he had his own investigators look at the two checks dated November 12, 2014, and November 13, 2014, made out to MDSC and signed by Patient A. Each check was for the amount of $10,000. The administrator stated the investigators told him Patient A's signature was probably forged. The Administrator stated MDSC had not told her supervisor that she had received these checks. In addition, MDSC had a box of blank checks for Patient A in her possession. The Administrator stated the bank had shown him transactions for Patient A, which occurred, with MDSC in attendance.The amounts were:1. On October 3, 2014, a withdrawal for $2000;2. On October 8, 2014, a withdrawal of $1000; and,3. On November 19, 2014, a withdrawal for $3000. These transactions were not made with the "buddy system" (two staff members present), per facility policy. MDSC had taken Patient A to the bank by herself. On December 23, 2014, at 4:25 p.m., an interview was conducted with the Director of Nurses (DON). The DON stated MDSC had met Patient A on admission and had always "taken a special interest in him, more than the other residents".On December 23, 2014, the employee file for MDSC was reviewed. MDSC had been hired July 1, 2010. MDSC had been disciplined in 2011, for attempting to discharge a resident to her own home. On December 9, 2014, MDSC was terminated for, "managing patient's funds without prior authorization or notifying a supervisor." On January 22, 2015, at 3:35 p.m., the caregiver (CG) at the board and care where Patient A then resided, was interviewed. CG stated she took Patient A to the bank to introduce herself (to the bank staff) and change his address. CG stated she was informed a woman had come in trying to close Patient A's account and transfer the funds to her account. CG stated the bank executive told her they flagged Patient A's account and notified Adult Protective Services. CG stated another check had cleared from Patient A's account made out to K-mart and was dated after Patient A had moved to the board and care home. CG stated she had not taken Patient A to K-mart and he had no way to get there on his own. CG stated the Eldercare Ombudsman (advocate for seniors) had come to her home to interview Patient A, but he could not remember the name of MDSC or any facts pertaining to his checking account. The facility's policy and procedure, dated February 2013, and titled, "Reporting Abuse", indicates, " IX. 'Financial Abuse' occurs when a person or entity does any of the following:A. Takes, secrets (sic), appropriates, obtains, or retains real or personal property of an elder or dependent adult for a wrongful use or with intent to defraud, or both;B. Assists in taking, secreting (sic), appropriating, obtaining, or retaining real or personal property of an elder or dependent adult by undue influence." The facility employee handbook, revised February 2012, indicated, "You may not accept a gift or gratuity from...customer..." The facility failed to protect Patient A from the misappropriation of the patient's funds by MDSC when Patient A's funds; totaling $ 6628.88, were deliberately used without the patient's consent and $20,000 was attempted to be used without Patient A's consent. This failed practice placed Patient A and other residents/patients at risk for fiduciary abuse by MDSC. The above violation caused or occurred under circumstances was likely to cause significant humiliation, indignity, anxiety, and/or other emotional trauma to patients. |
| 250000061 |
Desert Springs Healthcare & Wellness Centre |
250013252 |
B |
20-Jun-17 |
V7YE11 |
5728 |
H&S 1424 (e) Except as provided in paragraph (4) of subdivision (a) of Section 1424.5, class "B" violations are violations that the state department determines have a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or Patients, other than class "AA" or "A" violations. Unless otherwise determined by the state department to be a class "A" violation pursuant to this chapter and rules and regulations adopted pursuant thereto, any violation of a patient's rights as set forth in Sections 72527 and 73523 of Title 22 of the California Code of Regulations, that is determined by the state department to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient is a class "B" violation. A class "B" citation is subject to a civil penalty in an amount not less than one hundred dollars ($100) and not exceeding one thousand dollars ($1,000) for each and every citation.
WIC 15610.57 (a) (1) The negligent failure of any person having the care or custody of an elder or a dependent adult to exercise that degree of care that a reasonable person in a like position would exercise.
WIC 15610.57 (b) (3) Failure to protect from health and safety hazards.
The facility failed to provide required supervision of a Family Member 1 (FM 1) when FM 1 visited Patient 1. As a result of this facility failure, FM 1 abducted Patient 1 and took her across state lines, where the patient had to be admitted to an acute care facility.
On March 9, 2016, an unannounced visit was made to investigate an entity reported incident regarding the abduction of Patient 1.
On March 9, 2016, the medical record for Patient 1 was reviewed. Patient 1 was admitted to the facility on XXXXXXX, 2015, with diagnoses including COPD (Chronic Obstructive Pulmonary Disease- a condition causing shortness of breath) and dementia (loss of mental function which makes a person incapable of making their own decisions).
Patient 1 was placed under conservatorship (a person appointed by the court to ensure a Patient?s rights are protected) on September 9, 2015.
A Conservatorship Report dated October 20, 2015, indicated Adult Protective Services investigated seven allegations of abuse toward Patient 1 by FM 1. All of the allegations were for neglect; three of the allegations were substantiated. The Conservatorship Report indicated Patient 1, ?Requires 24-hour care and was unable to make decisions regarding her needs for physical health, food, clothing, or shelter and is unable to resist fraud or undue influence.?
Initially, FM 1 was barred from visiting Patient 1 because FM 1 made numerous statements she would remove Patient 1 from the facility and attempted to interfere with the patient?s care during visits.
Interdisciplinary Team Conference notes, dated December 5, 2015, indicated the conservator, who was in attendance at the meeting, stated FM 1 could start supervised visits with Patient 1.
During an interview conducted with Certified Nursing Assistant (CNA) 1 on March 16, 2016, at 11:45 a.m., she stated that, on Sunday, March 6, 2016, FM 1 came to the facility along with an unidentified male. CNA 1 stated that she believed FM 1 entered through the unlocked front door some time before 8:30 a.m., but no one saw her enter the building.
CNA 1 stated FM 1 asked her for a blanket and assistance to get portable oxygen for Patient 1. CNA 1 stated she did not know FM 1?s identity, but she complied with FM 1?s request. CNA 1 stated she was told the previous year that FM 1 could only have supervised visits with Patient 1, but she did not know who FM 1 was and never received any instruction on how to conduct a supervised visit.
During an interview conducted with the facility Receptionist (Staff) 1 on March 14, 2016, at 3 p.m., she stated, on March 6, 2016, FM 1 told her that she was taking Patient 1 to the patio. Staff 1 stated she saw FM 1 pushing Patient 1?s wheelchair down the hall. FM 1 asked Staff 1 for a cup of coffee for Patient 1. When Staff 1 returned with the coffee, FM 1 asked for Thickener (substance used to thicken liquids for individuals who are prone to choke on liquids) for the coffee.
Staff 1 stated when she returned with the thickened coffee, Patient 1, FM 1, and the unidentified male were gone. Staff 1 stated she reported Patient 1 was missing to the registered nurse and facility staff found the empty wheelchair and Patient 1?s discarded name band in the parking lot.
Staff 1 stated she remembered being told that FM 1 could only have supervised visits with Patient 1. Staff 1 stated she did not know the identity of FM 1 when she asked for assistance for Patient 1. Staff 1 stated she did not question FM 1 as to her identity and did not keep Patient 1 in view when FM 1 was with Patient 1.
An undated facility policy and procedure titled, ?Visitation Rights,? was reviewed and included the following: ?Procedure: ?III. Visitors may be subject to reasonable restrictions that protect the security of the other residents such as: ?B. Limiting or supervising visits from persons who are known or suspected to be abusive or exploitative to a resident.?
The policy and procedure did not include staff guidelines for conducting supervised visits.
The facility failed to ensure FM 1 was supervised during visits to Patient 1. This failure allowed FM 1 the opportunity to abduct Patient 1 from the facility during an unsupervised visit.
The above violation either jointly, separately, or in any combination had a direct or immediate relation to patient health, safety, or security. |
| 910000034 |
DRIFTWOOD HEALTHCARE CENTER |
910009863 |
A |
14-May-13 |
DE6F11 |
11388 |
F329 CCR 483.25(I) Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. F428 CCR 483.60(c) Drug Regimen Review The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon. The Department received a complaint allegation on April 1, 2010, that alleged a resident (Resident 7) was diagnosed at a general acute care hospital (GACH) of digoxin (used to slow and strengthen the heart rate for atrial fibrillation) toxicity (a poisoning that occurs with excess doses of digoxin).On April 28, 2010, an unannounced complaint visit was conducted to the facility. Based on interview and record review, the facility failed to ensure Resident 7 was free of unnecessary drugs due to inadequate monitoring and pharmacy review irregularities were acted upon by failing to: 1. Notify the physician of the pharmacist?s recommendations in June and August 2009, for Resident 7?s digoxin blood serum levels to be monitored.2. Follow the resident?s plan of care to maintain and monitor the digoxin level every three months. 3. Report to the physician the resident?s change of condition for over six days, which were signs and symptoms of digoxin toxicity that was stipulated in the resident?s plan of care to assess and report. These failures resulted in Resident 7 having low blood pressure, slow heart rate, being transferred to a GACH in critical condition requiring fluid volume intravenously ( IV/in the vein), and admission to the intensive care unit (ICU) for four days with a diagnoses of kidney failure, severe dehydration, and an acute digoxin toxicity. According to the skilled nursing facility (SNF) admission record, Resident 7 was a 85 year-old female who was admitted to the facility on January 2, 2009, with diagnoses that included atrial fibrillation (an irregular and often rapid heart rhythm), hypertension (high blood pressure) and muscle weakness. The physician's order, dated January 8, 2009, indicated the resident was to receive digoxin 125 micrograms (mcg) by mouth every other day, and alternate with digoxin 250 mcg every other day. Another physician's order, dated June 3, 2009, indicated to record an orthostatic blood pressure (excessive decrease in blood pressure that occurs when a person sits or stands up) every Thursday, while sitting and lying. According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 25, 2009, the resident had modified independence in cognitive skills for daily decision-making and had no difficulty in making herself understood.A review of a laboratory report, dated March 9, 2009, indicated the resident?s digoxin level was low at 0.6 nanograms (ng) per milliliter (ml). (Normal reference range is 0.8-2.0 ng/ml). A plan of care, dated January 2, 2009, which was updated every three months, indicated the resident was at risk for digoxin toxicity due to the resident receiving digoxin. The goal was to maintain the resident's digoxin level within a therapeutic range and to review every three months. The nursing interventions included monitoring the resident for signs and symptoms of digoxin toxicity, such as anorexia (a disorder of eating due to loss of appetite), fatigue (tiredness), arrhythmias (irregular heart rate), dizziness, headache, and hypotension (low blood pressure), and to hold the medication if the pulse rate was below 60. However, according to the record review, the resident?s digoxin level was not checked in June and September 2009, every three months as stipulated in the care plan, to ensure Resident 7?s digoxin level was within therapeutic range.A review of the Consultation Report forms dated June 15, 2009, and August 20, 2009, of Resident 7's drug regimen review revealed the pharmacist inquired about the resident's laboratory results, and indicated there were none in the resident's chart since April 2009. On both reports, the pharmacist documented the resident's digoxin level "needed to be checked," along with blood tests (chemistry 7 and complete blood count (CBC), which had been ordered to be done weekly. However, there was no evidence the physician was notified regarding the pharmacist's recommendations or that the recommendations were acted upon. A review of a Medication Administration Record (MAR), dated October 2009, indicated digoxin 250 micrograms (mcg), one tablet by mouth every other day, and alternate with digoxin 125 mcg, one tablet by mouth every other day, and hold if the apical pulse (heartbeat as heard with a stethoscope placed on the chest wall) was less than 60 beats per minute (BPM) for atrial fibrillation (an irregular and often rapid heart rate that commonly causes poor blood flow to the body). The MAR indicated on October 25, 2009, at 5 p.m., Resident 7 had a recorded blood pressure of 96/58 (normal blood pressure is 120/80). On October 28, 2009, at 9 a.m., digoxin 125 mcg was held because the resident's apical pulse rate was low at 55 BPM. These are signs and symptoms (S/S) of digoxin toxicity.On April 28, 2010, a review of the resident's clinical record indicated there was no documented evidence on October 25, 2009, that the physician was notified of the resident's low blood pressure of 96/58, or the resident?s low apical pulse on October 28, 2009. According to the resident's plan of care for risk of digoxin toxicity, low apical pulse and low blood pressure were S/S to be monitored. The Licensed Nurse's Progress Note dated October 27, 2009, and timed 3:20 p.m., revealed Resident 7 was refusing meals and had a poor appetitie, which is another S/S of digoxin toxicity. The notes dated October 31, 2009, at 1:30 p.m., indicated the resident was assessed to have weakness, disorientation, an altered mental status, and slurred incomprehensible speech. According to the nurse?s note, the resident's skin color was pale, her pulse was faint, with an undetectable blood pressure, and her oxygen saturation was 75 percent (%) on room air (normal reference range is 92-100%). The physician was then notified, after the resident had had a change in condition for six days, and Resident 7 was transferred to a GACH by paramedics.A review of the GACH Emergency Room's (ER) records, dated October 31, 2009, and timed at 11:09 p.m., indicated the resident's blood pressure was low, at 75/46 mm/Hg, with a low heart rate of 58 BPM, and the resident was very sluggish, somewhat lethargic (physical slowness and mental dullness) and disoriented (confused). The ER documentation indicated the resident received 1000 milliliters of normal saline intravenously (IV/into the vein) and remained hypotensive (low blood pressure) requiring an additional 500 milliliters of normal saline per IV with a blood pressure of 104/57 mm/Hg. The note also indicated, the resident's urinary output was slowly improving after the normal saline IV fluids were given.The blood test results (from the GACH) indicated the resident's digoxin serum level was high at 7.5 ng/ml (reference range 0.8-2.0 ng/ml). The resident?s blood urea nitrogen (BUN) level was also elevated at 70 mg/dl (normal reference range is 6-26 mg/dl), and the serum creatinine level was elevated at 2.1 mg/dl, (normal reference range is 0.40-1.00 mg/dl). (BUN and creatinine are by-products of the body's metabolism. These levels are used to monitor kidney functioning if the kidneys are not working properly the BUN and creatinine will be elevated). The electrocardiogram [(EKG or ECG) a test that checks for problems with the electrical activity of your heart] was consistent with a digoxin effect, and it was documented that Resident 7 was in critical condition (dangerous/life-threatening) with a blood pressure of 80 palpable per the EMS, with severe dehydration, acute hypotension and acute digoxin toxicity. The resident was admitted to the ICU.Resident 7 was transferred back to the SNF on November 3, 2009, four days after admission to the GACH, with discharge diagnoses that included acute digoxin toxicity, acute dehydration, and acute renal failure. According to the GACH?s discharge medication list, digoxin was no longer prescribed by the physician. During an interview with the acting director of nurses (ADON), on June 28, 2010, at 9:30 a.m., she reviewed the licensed nurse's progress notes, the Physician's Progress Notes, and the Pharmacy Consultation Book, and was unable to find written documentation of the physician being notified of the pharmacist's recommendations for the digoxin levels to be checked for Resident 7. The ADON also stated it was the facility?s policy for the physician to be notified and give a response to accept or reject the pharmacist's recommendations. The ADON further stated the last time Resident 7?s digoxin level was drawn by the facility was on March 9, 2009, and that digoxin level was low at 0.6 ng/ml. (0.8-2.0). The ADON stated the supervising registered nurse (RN) and she were responsible for receiving the pharmacist's recommendations and to communicate the information to the physician.A review of the facility?s policy titled, ?Medication Regimen Review? dated December 18, 2008, indicated a consultant pharmacist would conduct a comprehensive monthly review of all residents? medications and written recommendations are left for the physician/prescriber for review. The policy further indicated the physician/prescriber and the director of nursing must act upon the recommendations. According to the Drug Information Handbook for Nursing, 8th Edition, digoxin toxicity signs and symptoms and complications included weakness, confusion, anorexia, heart failure and arrhythmias with an abnormal heart rate.The facility failed to ensure Resident 7 was free of unnecessary drugs due to inadequate monitoring and pharmacy review irregularities were acted upon by failing to: 1. Notify the physician of the pharmacist?s recommendations in June and August 2009, for Resident 7?s digoxin blood serum levels to be monitored.2. Follow the resident?s plan of care to maintain and monitor the digoxin level every three months. 3. Report to the physician the resident?s change of condition for over six days, which were signs and symptoms of digoxin toxicity that was stipulated in the resident?s plan of care to assess and report. This violation presented either imminent danger that death or serious harm would and or a substantial probability that death or serious physical harm would and did occur to Resident 7. |
| 910000033 |
DEL AMO GARDENS CONVALESCENT |
910011975 |
AA |
17-May-16 |
CYGM11 |
15299 |
F32342 CFR 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.42 CFR 483.25 Quality of Care. 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.On August 7, 2015 at 1 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI) incident involving Resident 1. On July 31, 2015 at 1 p.m., Resident 1 sustained a fall from an Invacare lift sling (a full-body sling connected to a mechanical lifting device used to move heavy immobile residents) during the transfer from her wheelchair to the bed. The resident sustained a laceration to the back of her head, and was transferred to the general acute care hospital (GACH) emergency department (ED) for further evaluation.On July 30, 2015, at 1 p.m., Resident 1 was being transferred from the chair to the bed using the Invacare lift sling, when one of the lift sling straps broke. Resident 1 slid out of the sling onto the floor, hit the back of her head, sustaining a laceration (cut) measuring 5 centimeters (cm) by 5 cm. The resident also sustained skin tears to her right forearm and left posterior (back) upper ear. At 1:30 p.m., Resident 1 was transferred by the paramedics to the GACH-ED, and expired on the same day at 3:06 p.m. (two hours and six minutes after the fall incident). The death certificate indicated Resident 1 expired because of a traumatic hemothorax (the presence of blood in the lungs) that was caused by blunt force trauma (injury caused by an impact). The facility failed to ensure that Resident 1?s environment remained as free from accident hazards as possible, and received adequate supervision and assistance devices to prevent accidents; and failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The failures include but are not limited to: 1. Failure to follow the Invacare sling lift manufacture?s guidelines to inspect the full-body mesh sling after each laundering for wear, tear, and loose stitching, and to immediately discard bleached, torn, cut, frayed, or broken slings, 2. Failure to ensure direct care staff inspected the sling prior to each use for wear, tears, or frayed areas, and immediately stop the use of any unsafe slings, 3. Failure to implement the resident?s assessment to use two-plus-persons physical assistance while transferring the resident from the wheelchair to the bed using a mechanical lift. According to the facility's admission record, Resident 1 was a 97 year-old female readmitted to the facility on November 1, 2013, with diagnoses that included dementia (disease causing significant decrease in cognitive abilities with memory loss), angina pectoris (discomfort in the chest), osteoporosis (thinning of the bones), and chronic respiratory failure (diseases and condition that affect breathing) due to aspiration pneumonia (infection of the lungs from inhaling foreign matter).The Minimum Data Set (MDS, a standardized assessment care and screening tool) dated January 31, 2015, indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The resident was assessed as totally dependent on one person physical assistance with locomotion on and off the unit, dressing, personal hygiene, and needed two-plus-persons physical assistance with transfers. The resident was five feet and three inches tall, and weighed 164 pounds. The care plan dated November 1, 2013, indicated Resident 1 was at risk for falls/injury. The approach was to maintain a safe and hazard free environment.Another care plan dated November 1, 2013, for rehabilitation for activities of daily living (ADL, routine activities that residents perform every day such as eating, bathing, and dressing) indicated Resident 1 required total assistance from staff for transferring. The approach was to assist the resident with all transfers. The care plan did not address how to transfer the resident or what equipment to use. A review of the Licensed Personnel Progress notes, dated July 30, 2015 at 12:25 p.m., indicated Resident 1 was lifted using an Invacare lift. According to the documentation the resident fell from the Invacare lift sling, hit her head on the floor, and sustained a right forearm skin tear measuring 1 cm by 1 cm, left posterior (back) upper ear skin tear measuring 1 cm by 1 cm, and a laceration to the left posterior head measuring 5 cm by 5 cm, that was bleeding. The resident's vital signs (clinical measurements of the pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of the resident's essential body functions) were as follows: blood pressure (BP ? the pressure of the blood in the circulatory system) was 126/96 millimeters of mercury (mm Hg) (normal ranges 120 mm Hg systolic over 80 mm Hg diastolic), pulse rate (PR) was 87 beats per minute (bpm) (normal range 60 to 100 bpm), rate of respirations was 24 breaths per minute (normal range 12 to 20 breaths per minute), temperature was 97.1 degrees Fahrenheit (normal range 98.6 degrees Fahrenheit), and her blood oxygen saturation (amount of oxygen saturation in the blood) was 58 percent (normal ranges 95 to 100 percent, and 90 percent is considered low) using three liters of oxygen per minute via nasal cannula. Resident 1 was switched to a non-re-breathable face mask (NRB, allows for the delivery of higher concentrations of oxygen), and after three minutes the resident's blood oxygen saturation levels increased from 88 to 90 percent.At 12:40 p.m., the Licensed Personnel Progress Notes indicated Resident 1?s responsible party was called and notified of the incident. At 12:50 p.m., the Licensed Personnel Progress Notes indicated a message was left with the health management organization (HMO). The notes indicated transportation was called to transfer Resident 1 to her HMO hospital for evaluation of the laceration to her head. At 12:55 p.m., the Licensed Personnel Progress Notes indicated Resident 1's vital signs were rechecked, and indicated; BP 123/90, PR 76 bpm, RR 24 breaths per minute, pain 0/10 (no pain) and the oxygen saturation was 89 percent at 15 liters per minute via NRB face mask. The note indicated the transportation was cancelled.At 1:00 p.m., the Licensed Personnel Progress Notes indicated 911 (emergency number) was called due to Resident 1?s low oxygen saturation and head laceration. At 1:05 p.m., the paramedics arrived, and assessed Resident 1. The note indicated report was given regarding the resident's condition, incident of fall, head laceration and medical history. The resident was transferred to the GACH via paramedics at 1:30 p.m. The Emergency Medical Services (EMS) Report dated July 30, 2015 at 1:14 p.m., indicated Resident 1 was sitting in bed, and complained of shortness of breath, for 30 minutes. The notes indicated per nursing staff, the resident was in a wheelchair moving device when it malfunctioned and the resident fell. Resident 1 had a positive laceration to the back of her head which measured approximately 5.5 cm. The notes indicated after the resident fell, the nursing staff noticed a low oxygen level saturation, and per staff resident's oxygen saturation was normally 89 to 91 percent. At 1:40 p.m., the notes indicated the resident?s care was transferred to the facility (GACH). Resident 1?s vital signs were as follows: BP 112/58, PR 86 bpm, RR 22 breaths per minute and blood oxygen saturation at 88 percent with NRB face mask.A review of the GACH - ED notes dated July 30, 2015 at 2:50 p.m., indicated Resident 1's BP was 54/35 mmHg, PR 37 bpm, RR 28 bpm, and blood oxygen saturation was 26 percent. At 3:00 p.m., BP was 39/23 mmHg, PR 19 bpm, RR 14 breaths per minute and oxygen saturation was 16 percent. Resident 1's ?Do not Resuscitate (DNR)? status was confirmed, and because of possible pneumonia (lung infection) antibiotics were administered. The resident was placed on a bi- level positive airway pressure (Bipap machine to deliver pressurized oxygen) to ease the resident's breathing. The resident's head laceration which was approximately 10 cm with no bleeding was repaired. According to the notes the resident was not stable enough for a computerized axial tomography scan (x-ray procedure that produces cross-sectional images of the body). When the resident's blood pressure continued to drop, Levophed (medication to treat low blood pressure and heart failure) was started, but the resident's condition continued to deteriorate. Resident 1 expired at 3:06 p.m. (two hours and six minutes after the fall incident).A review of the facility's investigative notes dated August 4, 2015 at 5:40 p.m., indicated CNA 1 stated as she was waiting for someone to help her, she lifted Resident 1 up over the wheelchair. Then suddenly the corner of the sling strap ripped, and the resident slid out and fell to the floor. At the same time, the Invacare lift tipped over, and the resident ended up on top of the base legs of the Invacare lift. The notes indicated prior to the use of the Invacare lift sling, CNA 1 thought that the sling looked strong enough, and that she could not have controlled it from ripping.On September 7, 2015 at 1:20 p.m., during an interview the director of nursing (DON) stated she spoke to CNA 1, who was with Resident 1 when the resident fell out of the Invacare lift. The DON stated CNA 1 told her as she was waiting for assistance from another staff member she raised the lift to adjust the straps. When she raised the resident up and out of her wheelchair, one of the straps that held the sling broke off, resulting in the resident falling to the floor. The DON stated the resident was responsive, her vital signs were normal and she was not complaining of any pain. When the resident's blood oxygen saturation levels got too low, the facility called the EMS. The resident was then transferred to the GACH's emergency department. On September 7, 2015 at 1:35 p.m., the DON provided the Invacare lift machine and the administrator provided the same sling that was used during the incident involving Resident 1?s fall. During the inspection, the four slings straps were frayed. One of the straps was completely broken in half. The straps were observed with loose stitching, frayed and worn. On the same date a photo was taken of the same sling that was used to transfer Resident 1 on July 30, 2015, showing three connecting straps and one strap that was broken in half.On September 7, 2015 at 1:45 p.m., after showing the maintenance supervisor and the laundry staff person the same sling that was used during the incident, they both stated that the sling should have never been used. When asked why, they did not answer. The maintenance supervisor stated he usually asks the director of staff development (DSD) or the administrator for permission to discard frayed slings. The maintenance supervisor and the laundry staff were both asked why that particular frayed sling was not removed from use, they both did not answer. The maintenance supervisor and the laundry staff person were unable to provide documented evidence that the Invacare lift slings were inspected after laundering. On September 9, 2015 at 2:40 p.m., during a phone interview with CNA 1, she stated that on the morning of July 30, 2015, she obtained the mesh sling from the laundry room, in order to transfer Resident 1 to her bed. CNA 1 stated she hooked the sling straps to the Invacare lift, and while waiting for another staff member to help her, she lifted the resident up and out of her wheelchair. CNA 1 stated suddenly one of the sling straps broke off, and the resident hit her head on the machine and screamed "Help, help.? The resident denied having pain. CNA 1 stated the sling was old but she did not think it would rip.On November 12, 2015 at 1:05 p.m., during an interview the DSD, she stated that on June 2, 2015, an in-service was given to CNAs to provide two-staff assistance whenever the Invacare lift is used to transfer a resident. DSD stated two staff was needed to prevent injuries (skin tear) and falls, by one holding it, and the other guiding the sling. On November 12, 2015 at 1:29 p.m. during an interview, the administrator stated prior to the incident, the facility had no specific person or formal training to check and/or inspect the Invacare lift slings. There were no systems in place to identify the age of the slings. The new and old slings were mixed together. The tag attached to the same type of full body sling used in Resident 1's transfer indicated that bleached, torn, cut, frayed or broken slings are unsafe and could result in injury. The tag indicated to discard immediately.A review of the Invacare owner?s manual (revised December 4, 2008) indicated that after each laundering to inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. The tag attached to the same type of full body sling used in Resident 1?s transfer indicated that bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. The tag indicated to discard the slings immediately.The Certificate of Death dated August 21, 2015, indicated Resident 1?s immediate cause of death (final disease or condition resulting in death) was traumatic hemothorax (the presence of blood which may be from the chest wall, lung, heart, or great vessels that is in the pleural space [the thin covering that protects and cushions the lungs]. The death certificate indicated ?blunt force trauma? (injury caused by an impact) as the underlying cause of death. The Certificate of Death also indicated an autopsy (a highly specialized surgical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present) was performed.Resident 1?s autopsy report indicated fractures of ribs number 1 through 5 on the left frontal (anterior) part of the chest, and fracture of ribs number 1 through 10 on the left side of the back (posterior). The autopsy report also indicated the left side of the hemothorax (a collection of blood in the space between the chest wall and the lung) had 700 milliliters of fluid. There was hemorrhagic (bleeding) from the displaced rib fractures, left posterior ribs1 through 10, and left anterior ribs 1 through 5, with pleural lacerations (deep cuts or tears in the pleura [two-layers of tissue that protect and cushion the lungs]).These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were the proximate cause of death of the resident. |
| 910000033 |
DEL AMO GARDENS CARE CENTER |
910012603 |
A |
3-Oct-16 |
HQCC11 |
12482 |
F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On February 17, 2016, at 7 a.m., an unannounced visit was made to investigate an entity-self reported (ERI) regarding Resident 1 who walked out of the facility and had not returned. Based on observation, interview and record review, the facility failed to ensure a resident diagnosed with dementia, confusion, poor safety awareness, and exhibited elopement risk behaviors, as evidenced by trying to get in and out of the bed, looking for his family and verbalizing wanting to go home, did not elope from the facility by failing to: 1. Conduct an assessment of the resident's elopement risk behaviors upon admission to the facility, and periodically reviewing that assessment upon change of condition to ensure the safety of the resident. 2. Develop a care plan to address Resident 1's elopement risk behaviors. 3. Ensure all staff were aware of the resident's elopement risk and not only Registered nurse 2 (RN 2), and Certified Nursing Assistant 1(CNA 1). This deficient practice resulted in Resident 1 eloping from the facility undetected and missing for three consecutive days. Consequently, the police department found Resident 1, approximately 22 miles away from the facility. Resident 1 was then transferred to the general acute care hospital (GACH) where he was hospitalized for dehydration. Review of Resident 1's admission record indicated the resident was admitted to the facility on February 10, 2016, with diagnoses that included dementia without behavioral disturbances (a condition marked by memory disorders, personality changes, and impaired reasoning), chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breath), exacerbation (sudden worsening), asthma (a condition causing difficulty with breathing), benign prostate hypertrophy ([BPH] age-associated prostate gland enlargement that can cause urination difficulty, pain, and infections), and hypertension ([HTN] high blood pressure) and was assessed as having poor safety awareness, ambulatory, and was admitted to a room next to the side exit doors. On February 17, 2016, at 7 a.m., an unannounced visit was made to the facility to investigate an entity-reported incident (ERI) regarding Resident 1 who walked out of the facility and was still missing During an interview on February 17, 2016, at 7:50 a.m., Employee 1 (DON) stated Resident 1 was found in another city by the police and was transferred to the acute care hospital (GACH) for an evaluation. During an interview with Employee 2 (Administrator) on 2/17/16, at 7 a.m. he stated the facility's surveillance cameras recorded Resident 1 leaving the side exit doors adjacent to his room around 4:57 p.m. on 2/14/16. The resident eloped and could not be found by the facility staff. The resident was found on the ground, three days later by the police department in another city (approximately 22 miles away from the facility). He was taken to the acute hospital and was diagnosed with dehydration and was administered Intravenous ([IV] fluids. On the day of the elopement, the facility documented and notified the family to visit with the resident because he was trying to get in and out of the bed and wheelchair, was looking for his family, and verbalized he wanted to go home. A review of the care plan dated February 11, 2016, indicated Resident 1 was at risk for fall/injury related to unsteady gait, poor safety awareness, confusion, dementia, COPD, asthma, and generalized weakness. The listed care plan goal indicated the resident would be free from injuries. The approaches included to assess the resident for safety awareness and to determine his safety needs, to maintain a safe and hazard free environment, and to monitor the resident's alarm. The comprehensive care plan did not address or include interventions or goals related to the resident?s elopement behaviors to reduce the risk for injuries. A review of Resident 1's clinical record did not contain documented evidence Resident 1?s elopement risk factors were assessed and care planned to reduce the risk for injuries. A review of the daily licensed nurses notes dated February 14, 2016, for the 3 p.m., to 11 p.m., shift, indicated Resident 1 was confused, forgetful to person, place, and time, but was able to recognize his family members. The licensed nurses documented, although the resident was provided with reality awareness after he verbalized he wanted to go home to look for his family, he was still trying to get out of his bed and wheelchair. A review of the licensed nurse's notes dated February 14, 2016, at 4 p.m., indicated RN 2 called the family about the resident's behavior and requested them to come to the facility to be with the resident. At 5 p.m., the licensed nurse documented the resident stayed in his room, and was closely monitored. At 5:30 p.m., Family Member 1 informed the nurses she could not find Resident 1. It was further documented that the staff searched the facility and the parameters but still were unable to locate the resident. At 5:40 p.m., the police department was called to report that Resident 1 was missing. A review of the fire department emergency medical services (EMS) report form dated February 16, 2016, indicated the paramedics were called at 8:57 p.m., because Resident 1 was found lying on the ground. According to this report the resident was confused and had a blood sugar level of 268 milligram per deciliter (mg dl) (normal blood sugar is below 110 mg dl to 140). The resident was transferred to the acute hospital for further evaluation. A review of Resident 1's history and physical from the acute hospital, dated February 18, 2016, indicated Resident 1, who had an advanced dementia, and resided at a skilled nursing, facility was brought to the emergency room (ED) by the police after he was found wondering out in the streets. The resident was reported missing for three days after he eloped on 2/14/16. According to the acute hospital laboratory report , the resident had a high sodium level of 148 milimole per liter, (mmol/L - unit in medicine for measuring concentrations of substances in the blood) (normal range 135 - 147 mmol/L), had renal failure with an elevated blood urea nitrogen (BUN - test is done to see how well your kidneys are working) of 69 milligram per deciliter (mg/dl) (normal range 9- 23 mg/dl), a Creatinine level which measured 1.6 (mg/dl) (normal range 0.70 - 1.30 mg/dl), and a white blood cells count of 14.4 cubic milliliter (k/ul) (normal range 4.3 -10.0 k/ul). According to the ED physician's note Resident 1 had an altered mental status (a disruption in brain that causes a change in behavior) likely secondary to toxic metabolic encephalopathy (exposure to toxic substances) brought on by dehydration. The resident was hydrated with Normal Saline (is the name for the 0.9% strength of sodium chloride (salt) solution in water), with daily blood testing to monitor the electrolyte levels. On February 18, 2016, the resident was discharged to another facility. On February 17, 2016 at 2:30 p.m., during a phone interview certified nursing assistant 1 (CNA 1), who was assigned to the resident on the day he went missing, stated Resident 1 was ambulatory without using his walker, was very confused and always asked the staff ?Where is his family and where is he going?? On February 14, 2016, when CNA 1 started her shift the resident was brought to the nurse's station, and seated in his wheelchair because he was getting in and out of his chair. CNA 1 stated Family Member 1 came to the facility, but could not locate the resident so she alerted the staff. CNA 1 stated Family Member 1 was saying ?you guys have to look for him; he does not know what he is doing." RN 1 then called the police department and searched the parameters, but failed to locate the resident. CNA 1 stated the facility used a chair alarm to alert the staff for confused residents and the door the resident exited from had an alarm. CNA 1 could not understand why no one heard the door alarm and why the staff did not hear the resident's chair alarm. CNA 1 confirmed the resident could not have protected and supported himself without staff's assistance. On February 17, 2016 at 4 p.m., the DON stated the facility had an elopement risk assessment but did not use it because they do not admit residents with an elopement behavior. The DON stated if there was an elopement problem the facility would use 72 hour charting, nurse?s notes, and the communication book to monitor the resident ' s behavior. The DON identified any resident's elopement risk factor as one or two attempts at leaving the facility, and or standing by the exit doors. When asked if diagnoses of confusion/dementia, and ambulating without any assistive devices would increase the elopement risks, she stated that it was a probability. The DON could not find a care plan addressing the resident's elopement risk behaviors prior to leaving the facility. On February 26, 2016 at 10:28 a.m., during a phone interview with Resident 1's family member, it was stated the resident was very confused, and needed constant monitoring. The family member stated the resident had wondered from their home on couple of occasions, which was typical for dementia patients. The family member stated the facility was informed about the resident?s confusion and could not understand why the staff did not communicate that information to each other. The family member stated even though the facility may have not been aware of the fact the resident had eloped in the past, the facility should have known that dementia patients are confused and tend to wander. The family member stated it should have given the facility staff a clue when they placed an alarm on the resident, and when they called the family to sit with the resident. The family member further stated that on February 14, 2016, between 1 p.m., to 2 p.m., he received a call from the facility begging them to come back because the resident was very agitated and was getting in and out of his chair trying to look for family. On March 2, 2016, at 1:20 p.m., during a phone interview with RN 2, who was at the facility on the day of Resident 1's elopement, described Resident 1 as confused, who constantly got in and out of his bed/chair, and who wanted to find his family. RN 2 stated she called the resident's family members to visit with the resident because he was very agitated and the agitation could have been relieved by the family visit, but when his wife arrived, she could not find him. RN 2 stated she alerted the staff and called the police department. RN 2 was asked if a dementia, confused, ambulatory resident was ever at risk of leaving the facility, she stated she had never thought about that. RN 2 stated the only people aware of the resident's behavior on the day of elopement were the facility's charge nurse, herself, and CNA 1. RN 2 confirmed she did not alert all staff about his behavior, did not care plan the resident ' s behavior in order to safeguard him, and did not hear the resident's tab alarm and or the door alarm before the resident left the building. A review of the facility's policy on Elopement and Wandering dated February 14, 2011, indicated that it was the policy of the facility to assess the residents at risk for elopement on an individual basis, and all residents who are at risk for harm because of wandering behavior will have an assessment and care plan that addresses the issue. The facility failed to: 1. Conduct an assessment of the resident's elopement risk behaviors upon admission to the facility, and periodically reviewing that assessment upon change of condition to ensure the safety of the resident. 2. Develop a care plan to address Resident 1's elopement risk behaviors. 3. Ensure all staff were aware of the resident's elopement risk and not only Registered nurse 2 (RN 2), and Certified Nursing Assistant 1(CNA 1). 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. |
| 940000017 |
DOWNEY CARE CENTER |
940008718 |
AA |
24-Jan-12 |
ZFSX11 |
12871 |
72311. Nursing Service - General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon 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. On 4/1/10, at 3:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1, who was transferred to an acute hospital on 3/10/10, due to a high blood sugar (glucose) level and expired on 3/15/10. Based on interview and record review, the facility failed to identify Patient 1?s care needs based upon a continuing assessment with input from health professionals involved in the patient?s care by failing to: 1. Inform the attending physician that upon readmission from an acute care hospitalization, there was no order for Patient 1 to monitor routinely the blood glucose levels, when the patient was known to the facility (had four previous admissions) to have diabetes mellitus (condition characterized by abnormally high glucose levels in the blood), used subcutaneous (SQ - under the skin) injections of insulin (medication to lower the blood glucose level), and had routine finger-stick (a device used to prick the skin and obtain drops of blood for testing) blood sugar levels checked (with the use of a glucose monitor or glucometer) at least daily. 2. Follow up with the attending physician and the visiting Physician?s Assistant (PA), to assess for the need of routine monitoring of the blood glucose levels. As a result, Patient 1 developed diabetic ketoacidosis (diabetic coma), became brain dead and died on 3/15/10.According to the American Diabetes Association (www.diabetes.org/), blood sugar monitoring is the main tool to check diabetes control. The target blood glucose range in plasma before meals is from 70 to 130 milligrams per deciliters (mg/dl) and the target range after meals is less that 180 mg/dl. The American Diabetes Association further defines diabetic ketoacidosis (DKA) as a serious condition that can lead to diabetic coma (passing out for a long time) or even death. When the cells do not get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood when there is not enough insulin. High levels of ketones can poison the body, causing DKA. DKA can be prevented by learning the warning signs and checking urine and blood sugar levels regularly. Early warning signs are thirst or a very dry mouth, frequent urination, high blood glucose levels and high levels of ketones in the urine.A review of clinical record revealed Patient 1 was admitted to the facility a total of five times. The first admission to the facility was from 4/23/09 to 5/19/09. The patient was admitted from Acute Care Hospital 1, where she had been from 4/20/09 to 4/23/09, and had diagnoses of diabetes mellitus. On 5/1/09, the Attending Physician ordered blood sugar monitoring before meals and at night with Regular Insulin coverage per sliding scale (instructions for administering insulin dosages based on specific blood glucose readings). The patient was discharged home 5/19/09. The second admission to facility was from 9/18/09 to 9/26/09. The patient was admitted from home with diagnoses of diabetes mellitus and an order for Lantus Insulin 30 units SQ every night. The patient was discharged home 9/26/09, with the insulin order. The third admission to the facility was from 10/27/ 09 to 11/13/09. The patient was admitted from home with diagnoses of diabetes mellitus and orders for Lantus insulin 10 units twice daily before meals, blood sugar checks twice daily before meals and to call the physician if the blood glucose was below 60 mg/dl or above 300 mg/dl. The patient was discharged home on 11/13/09, with the insulin order. The fourth admission to the facility was from 12/9/09 to 12/23/09. The patient was admitted from Acute Care Hospital 1, where she had been from 12/6/09 to 12/09/09, had diagnoses of diabetes mellitus Type II and order for Lantus Insulin 10 units SQ daily. The patient went home 12/23/09, with the insulin order. The fifth and last admission to the facility was from 2/9/10 to 3/10/10. The patient was admitted from Acute Care Hospital 1, where she had been from 2/6/10 to 2/9/10, due to recurrrent urinary tract infection with nausea and vomiting, and dehydration. According to the transfers documents including the medication administration record (MAR) from the Acute Care Hosptial 1, the patient was having blood glucose checks before meals with Regular insulin coverage per sliding scale every day of the patient?s hospitalization including the day of transfer, 2/9/10. A review of the facility?s admission record revealed the patient was a 79 years-old female admitted on 2/9/10, at 6 p.m., with diagnoses that included diabetes mellitus, urinary tract infection, dementia and depression. The admitting orders did not include medications for diabetes mellitus (oral or SQ) and no orders to monitor blood glucose levels.On 2/10/10, Physician?s Assistant 1 (PA 1) evaluated the patient and ordered blood laboratory tests, complete blood count (CBC), pre-albumin level, and basic metabolic panel (BMP). The results dated 2/11/10, included glucose plasma value of 86 mg/dl with a reference range from 85 to 125 mg/dl. A plan of care dated 2/11/10, developed for the patient?s risk for hyperglicemia (high blood glucose level) or hypoglycemia (too low blood glucose level) related to diabetes, did not have a measurable goal stated, and the interventions included to monitor finger stick blood sugar (FSBS) per physician?s orders and to notify the physician of any significant results, however, there was no physician?s order to perform blood sugar tests. The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 2/22/10, indicated the patient had short and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making, required limited assistance with transfers and bed mobility, did not walk, and required extensive assistance with dressing, toilet use and personal hygiene. The patient was incontinent of both bowel and bladder functions, had diabetes mellitus disease and urinary tract infection in the last 30 days. Further record review revealed the Attending Physician visited the patient on 2/13/10, and PA 1 visited the patient three times, on 2/10/10, 2/16/10 and 3/4/10. However, their documentation did not address the lack of routine blood glucose testing and lack of blood glucose values after 2/11/10, to determine diabetes control. A review of the nursing and interdisciplinary team notes revealed that from 2/11/10 to 3/10/11, a total of 29 days, there was no documented evidence nursing staff brought to the attention of Attending Physician and PA 1 the lack of order to routinely monitor the patient?s blood glucose levels to ensure adequate blood sugar levels and prevent complications from uncontrolled diabetes. According to a nursing note dated 3/10/10, timed at 9:05 a.m., the patient was noted in bed with Altered Level of Consciousness, unable to obtain vital signs and pulse oxymetry (diagnostic test that measures the amount of oxygen in a person's blood with the use of a pulse oxymeter, applied on the finger, toe, or earlobe. The device contains a sensor that is connected to a machine that displays the oxygen saturation and pulse rate), and the respiration was shallow. The blood sugar was checked and the reading was Hi (which per glucometer manual indicate a reading above 500 mg/dl). 911 (paramedics) was called. At 9:10 a.m., the paramedics arrived and transported the patient to Acute Care Hospital 1 at 9:15 a.m.According to Acute Care Hospital 1 Emergency Room (ER) records dated 3/10/10, a laboratory test done at 10 a.m., revealed the blood glucose was 1,229 mg/dl. The ER Admission record indicated the ER physician documented, ?The nursing home was contacted and they stated they have been unable to check the patient's blood sugars. They cannot do it unless they get a doctor?s order to do it per information relayed to me by my nurse when she called.? The patient was placed on an endotraqueal tube (breathing tube). The History and Physical dated 3/10/10, documented in the impression diagnosis, diabetic ketoacidosis, urinary tract infection, sepsis (severe illness in which the bloodstream is overwhelmed by bacteria), Altered Level of Consciousness, acute renal failure, and diabetes mellitus. A Neurology Consultation dated 3/12/10, documented the patient was deeply comatose clinically consistent with brain death. A Discharge Summary dated 3/15/10 (expiration date), indicated the patient neurologically remained unresponsive throughout the course of the hospitalization, was pronounced brain dead by neurology, the finding were related to the patient?s family who decided to extubate (remove the breathing tube). The patient was pronounced dead on 3/15/10, at 7:55 p.m. The diagnoses included brain death, diabetic ketoacidosis, septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure), and urosepsis (infection ranging from urinary tract infection to generalized sepsis). According to the Certificate of Death, the date of death was 3/15/10, at 7:55 p.m., with the cause of death indicating septic shock, urosepsis, diabetic ketoacidocis, and diabetes mellitus type II. On 5/5/10, at 1:20 p.m., during an interview, the Director of Nursing stated the patient was readmitted without an order for insulin and, ?If the physician does not order the blood sugar to be checked we will not check it." The Director of Nursing further stated that on the day the patient was transferred the blood sugar was checked because it was an emergency. The Director of Nursing explained the patient had multiple admissions to facility because the family brought her to the facility each time the patient?s husband, who was the caregiver, was hospitalized. On 5/5/10, at 2:55 p.m., during another interview, the Director of Nursing stated both the admitting nurse and the physician are both responsible to make sure all orders are current and correct.On 7/25/11, at 1:30 p.m., an interview was conducted with Registered Nurse 1 (RN 1), the admitting nurse on the patient?s last admission to the facility dated 2/9/10. RN 1 stated that he knew the patient from previous admissions and that the patient was diabetic and had insulin per sliding scale, however, the transferring hospital stopped the order upon transfer. RN 1 further stated he did clarify it with the nurse (did not know the name) from the hospital but forgot to document it. RN 1 explained that the Attending Physician had two PAs working for him, PA 1 and PA 2. RN 1 faxed all the admission orders written in the transfer documents to the Attending Physician?s office and if there were any changes PA 2, on duty that evening, would call him. However, no changes to the admission orders were made.On 7/25/11, at 2:45 p.m., during an interview with PA 2, she acknowledged being on call on the evening the patient was admitted, however, she never saw the patient. PA 2 stated she verified the orders written by the acute hospital discharging physician and did not make any changes. Multiple attempts were made to interview Attending Physician and PA 1 but failed, since they were no longer associated with the facility or for Acute Care Hospital 1 and their telephone numbers are no longer current. The facility failed to identify Patient 1?s care needs based upon a continuing assessment with input from health professionals involved in the patient?s care by failing to: 1. Inform the attending physician that upon re-admission from an acute care hospitalization, there was no order for Patient 1 to monitor routinely the blood glucose levels, when the patient was known to the facility to have diabetes mellitus, had used SQ injections of insulin, and had routine finger-stick blood sugar levels checked at least daily. 2. Follow up with the attending physician and the visiting PA, to assess for the need of routine monitoring of the blood glucose levels. As a result, Patient 1 developed diabetic ketocidosis (diabetic coma), became brain dead and died on 3/15/10.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 direct proximate cause of Patient 1's death. |
| 940000017 |
DOWNEY CARE CENTER |
940011403 |
B |
17-Apr-15 |
ZI5D11 |
3997 |
F-323 CFR 843.25(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 accident. On 4/6/15, an unannounced visit was made to the facility to conduct a standard recertification survey which was completed on 4/10/15.Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free from hazards as was possible by failing to: Provide safe hot water temperatures between 105 and 120 degrees Fahrenheit (ΓΈF) according to the facility?s policy. The hot water temperature in bathroom hand washing sinks was above 120 ΓΈF placing the residents at risk of burn and scalding.During the Environmental inspection tour of the facility on 4/6/15, at 9:15 a.m., Employee 1 in the presence of the evaluator measured the temperature of the hot water delivered to the plumbing fixtures (hand-washing sinks) used by the residents in the residents? bathroom.The following unsafe hot water temperature readings were measured in the resident?s hand washing sinks located in the residents? bathrooms near the East Nurses? Station area of the facility:1. Bathroom located inside Room 27 =133.7 ΓΈF. 2. Bathroom between Rooms 28 and 30 = 130.8 ΓΈF. 3. Bathroom between Rooms 32 and 34 = 135.0 ΓΈF. 4. Bathroom between Rooms 36 and 37= 136.0 ΓΈF. According to the U.S. Consumer Product Safety Commission (http://www.cpsc.gov/), most adults will suffer third-degree burns if exposed to 130 ΓΈF for 30 seconds. A temperature of 120 ΓΈF 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 ΓΈF to prevent scalding, injuries, and death in elderly. There were a total of 17 residents in the affected rooms and five of 17 residents were able to use the hand washing sink independently. The other twelve residents required assistance by staff to use the hand washing sinks. Two of the five residents were also diagnosed with cognitive impairment. The unsafe hot water temperature placed the residents at risk for burns, scalding and tissue damage. On 4/6/15, at 11:30 a.m., during an interview, Employee 1stated he was not sure if the high hot water 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). On the same date, at 11:45 a.m., Employee 1stated the facility will contact the plumbing company to evaluate and repair the unsafe hot water temperature in the affected resident bathrooms. A review of Water Temperature Log revealed that the temperatures measured prior to 4/6/15 were below 120 ΓΈF. A further review of the temperature log indicated that the last temperature check on the affected bathrooms was taken between 2/23/15 and 3/11/15. The facility's policy and procedure indicated that hot water temperature in resident bathrooms should be between105 -120 ΓΈF. During an interview on 4/6/15, at 4:25 p.m., the administrator stated that the facility would ensure that the hot water temperatures in affected residents? bathrooms are below 120 degrees F.The review of the plumber's invoice dated 4/6/15, indicated the boiler temperature valve was evaluated and adjusted to lower the hot water temperature of between 110 - 117 ΓΈF. The facility failed to ensure that the resident environment remained as free from hazards as was possible by failing to: Provide safe hot water temperatures between 105 and 120 degrees Fahrenheit (ΓΈF) according to the facility?s policy. The hot water temperature in bathroom hand washing sinks was above 120 ΓΈF placing 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. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940011481 |
B |
20-May-15 |
UTJL11 |
4781 |
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).F- 226 ? 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 the facility is doing all that is within its control to prevent occurrences. On 11/26/13 at 11:30 am, an unannounced visit was made to the facility regarding a complaint alleging resident rights. Based on interview and record review, the facility failed to implement established abuse policy by failing to report an incident of abuse to the Department of Public Health and the Ombudsman. On 11/26/13 at 11:34, during an interview Resident 1 stated on November 6, 2013 at 5 pm in the dining room, he witnessed his roommate, Resident 3; hit Resident 2 in the head. Resident 1 recalled when he had an altercation in the facility he was sent out for week and a half. Resident 1 said he was told he would have to leave if he had another altercation. Resident 1 said that Resident 3 was never sent out of the facility.Resident 2's medical recordindicated Resident 2 is 55 years old, and was admitted to the facility on 2/9/13. Her admitting diagnoses consisted of CVA with Left hemiparesis, symptoms involving head and neck, asphasia, myocardial infarction, GERD, depressive disorder, hypertension and diabetes insulin dependent. A review of her quarterly minimum data set dated 11/22/13, revealed Resident 2 has minimum difficulty hearing without the use of a hearing aid. Her speech is clear, she is understood, she understands, and her vision is impaired without the use of eyeglasses. There was no documentation in the nurses? notes or the social service notes as to the incident described by Resident 1. Resident 3?s medical recordindicated Resident 3 is 66 years old, and was admitted to the facility on 2/8/13. His admitting diagnoses consisted of: end stage renal disease, liver abscess and sequelae of chronic liver disease, hepatic coma, chronic liver disease and cirrhosis of liver without mention of alcohol, hypertension, schizophrenia, and a history of ETOH abuse.Resident 3?s quarterly MDS dated 11/21/13 revealed he has adequate hearing, clear speech, understood, understands, and has adequate vision. Further record review revealed there was a care plan, and nurses? notes regarding the incident.On 11/26/13 at 12:15 pm, during an interview with Resident 2, she explained how she was having dinner in the dining room when Resident 3 started pushing her wheelchair. She said she told Resident 3, to stop pushing her wheelchair, but he didn?t, so she started swinging at him from over her head as he was behind her. Resident 2 said she hit Resident 3 in the nose, and that?s when Resident 3 came around in front of her and hit her in her left eye. Resident 2 said she did not feel safe in the facility, and wanted to relocate to a facility closer to her boyfriend. On 11/26/13 at 12:30 pm, during an interview with the administrator, he said that the facility does not report all allegations of abuse, and this incident was not reported. On 11/26/13 at 12:50 pm during an interview with Resident 3 through an interpreter, he said that Resident 2 crashed into him very hard in the dining room, while he was eating his dinner. Resident 3 explained how he took his leg with his hand to swing it to kick Resident 2. When Resident 3 was confronted with the nurses? notes, he admitted Resident 2 was blocking his way; he got frustrated, and hit her. On 11/26/13 at 1:30 pm, during a review of the facility?s policy on abuse, it read, ?It is the policy of the facility to protect its residents from acts of abuse?? Further investigation revealed that the facility will conduct; ?an internal investigation in addition to notifying within 24 hours the Department of Public Health, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, notify in writing all the appropriate agencies.?The facility failed to implement established abuse policies and procedures by failing to report the abuse incident to the Department of Public Health and the ombudsman. The above violation had a direct or immediate relationship to the health, safety or security of Resident 2. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940012355 |
A |
28-Jun-16 |
E1ZX11 |
9237 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 5/20/16, alleging that a resident (Resident 1) was found with the lower part of the body on the floor and the upper body stuck between side rail and bed. Resident 1 sustained discoloration to the left side of the neck and with purple discoloration skin tear to right posterior arm. The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding restraints. 2. Failure to implement the IDT recommendations to prevent reoccurrence of entrapment. 3. Failure to ensure Residents 1, 2, 3, 4, and 5?s beds no longer had gaps between the mattresses and side rails after Resident1?s incident occurred. These facility's failures resulted in Resident 1 being entrapped between the mattress and side rails sustaining a neck bruise/discoloration and a skin tear to the right forearm. These failures had the potential to affect four other residents (Residents 2, 3, 4, and 5), who had ill-fitting LAL mattresses with side rails up creating a gap for entrapment. During an unannounced visit on 5/31/16 at 12:15 p.m., an entity reported incident (ERI) was initially investigated. Resident 1 was observed in a wheelchair, eating in the dining room. There was a reddish discoloration on the left side of Resident 1's neck. A review of a nurse's progress note, dated 5/18/16, and timed at 8 a.m., indicated Resident 1 was found with the lower part of his body on the floor and the upper body stuck between the side rail and bed. According to the note, Resident 1 had a discoloration to the left side of the neck and a skin tear to the right posterior (of or nearer the rear or hind end) forearm. A review of the paramedic's sheet, dated 5/18/16 indicated Resident 1 was transferred to a GACH for abnormal labs and a mechanical fall. Resident 1, who had dementia (brain diseases that cause a long term and often gradual decrease in the ability to think and remember) and was legally blind, was found on 5/18/16, by the facility's bed maker on her routine tour looking for unmade beds, with his head entrapped between the side rail and the LAL mattress, while his body dangled on the floor. The bed maker stated Resident 1, who usually made noises when his name was called, did not respond when she called out his name. A review of Resident 1's Record of Admission face sheet indicated Resident 1 was an 81 year-old male who was admitted to the facility on XXXXXXX and recently re-admitted on XXXXXXX Resident 1's diagnoses included dementia, asthma (long term inflammatory disease of the airways of the lungs), diabetes mellitus (having high blood sugar), legally blind, hypertension (high blood pressure) and a healing Stage III pressure sore (full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present due to pressure) on the coccyx (tailbone of the buttocks area). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/13/16, indicated Resident 1 had difficulty making himself understood and understanding others, and was moderately impaired in skills for decision-making with memory problems. According to the MDS, Resident 1 required extensive assistance in all activities of daily living. On 5/31/16 at 12:48 p.m., during a general tour of the facility and a concurrent interview with the maintenance supervisor, Resident 1's bed was observed with the side rails up and an ill-fitting LAL mattress that did not fit the bed frame. The maintenance supervisor measured the space between the mattress and the side rails which was 2 Β« inches on the right side facing the wall, and 3 inches on the left side. When hand pressure was applied to the mattress by the maintenance supervisor the spacing/gap increased in size. On 5/31/16 at 1:05 p.m., a certified nurse assistant (CNA 1) stated she was working with another resident on the day of the incident (5/18/16), when she was called to Resident 1's room, by the bed maker. CNA 1 stated Resident 1 was seen stuck between the side rail and mattress. CNA 1 stated Resident 1 was not screaming or calling out, as he would usually do when she entered the room. A review of an Interdisciplinary Team (IDT) note for Resident 1, dated 5/18/16, after the entrapment incident, indicated the plan for the resident to prevent another incident was to use a low bed without side rails, floor pads, and a bed alarm at all times while Resident 1 was in bed .However, on 6/1/16, at approximately 12:15 p.m., Resident 1 was seen in the same low bed with the ill-fitting LAL mattress, with the side rails up resulting in a gap between the side rails and the LAL mattress. A review of Resident 1's physician's orders, dated 5/25/16, upon the resident's return to the facility from the GACH, indicated orders for a low bed, floor pads and half side rails to be up. The physician's orders, dated 5/25/16, did not include bed alarms, as stipulated in the IDT's plan to prevent entrapment for Resident 1. At 1:10 p.m., on 5/31/16, during an interview, the bed maker stated that on the day of the incident, 5/18/16, she saw the back of Resident 1's stuck head between the railing and the bed, when she was looking for beds and she called for help. A review of the bed maker's declaration, dated 6/1/16, and timed at 1:41 p.m., indicated she found Resident 1 in his bed with his head stuck in between the mattress and bed railing. The bed maker documented that Resident 1 was facing the wall and his body was on the floor. During a tour of the facility on 6/1/16, between the hours of 11:30 a.m. and 12 p.m., Resident 1 was observed lying in the same low bed he had been entrapped in on 5/18/16, with the ill-fitting LAL mattress and the side rails up. Resident 1 was observed to have a red discoloration on his left neck. There was no bed alarm on Resident 1's bed. Resident 1's bed alarm and discontinuance of the half side rails were not implemented, as stipulated in the IDT's plan, dated 5/18/16, to prevent another entrapment incident. Residents 2, 3, 4, and 5's beds were also observed with large gaps between the side rails and mattresses. A review of the facility's undated policy titled, "Restraints Devices, Physical," indicated under Assessment Guidelines, included functional ability and potential to injure self and others should be assessed and the staff approaches included to list observation for risks and complications. There was no documented evidence these areas were assessed for Resident 1, especially after being entrapped. According to an article titled, "FDA [Food and Drug Administration] Issues Guidance on Hospital Bed Design to Reduce Patient Entrapment,? dated 3/9/06, the FDA indicated there were approximately 691 entrapment reports over a period of 21 years from 1/1/85 to 1/1/06. In these reports, 413 people died, 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. The entrapment events were a result of openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and the head or foot boards. The article indicated elderly patients in hospitals and nursing homes, especially those who are frail, confused, restless, or who have uncontrollable body movement, are most vulnerable to entrapment." A review of an article titled, "Low Air Loss (LAL) Therapy," dated 12/2001, indicated most LAL systems do an excellent job of equalizing pressures, but most are simply not made to withstand a user?s concentrated body weight in any one spot on the surface. The edge of the mattress can collapse when a user rolls or shifts sideways, which when the side rails are up, this collapse can leave a dangerous gap beneath the side rail. Such gaps pose an entrapment danger, as they have caused several suffocation deaths when the user's head has become entangled under the rail at www.spanamerica.com/.../download.php?...easyairwh. The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding restraints. 2. Failure to implement the IDT recommendations to prevent reoccurrence of entrapment. 3. Failure to ensure Residents 1, 2, 3, 4, and 5?s bed no longer had the gap between the mattress and side rail after the incident occurred. 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. |
| 940000040 |
DEL RIO CONVALESCENT CENTER |
940012488 |
B |
4-Aug-16 |
CWU311 |
3412 |
?1418.21. (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations in the facility: (A) An area accessible and visible to members of the public. (B) An area used for employee breaks. (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. On 7/19/16 at 7:30 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. Based on observation, interview, and record review, the facility failed to implement its policy and procedure to post the most recent overall star rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) by failing to: 1. Post the information in the following location: a. An area used for communal activities including a dining area or activities room. On 7/19/16 to 7/26/16, during observations of the facility, the evaluator noted that the facility's overall star rating information was only posted in the facility's lobby and in the employee lounge. The posting indicated the facility had "three stars," there was no overall star rating information posted in the facility's dining area or activities room. According to the facility's undated policy and procedure titled, "Star Rating (5 Star Rating)," it was the policy of the facility to ensure the public was informed about the facility's current star rating according to the California regulations. The policy indicated that the star rating should be posted on the following locations: lobby, dining/activity area, and nursing (employee) lounge. On 7/21/16, at 12 p.m., the administrator provided a copy of an updated print-out of the facility's STAR rating from CMS. The print-out indicated the facility had "one star." On 7/21/16, at 12:30 p.m., during an interview, the director of nursing (DON) stated she was not aware that the current one star rating information was supposed to be posted in three areas. The DON stated she thought it was supposed to be posted only in the facility's lobby and nursing (employee) lounge. On 7/21/16, at 12:40 p.m., during an interview, the administrator stated the facility received a letter from CMS indicating the facility's overall star rating was one (1) star for June 2016. The administrator stated the three (3) star rating for the year 2015 information was posted in the facility's lobby and nursing (employee) lounge, because the facility's staff failed to update and post the current information. The administrator stated the facility did not post the current one star rating in one more area, such as the facility's dining area or activities room as indicated in the facility's policy. The facility failed to implement its policy and procedure to post the most recent overall star rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) by failing to: 1. Post the information in the following location: a. An area used for communal activities including a dining area or activities room. This violation had a direct or immediate relationship to the health, safety, or security of patient. |
| 940000057 |
DOWNEY COMMUNITY HEALTH CENTER |
940012949 |
A |
4-Feb-17 |
2YOC11 |
19968 |
F441
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.
The facility failed to establish and maintain an infection control program for the protection of residents, staff, and visitors including, but not limited to:
1. Following its policy regarding contact isolation for MRSA ([Methicillin-resistant Staphylococcus aureus] a contagious and antibiotic-resistant staph bacteria that leads to potentially dangerous infection).
2. Maintaining an infection control program that tracked and performed surveillance of flu infections and vaccination.
3. Adhering to the Los Angeles County/Department of Public Health letter, dated 8/10/16, regarding staff that refused the influenza ([Flu] an infectious disease caused by an influenza virus) vaccination must wear a face mask.
4. Ensuring the staff, who refused the influenza vaccination, wore face mask properly.
These failures had the potential in cross contamination of MRSA to all residents, staff, and visitors. In addition, due to the facility's staff failure to receive the Flu vaccine while continuing to work without either wearing a face mask, or wearing it improperly, put the large population of geriatric (an old person, especially one receiving special care) residents at risk for the Flu infection.
a. On 12/15/16, at 8:31 a.m., a certified nurse assistant (CNA 1) was observed entering a randomly selected (RSR 32) resident's room while caring for RSR 32 inside the room without wearing gloves. Outside RSR 32's room door displayed an orange contact isolation precaution sign on the wall that indicated, "Contact Precautions? in addition to Standard precautions (minimum infection prevention practices used in the care of all patients, at all times, which included hand hygiene and the use of personal protective equipment [PPEs], such as gloves). Visitors - Report to the nurses' station before entering room.
The sign indicated:
1. Wash hands.
2. Gowns are indicated if soiling is likely.
3. Gloves are indicated, when touching infective material. Change frequently after contact.
4. Bag linen to prevent contamination of self, environment, or outside of bag.
5. Discard infectious trash to prevent contamination of self, environment or outside of bag.
6. Wash hands.
On 12/15/16 at 8:33 a.m., CNA 1 was observed walking from the contact isolation room and went directly across the hall into another resident's room, without washing her hands. There was no cart outside of RSR 32's room for PPEs availability for the facility's staff and visitors.
At 8:34 a.m., on 12/15/16, during an interview, a licensed vocational nurse (LVN 6) was asked which resident in the contact isolation room was on contact isolation. LVN 6 stated, ?The resident in Bed A (RSR 32)." LVN 6 was asked if the staff should wash their hands after exiting the contact isolation room and LVN 6 replied, ?Yes, and they should wear a gown and gloves. I will get a cart set up now."
At 8:39 a.m., on 12/15/16, during an interview, CNA 1, who was caring for Resident 32 while on contact isolation, was asked did she wash her hands after leaving the room. CNA 1 stated, ?I was only there for a moment. No, I did not wash my hands."
At 8:48 a.m., on 12/15/16, during an interview, the DON, who was also the facility's infection control nurse, was asked about contact isolation precautions. The DON stated, ?There was no need to wash hands in the contact isolation room, because the resident had MRSA of the left hip wound and the wound is covered."
At 8:50 a.m., on 12/15/16, during an interview, a physician (Physician 2) in the facility was asked how MRSA contact isolation should be handled. Physician 2 stated, "It is best practice to wash hands and wear gloves / gowns when providing care to the resident, and most importantly after exiting the resident?s room to prevent the spread of the infection."
While interviewing Physician 2, on 12/15/16 at 8:52 a.m., CNA 12 was observed entering the contact isolation room and exiting the room at 8:57 a.m., without washing her hands.
At 8:58 a.m., on 12/15/16, during an interview, LVN 5, who was the facility's treatment nurse, was asked about the importance of washing hands in an isolation room. LVN 5 stated, ?When we enter and when we leave the isolation room, we always wash our hands."
However, minutes later on 12/15/16, at 9:03 a.m., LVN 5 was observed entering the contact isolation room and did not wash his hands upon entering and began to care for one of the residents in the contact isolation room.
At 9:04 a.m., on 12/15/16, a cart with PPEs was placed outside the contact isolation room, which consisted of yellow disposable gowns and a box of gloves.
On 12/15/16 at 10:17 a.m., during a face-to-face interview, the facility's medical director (Physician 1) stated, "MRSA is a common skin infection that can happen in nursing homes. If a resident has MRSA, it is important for us to use universal precautions (preventing transmission of infections), like handwashing and use of gloves, because MRSA can live on a surface for a long time and it is important to practice universal precautions to prevent an outbreak."
At 10:45 a.m., on 12/15/16, the administrator and the DON stated, "The staff does not have to wash their hands, only if they give direct care to the MRSA resident in the contact isolation room. It says it in our policy." The DON, the facility's infection control nurse, was asked for the policy that stipulated handwashing was not required for contact isolation, but it was not provided.
A review of Resident 32's Admission Face Sheet indicated Resident 32 was originally admitted to the facility on XXXXXXX10, and last readmitted on XXXXXXX13. Resident 32's admission diagnoses included Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), essential hypertension (abnormally high blood pressure), chronic obstructive pulmonary disease ([COPD] a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing, and type II diabetes (a long term metabolic disorder that is characterized by high blood sugar).
A review of Resident 32's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/18/16, indicated Resident 32 had no memory problems, no impairment with decision-making and was able to make needs known, and understood others. According to the MDS, Resident 32 was assessed as being dependent (requiring assistance) with bed mobility, transferring, locomotion on and off the unit, but required supervision with eating and a two-person assistance with personal hygiene.
On 12/16/16 at 12:30 p.m., CNA 4 was observed walking in the contact isolation room passing lunch trays and came out without washing her hands and proceeded to pass more residents ' lunch trays to other residents.
A review of Resident 32's laboratory results, dated 12/10/16, indicated Resident 32 had an elevated white blood cell (WBC) count of 11.2 thousands/mcl (normal reference range [NRR] is 4.0-10.5) an elevated WBC count is indicative of an infection).
A review of Resident 32's Medication Administration Record (MAR) for the month of 12/2016, indicated Resident 32 was receiving Levaquin ([levofloxacin] an antibiotic) 500 milligram (mg) tablets daily for 14 days, initiated on 12/11/16, due to an infected left hip wound.
A review of Resident 32's nurse note, dated 12/9/16, and timed at 2300 (11 p.m.), indicated Resident 32's left hip wound dressing was soaked with yellowish-dark grey purulent (discharging pus [inflammation/infection]) drainage.
A review of Resident 32's culture and sensitivity ([C/S] done to determine the presence of pathogens, which are most often caused by pus-forming organisms and which antibiotics are required to treat the organism effectively) results of the left hip wound drainage, dated 12/13/16, indicated the C/S was positive for MRSA. The C/S indicated the MRSA organism was resistant to levofloxacin (Levaquin) and multiple other antibiotics.
A review of Resident 32's physician's orders, dated 12/13/16, and timed at 6 p.m., indicated new orders to discontinue Levaquin 500 mg tablet daily and start Bactrim DS (an antibiotic [DS] double strength) one tablet twice daily for 14 days (which the C/S indicated the MRSA organism was sensitive to). The physician's order also indicated to place Resident 32 on contact isolation.
A review of Resident 32's short-term care plan, initiated on 12/13/16, indicated Resident 32 was receiving antibiotic therapy for MRSA of the left hip wound. The staff's interventions included administering Bactrim DS twice daily for 14 days, place the resident on contact isolation, observe good hand hygiene at all times, especially after each contact with the resident (Resident 32), and provide room sanitation at least daily.
A review of the Centers for Disease Control (CDC) website titled, Contact Precautions in Non-Hospital Healthcare Facilities for Patients with Draining Wounds Positive for MRSA, the CDC guidelines indicated for the healthcare staff were as following:
1. Wear gloves upon entry into the room.
2. Wear gown upon entry into the room.
3. Remove gown and observe hand hygiene before leaving the patient-care environment.
A review of the facility's policy, titled MRSA Guidelines, dated 2/24/92, indicated modified contact isolation can be discontinued when three consecutive negative cultures taken 48 hours apart after therapy for MRSA has ended and at least 24 hours apart, have been obtained from the original site of the infection or colonization, other wounds or nares.
b. During the facility's recertification survey tour, conducted on 12/13/16 at 7:45 a.m., a certified nurse assistant (CNA 3) was observed not wearing a face mask, while feeding a resident in the room.
During a concurrent observation and interview on 12/13/16 at 8:15 a.m., a licensed vocational nurse (LVN 7) was observed at the nurse's station not wearing a face mask, but five minutes later, at 8:20 a.m., the same day, LVN 7 was observed in the hallway, next to the medication cart in front of Room 110 with a face mask on. LVN 7's face mask was on her chin, not covering her nose and mouth, while talking to staff and residents. During the interview, LVN 7 stated she refused the Flu shot and only wears the face mask when she was inside residents? rooms and not at the nurse's station.
On 12/13/16 at 8:25 a.m., during a concurrent observation and interview, an activity staff (AS) was observed wearing a mask covering the nose and mouth. Upon interview, the AS stated she wears the face mask at all times while she was at work, because she refused the Flu vaccine due to being pregnant.
At 8:35 a.m., on 12/13/16, during an observation, an unidentified staff member was observed in the hallway, next to the contact isolation room wearing a face mask on his chin that was not covering the nose or mouth. The staff then was observed going into the contact isolation room, where RSR 32 was already compromised with MRSA, with the face mask on his chin, but not covering the nose and mouth while talking to the residents in the room.
At 8:45 a.m., on 12/13/16., CNA 3, who was observed earlier (at 7:45 a.m.), not wearing a face mask was observed with a face mask on her chin, but not covering her nose/mouth, while walking in the hallway. CNA 3 stated she only puts the face mask on completely when she was inside the residents' rooms.
At 9:15 a.m., on 12/13/16, a program staff (PS 3) was observed with a face mask on, but was not covering PS 3's nose or mouth. PS 3 stated he only wore the face mask when he talked to the residents. PS 3 stated he refused the Flu vaccine and that was why he was wearing the face mask.
On 12/13/16 at 9:20 a.m., CNA 7 was observed taking off the mask for the interview and stated she only wore the face mask when talking to residents. CNA 7 stated she refused the Flu vaccine and that was why she was wearing the mask.
On 12/13/16 at 11:20 a.m., LVN 7 was observed without a face mask on while walking down the hallway.
During an interview on 12/13/16 at 11:30 a.m., CNA 8 stated she refused to have the Flu vaccine and that was why she had the face mask on, but CNA 8 stated she only wore the face mask when she interacted with the residents.
On 12/13/16 at 2:45 p.m., during an interview, the director of staff development (DSD) stated when a staff member refused the Flu vaccine, they had to sign a declination form and wear a mask when at work. The DSD stated the Flu season was between the months of October and March. The DSD stated the facility only had 16 staff members who refused the Flu vaccine and provided a list of the staff member's names.
At 8:45 a.m., on 12/14/16, PS 1 was observed in the psych unit (Station 2) talking to a resident (within arms distance) with the face mask dangling from one ear, not covering the nose or mouth. Once he saw he was being watched, PS 1 immediately placed the face mask properly on his face.
On 12/14/16 at 9:56 a.m., the psych unit's licensed vocational nurse (LVN 1) was asked when the staff was supposed to wear a face mask. LVN 1 stated the staff who refused the Flu vaccine or had not had the vaccine as of yet should wear the face mask properly over their nose and mouth within five feet of the residents.
On 12/14/16 at 11:45 a.m., PS 2 was observed not wearing a face mask; PS 2 stated he refused the Flu vaccine. PS 2 was asked where his face mask was and PS 2 was observed pulling out the face mask from his shirt pocket. PS 2 stated he only wore the face mask during resident care.
During a concurrent observation and interview on 12/15/16 at 8:16 a.m., CNA 11 was observed carrying a breakfast tray to a resident's room, she entered the room with a face mask on, but it stayed on her chin and did not cover her nose and mouth. CNA 11 stated, "I use the mask when I work inside the room, but not outside the room," while inside the resident's room. She then quickly covered her mouth with the mask.
During an interview on 12/15/16, at 10:15 a.m., Physician 1 who was the facility's medical director stated the Flu virus can kill individuals, especially the geriatric residents in nursing homes. According to the facility's demographic (statistical data relating to the population and particular groups within it) report, the facility had 144 residents who were 65 years-old and older, which was 79% of the facility's population. The medical director also stated that if a staff member refused the Flu vaccine, the staff member should wear a mask at all times, upon entering the facility until he or she left for the day. The medical director stated because the Flu virus can be spread via droplets (a very small drop of a liquid) and airborne (transported by air) transmission.
On 12/19/16 at 8:35 a.m., during an interview, the DSD was asked if she was tracking which staff members had the Flu vaccine and which ones refused. The DSD initially indicated on 12/13/16, that the facility only had 16 staff members who refused the Flu vaccine and later recanted that there were more than 55 staff members who had refused the Flu vaccine. The DSD stated she should have been tracking which staff had received and or refused the Flu vaccine to identify which staff was required to wear the face mask while at work. The DSD stated only 50 staff members had shown her proof that they had received a Flu vaccine outside the facility, but the facility had 211 staff members. The DSD stated she did not start tracking who had the Flu vaccine until after the Immediate Jeopardy was called, but should have.
During an interview, on 12/19/16 at 11:47 a.m., the DON, who was the facility's infection control nurse, stated she was not aware of the full extent of the Flu vaccine protocol. The DON stated she thought staff members who refused the Flu vaccine should only wear a face mask when they were three feet away from residents. The DON presented a binder of surveillance of residents? infection with the use of antibiotics, but no information related to the Flu vaccine.
A review of the facility's policy titled, ?Influenza Vaccine,? with a revision date of 10/2016, indicated between the months of October 1st and March 1st the influenza vaccine will be offered to residents and employees. The policy also indicated if a resident or staff refused the vaccine, a declination form indicating the reason would be completed, which was not followed by the facility. The policy was vague and there was no explanation given as what would happen next after the employee refused the vaccine. The policy also indicated the immunization coordinator would maintain surveillance data, but the facility's staff failed to implement, and was unable to provide evidence that surveillance was being done.
A review of a letter, sent to all health facilities in the County of Los Angeles, dated 8/10/16, from the Department of Public Health, titled "Monitoring the Implementation of the Health Officer Order For Annual Influenza Vaccination Of Healthcare Personnel Or Masking During The Influenza Season," indicated all the health facilities (Acute, SNF, and ICF) required influenza vaccination for their health care personnel (HCP) or that HCP who decline to be vaccinated must wear a mask when they are in contact with patients or working in patient-care areas during the annual influenza season. For this Order, as per the letter, this Flu season was defined as November 1, 2016 through March 31, 2017, unless surveillance data suggested that the Flu activity in Los Angeles County continued after March 31, 2017. The Order included, but was not limited to, physicians, nurses, environmental services, students, volunteers, and contractors (e.g., occupational therapist, physical therapist, physical therapist, phlebotomist, podiatrist, dentist, etc.).
The facility failed to:
1. Follow its policy regarding contact isolation for MRSA ([Methicillin-resistant Staphylococcus aureus] a contagious and antibiotic-resistant staph bacteria that leads to potentially dangerous infection).
2. Maintain an infection control program that tracked and performed surveillance of Flu infections and Flu vaccinations.
3. Adhere to the Los Angeles County/Department of Public Health letter dated 8/10/16, regarding staff that refused the influenza vaccination must wear a face mask.
4. Ensure the staff, who refused the influenza vaccination, wore face mask properly.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000057 |
DOWNEY COMMUNITY HEALTH CENTER |
940012950 |
A |
6-Feb-17 |
2YOC11 |
18320 |
F 309
?483.25 Provide Care / Services for highest well being
Each Resident must receive and the facility provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
F 325
?483.25(i) Nutritional Status
Based on residents comprehensive assessment, the facility must ensure that a resident ?
48325 (i) (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident?s condition demonstrates that this is not possible; and
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 to ensure that a resident received continuity of care for nutritional and medical care to maintain the overall well-being of Resident 8, including, but not limited to:
1. Failure to implement Resident 8?s plan of care, physician?s orders and assessment for Resident 8?s need to be assisted with eating.
2. Failure to follow its policies regarding residents? assistance with meals, hospice program, and implementing resident?s care plans.
3. Failure to report to the physician of Resident 8?s change of condition of refusal to eat with weight loss.
4. Failure to ensure Resident 8 was eating adequately before administering insulin (a hormone that regulates the metabolism of carbohydrates [sugars]) to prevent episodes of low blood glucose levels.
5. Failure of the registered dietician (RD) to assess Resident 8?s weight loss.
6. Failure of the hospice (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain) and the facility to coordinate Resident 8?s plan of care.
These failures resulted in Resident 8, who was assessed as requiring assistance with eating, not being implemented, eating poorly, being hungry, exhibiting intermittent low blood glucose levels, while continuing to receive insulin (regulates the metabolism of carbohydrates [sugars]), and an eleven pound weight loss. These failures had the potential for serious adverse consequences related to Resident 8 not eating and continuing to receive insulin.
On 12/14/16 at 8:18 a.m., Resident 8 was observed in the bed shivering with a tray of breakfast food on Resident 8's bedside table without any staff members assisting Resident 8 with his food. The breakfast tray of food was observed to have a pool of water over the plate and tray. The eggs and bread on the resident's tray were wet and soggy and his gown and blanket were wet.
At 8:20 a.m., on 12/14/16, during an interview, a certified nursing assistant (CNA 13) was informed that Resident 8 was observed cold, shivering, and wet, and his breakfast tray had spilled water all over the food.
At 8:23 a.m., on 12/14/16, CNA 13 was observed returning to Resident 8's room with dry bedding and a gown and CNA 13 ordered a new breakfast tray for the resident.
At 8:31 a.m., on 12/14/16, during an interview, Resident 8 stated, ?I am hungry and I need help eating."
At 8:35 a.m., on 12/14/16, the dietary supervisor (DS) arrived to Resident 8's room with a new breakfast tray for the resident and placed it on the bedside table.
On 12/14/16, at 8:40 a.m., CNA 13 returned to Resident 8's room and set-up the breakfast tray, and then left the room without assisting the resident with his meal, as stipulated in the resident's assessment and plan of care.
At 8:51 a.m., on 12/14/16, Resident 8 was observed not eating his breakfast, but was just staring at the breakfast tray. There was no staff member observed in Resident 8's room.
A review of Resident 8's Admission Face Sheet indicated Resident 8 was admitted to the facility on XXXXXXX16 on hospice care. Resident 8's diagnoses included malignant neoplasm of the prostate (growth of cancerous tissue of a gland surrounding the neck of the bladder in males), dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and diabetes (a long-term metabolic disorder, characterized by high blood glucose, insulin resistance, and relative lack of insulin).
A review of Resident 8's quarterly Minimum Data Set (MDS), dated 11/17/16, indicated Resident 8 had memory problems, impaired decision-making with a brief interview of mental status (BIMS) score of 9 (a score 9-15 indicated a resident was inter-viewable) and was able to make needs known and understand others. According to the MDS, Resident 8 required a two-person physical assist with bed mobility, transferring, and locomotion on and off the unit, with personal hygiene, dressing, and required a one-person physical assist with eating.
At 10:54 a.m., on 12/14/16, during an interview, CNA 14 when asked about Resident 8 being assisted with high protein nutrition (HPN) supplemental drinks in between meals, CNA 14 replied, ?No, he (Resident 8) does not get them because he is usually asleep."
At 12:26 p.m., on 12/14/16, Resident 8 was observed waiting for his lunch tray. There were no snacks or supplements observed at Resident 8's bedside per the physician?s orders and Resident 8?s plan of care. A record review of the physician order summary report, dated 5/18/16, indicated Resident 8 was to receive four ounces of HPN supplemental drinks two times a day between meals at 10 a.m. and 2 p.m., four ounces of HPN with meals and four ounces of HPN at bedtime.
According to an article by the National institute of aging titled, "Encouraging Eating: Advice for at-home dementia caregivers," people with AD (Alzheimer's disease [progressive mental deterioration that caused problems with memory, thinking and behavior]) and related dementia, eating-related challenges can result from: Cognitive issues, such as inability to express one's needs or desires, initiate or persist with eating, use utensils, remember to eat, and distinguish the food from the plate (visual-perceptual challenges).
A review of Resident 8's physician's orders, dated 11/27/16, indicated to give HumuLIN R Solution (short-acting insulin) an injection subcutaneously (under the skin ) before meals and at bedtime, in addition to Lantus Solution [long-acting insulin] 15 units of insulin subcutaneously at bedtime daily. Resident 8's sliding/scale (progressive increase in the pre-meal or night time insulin dose, based on pre-defined blood glucose [BS] ranges) per Resident 8?s Medication Administration Record (MAR) the following was documented:
* BS less than (<) 70 give orange juice;
* Blood sugars (BS) finger sticks of 70-130 = 0 administration of insulin:
* BS 131-180 milligram/deciliter (mg/dl) =2 units insulin;
* BS 181-240=4 units of insulin;
* BS 241 - 300= 6 units;
* BS 301- 400= 10 units
* BS of 401 and above=20 units and call physician.
A review of Resident 8's care plan, dated 2/18/16, titled, ?At risk for Weight Loss and Malnutrition (improper intake of nutrients as a result of poor unbalanced diet),? indicated the staff's interventions included encouraging Resident 8 to consume 80-100% of each meal, and offering and providing favorite foods.
A plan of care, dated 2/11/16, indicated Resident 8 was at risk for hyperglycemia and hypoglycemia (high and low blood sugar, respectively). The goal for Resident 8 was the blood sugar will be medically acceptable. The staff?s interventions included providing a diet as ordered, encouraging Resident 8 to take in at least 80-100% of the meal, and notify physician of any problems.
A review of Resident 8's monthly record of vital signs/weights indicated the resident's admission weight was 115 pounds (2/2016). The record indicated Resident 8 lost five pounds in the months from March-April 2016, and an additional six pounds in the months from May-June 2016, for a total of 11 pounds from March 2016-June 2016.
A review of Resident 8's nutritional assessment, dated 4/12/16, indicated Resident 8 was receiving a controlled carbohydrate diet with four ounces of house protein nutrition (HPN). Resident 8?s ideal body weight (IBW) was calculated by the RD to be 133-163. Resident 8?s body mass index (BMI) was 17.8 (a BMI of less than 18.5 = underweight). The RD documented Resident 8 lost five pounds since admission.
On 12/14/16 at 12:33 p.m., CNA 14 was asked to weigh Resident 8. The resident was weighed in his wheelchair by CNA 14 and a registered nurse (RN 4), which was a total of 165 pounds, minus the weight of the wheelchair (60 pounds). Resident 8 weighed a total of 105 pounds.
On 12/14/16 at 1:41 p.m., during an interview, CNA 13 was asked how much food was consumed by Resident 8, and CNA 13 replied, ?For breakfast the resident (Resident 8) ate 30 percent and for lunch 20 percent."
On 12/14/16 at 1:58 p.m., during an interview, RN 5 was asked about Resident 8's meal consumption and RN 5 stated, ?When he (Resident 8) refused to eat we call the hospice nurse and she contacts Resident 8's doctor. We do not call the doctor; we give the resident (Resident 8) a supplement drink two times a day."
A review of a document titled, "Record of Meal Consumption,? indicated there were many missing documentations of Resident 8's meal intake totaling 21 opportunities per week for breakfast, lunch and dinner as following:
From 10/30-11/5/16: 14 missing documentations.
From 11/6-11/12/16: 15 missing documentations.
From 11/13-11/19/16: 16 missing documentations with one refusal to eat.
From 11/20-11/26/16: 13 missing documentations, with two refusals to eat.
From 11/27-12/3/16: 16 missing documentations, with one refusal to eat.
From 12/4-12/10/16: 12 missing documentations, with four refusals to eat.
From 12/11-12/17/16: 19 missing documentations and two refusals to eat.
The staff was not consistently assessing and documenting Resident 8's meal consumption with many blank spaces for Resident 8's meals consumption, although Resident 8 continued to receive insulin injections.
A review of Resident 8?s MAR for 12/2016, indicated on 12/1/16 at 2100 (9 p.m.) Resident 8 received 4 Units of Lantus insulin. The Record of Meal Consumption for 12/1/16 for all three meals (breakfast, lunch and dinner) indicated resident 8 refused all three meals. On 12/2/16 at 6:30 a.m., Resident 8?s blood sugar was low at 60. On 12/22/16 at 2100, Resident 8 received 10 units of Lantus insulin. The Record of Meal Consumption indicated Resident 8 refused all three meals for that day. On 12/23/16 at 11:30 a.m. and 4:30 p.m., Resident 8?s BS was low at 39 mg/dl. and 48 mg/dl., respectively.
A review of Resident 8's physician's order, dated 12/5/16, and timed at 4:05 p.m., indicated to give glucagon (medication used to raise very low blood sugar) 1 milligram (mg) intramuscularly ([IM] injection into the muscle) one time now for low glucose. The physician's order also included Glucagon 1 mg IM daily as needed (PRN) for blood glucose level below 50 mg/dl. A different physician?s order, on the same date (12/5/16), and timed at 10:50 p.m., indicated to discontinue the blood glucose check every four hours until 8 a.m. the next day (12/6/16). As a result of Resident 8 not eating, as indicated on his consumption record Resident 8 had repeated low glucose levels.
A review of Resident 8's Medication Administration Records (MAR), for the months of 10/2016 and 12/2016, indicated the following subnormal blood glucose levels:
10/2/16: glucose level ? 45 mg/dl.
10/5/16: glucose level ? 41 mg/dl.
10/10/16: glucose level- 26 mg/dl.
10/14/16: glucose level ? 62 mg/dl.
12/2/16: glucose level- 60 mg/dl.
12/2/16: glucose level -52 mg/dl.
12/6/16: glucose level -49 mg/dl.
12/23/16: glucose level- 39 mg/dl.
12/23/16: glucose level -48 mg/dl.
The normal reference range [NRR] of blood glucose level was 70-100 mg/dl. There was no documented evidence that Resident 8's physician and or hospice were notified of the above low blood sugar levels.
A review of the Hospice Visits Description Log (HVDL), dated 10/10/16, indicated Resident 8 had a blood glucose level of 26, which was below the normal limit. According to the log, Resident 8 was given an unspecified amount of orange juice and glucagon via intravenous ([into the vein] a rapid injection of a solution or medication directly into a vein) push of Dextrose-5 (liquid sugar). There was no documentation that Residents 8's family or physicians were notified.
A review the HVDL, dated 11/28/16, documented by the hospice nurse (RN 6) indicated, ?A routine visit, resident was friendly and in no distress, drinking a shake." However, on the same date as the hospice nurse visit, the facility failed to document evidence of Resident 8's consumption of meals on that day.
A review of Resident 8's physician's order, dated 11/27/16, indicated Resident 8 to have four ounces of house high protein nutrition (HPN) at bedtime, two times a day between meals, at 10 a.m. and 2 p.m., also at lunch and dinner.
On 12/15/16 at 8:12 a.m., during a concurrent observation and interview, Resident 8 was observed sitting on his bed finishing his breakfast, being fed by CNA 13. CNA 13 stated, ?The resident (Resident 8) ate 100 percent of his food today." The facility?s staff did not feed Resident 8 until after the facility was interviewed about Resident 8's dietary intake and plan of care not being implemented, which indicated Resident 8 required assistance and encouragement with eating.
At 12:10 p.m., on 12/15/16, Resident 8 was observed in his room in the wheelchair, but no meal supplements or snacks were observed.
On 12/15/16 at 3:48 p.m., RN 4 was asked about the nursing interventions related to Resident 8's eating, RN 4 stated, ?Today, he (Resident 8) ate 100 percent of his breakfast and 40 percent of his lunch, after being fed. It was only when the survey team brought it to the facility?s attention, did they follow Resident 8?s plan of care and provide assistance with meals.
On 12/16/16 at 11:10 a.m., during a telephone interview, Resident 8's hospice physician (Physician 3) stated, "My experience with hospice residents is to make them comfortable; these resident refuse meals intermittently, if he (Resident 8) is having problems with eating, I will write orders for snacks, meal supplements, and meal assistance with a feeder for every meal." Physician 3 stated she was not made aware of Resident 8's refusal to eat with weight loss.
At 11:36 a.m., on 12/19/16, during an interview, the facility?s RD was interviewed regarding Resident 8?s weight loss and replied, ?I?ll assess him, if he loses one more pound. The staff should help him (Resident 8) eat and we provide snacks for him.?
At 11:51 a.m., on 12/19/16, during an interview, the hospice nurse (RN 6) was interviewed about Resident 8's decline in eating and not being fed and what the plan was, RN 6 stated, ?To slowly approach him because he can get combative at times. Today he ate 100 percent of his breakfast and his glucose was over 300." RN 6 stated she had not called Resident 8's physician, because she had spoken to various facility's nurses and the facility's dietician, who stated the resident (Resident 8) received two snacks a day.
A review of the 12/2016?s hospice visit calendar indicated RN 6 documentation was inconsistent with days she visited and the care provided to Resident 8. As a result of the hospice inconsistent documentation and not notifying Resident 8?s physician, there was a lack of continuity of care for Resident 8 between the hospice and the facility.
On 12/19/16 at 12:31 p.m., during a telephone interview, Resident 8's family member was asked if she had been notified of Resident 8's poor eating. Resident 8's family member stated she visited Resident 8 four days prior and had brought Resident 8 a chili dog with fries. Resident 8's family member stated, ?He (Resident 8) loved it, and ate it all and the facility's staff never asked me about his (Resident 8's) favorite foods."
A review of the hospice?s contractual document titled, "Agreement for nursing facility," for inpatient and inpatient respite services, indicated Whereas, (Hospice Name) desires to provide hospice services to residents of the facility in coordination with the management and staff of the facility.
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 implement Resident 8?s plan of care, physician?s orders and assessment for Resident 8?s need to be assisted with eating.
2. Failure to follow its policies regarding residents? assistance with meals, hospice program, and implementing resident?s care plans.
3. Failure to report to the physician of Resident 8?s change of condition of refusal to eat with weight loss.
4. Failure to ensure Resident 8 was eating adequately before administering insulin (a hormone that regulates the metabolism of carbohydrates [sugars]) to prevent episodes of low blood glucose levels.
5. Failure of the registered dietician (RD) to assess Resident 8?s weight loss.
6. Failure of the hospice (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain) and the facility to coordinate Resident 8?s plan of care.
The above violations, 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 or mental harm would result. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940012979 |
B |
22-Feb-17 |
9UZX11 |
2788 |
?483.13(b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
On 09/20/16 at 10:15 am, an unannounced visit was made to the facility to investigate an entity reported incident of employee to resident verbal abuse.
Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was free from verbal abuse when Certified Nursing Assistant (CNA 2) referred to Resident 1 as an ?Asshole.? Resident 1 was unhappy about the remark and responded by stating that he was not crazy.
A review of Resident 1?s Admission Record (Face Sheet) indicated that the resident was admitted to the facility on XXXXXXX16 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, and loss of consciousness), history of traumatic brain injury, and mental disorder.
A review of Resident 1?s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/16/16, indicated that the resident was able to make his needs known and was independent in performing activities of daily living (ADLs).
A review of the facility?s interview Investigation dated 9/9/16, indicated that a certified nursing assistant (CNA 1) reported to the staff developer (DSD) who was giving an abuse in-service training to the facility staffs, that she witnessed and heard CNA 2 call Resident 1 a bad name (profanity word)
On 9/20/16 at 10:39 a.m. during an interview with Resident 1, Resident 1 stated that he did not remember when the incident happened. Resident 1 stated that he was not hearing voices and he was not crazy.
During an interview on 9/20/16 at 11:06 a.m., CNA 1 stated that she was approaching CNA 2 and overheard CNA 2 called Resident 1 an ?Asshole.? CNA 1 stated that Resident 1 responded to by using the same bad word that CNA 2 used against Resident 1.
A review of CNA2?s Employee File indicated that a written warning notice dated 8/4/16 stating ?You are receiving this warning due to the use of bad words in front of the residents.? This document indicated that the incident dated 9/20/16 was not the first time that CNA 2 had used bad words in front of the residents.
According to the facility?s undated policy and procedures on Abuse Prevention indicated that, the facility was to protect its residents from acts of abuse and prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
The failure of the facility to ensure that Resident 1 was free from verbal abuse when Certified Nursing Assistant (CNA 2) referred to Resident 1 as an ?Asshole,? had a direct or immediate relationship to the health, safety, and security of Resident 1. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940012981 |
B |
22-Feb-17 |
9UZX11 |
3159 |
?483.13(b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
On 09/20/16 at 10:15 am, an unannounced visit was made to the facility to investigate an entity reported incident of employee to resident verbal abuse.
Based on observation, interview, and record review, the facility failed to ensure that Resident 2 was free from verbal abuse when Certified Nursing Assistant (CNA 2) referred to Resident 2 as a ?Motherfucker? which made the resident feel disturbed and disrespected by the comment.
A review of Resident 2?s Admission Record indicated that the resident was admitted to the facility on XXXXXXX08 with diagnoses that included chronic obstructive pulmonary disease (a progressive disease that makes it hard to breath), hypertension (high blood pressure), diabetes mellitus (a disease in which there are high blood sugar levels over a prolonged period), blindness in one eye and low vision in the other eye.
A review of Resident 2?s Minimum Data Set (MDS, an assessment and care screening tool), dated 9/08/16 indicated that the resident required extensive assistance from the staff with eating, toileting, and personal hygiene.
The review of the facility Staff?s Interview Investigation dated 9/9/16 indicated, that while the staff developer (DSD) was giving abuse in-service training to the facility staff, a certified nursing assistant (CNA 1) reported that she had witnessed and heard CNA 2 calld Resident 2 a bad name (profanity word).
On 9/20/16 at 10:27 a.m. Resident 2 was observed sitting in a Geri-chair (recliner chair) in the activity room. During an interview with Resident 2 during the complaint investigation, the evaluator noted that the resident was unable to answer the evaluator?s questions due to confusion.
On 9/20/16 at 11:06 a.m., during an interview with certified nursing assistant (CNA 1), CNA 1 stated that while CNA 2 was feeding Resident 2 during dinner time in the activity room, Resident 2 started to hit CNA 2. CNA 2 then said ?I?m not touching that Motherfucker,? referring to Resident 2. CNA1 stated that she could not remember the date when the incident happened.
A review of CNA2?s Employee File indicated that a written warning notice dated 8/4/16 stating ?You are receiving this warning due to using bad words in front of the residents.? This document indicated that the incident dated 9/20/16 was not the first time that CNA 2 had use bad words in front of the residents.
According to the facility?s undated policy and procedures on Abuse Prevention indicated, that it was the policy of the facility to protect its residents from acts of abuse and prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
The failure of facility to ensure that Resident 2 was free from verbal abuse when Certified Nursing Assistant (CNA 2) referred to Resident 1 as a ?Motherfucker,? made the resident feel disturbed and disrespected by the comment.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 2. |
| 940000057 |
DOWNEY COMMUNITY HEALTH CENTER |
940013044 |
A |
24-Mar-17 |
2YOC12 |
16378 |
?483.25(c)(2)
F 314 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.
?483.25
F309 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 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 37's pressure ulcers.
2. Failure to implement the facility's policy, revised on 10/2010, and titled, "Pressure Ulcer Treatment."
3. Failure to follow Resident 37's plan of care in pressure sore prevention in turning every two hours and reporting changes to the physician.
This deficient practice resulted in Resident 37's pressure ulcers (a localized damage to the skin and/or underlying tissue that usually occur over a bony prominence [are areas of the body that are at the greatest risk for developing pressure sores resulting in wounds] as a result of pressure, or shear and/ or friction), not being accurately assessed, which included actual size, depth, and staging (Stage I to Stage IV[ injury to the skin and underlying tissues]) worsening in Stage and size and the physician not being notified of Resident 37's wound changes for a new assessment and a change in wound care treatment.
Resident 37, a 65 year-old male, who was admitted to the facility with a Stage I pressure ulcer (intact skin with non-blanchable (skin loses redness with pressure) on the buttocks, was not being turned every 1-2 hours, per the facility's policy and Resident 37's plan of care. The treatment nurse, a licensed vocational nurse (LVN 12) was not assessing Resident 37's wounds accurately regarding the staging (an injury to the skin and underlying tissue [Stages I through IV]) and number of wounds and did not measure the depth of the resident's wounds as part of the complete assessment.
On 2/14/17, at 8:30 a.m., during the facility's initial tour, Resident 37 was observed lying on his back with the head of bed (HOB) elevated at 30 degrees. A nasogastric ([NGT] a plastic tube inserted through the nose passing the throat and down into stomach for feeding and hydration) was placed in Resident 37's right nostril without an enteral feeding ([chiefly of nutrition] infusion of liquid nutrients) infusing at the time. Resident 37 was asleep.
At 10:20 a.m., 12 p.m., and 1:24 p.m., on 2/14/17, during an observation, Resident 37 remained on his back with the HOB elevated at 30 degrees and was not turned in another position. On 2/14/17, Resident 37 was observed on his back, in the same position, from 8:30 a.m. to 1:24 p.m. (approximately five hours).
At 7:50 a.m., on 2/15/17, during an observation, Resident 37 was lying in bed on his back, awake, but drowsy with the HOB elevated at 30 degrees.
On the same day (2/15/17), at 10:05 a.m., Resident 37 was observed in bed, in the same position on his back with the HOB elevated at 30 degrees.
A review of the facility's policy and procedure, with a revised date of 10/2012 and titled, "Repositioning," indicated repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. The policy indicated residents who were in bed should be on an every two hour turning program. However, the policy stipulated residents with a Stage I or above pressure ulcer, an every two hour turning schedule may be inadequate.
A review of Resident 37's Admission Face Sheet indicated Resident 37 was admitted to the facility on XXXXXXX17. Resident 37's diagnoses included aphasia (a disorder that affects the ability to speak due to brain disease or damage), hemiplegia and hemiparesis (paralysis and or weakness on one side of the body) unspecified cerebrovascular disease affecting left non-dominant side, (stroke affecting the left side of body), and dysphagia (difficulty in swallowing) with a NGT.
A review of Resident 37's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 1/18/17, indicated Resident 37 had memory and cognition problems. According to the MDS, Resident 37 was non-ambulatory, totally dependent on staff for all care, required a two-person assist for transferring and a one-person assist with bed mobility.
A review of Resident 37's short-term resident care plan, dated 1/23/17, for altered skin integrity, due to Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) on the resident's left and right buttocks, indicated the staff's approaches included to turn Resident 37 every two hours and as needed, and keep the resident off the affected area; clean the wound with normal saline (a sterile mixture of salt and water), pat dry, and apply Bactroban (an antibiotic that prevents bacteria from growing on skin) ointment then cover with dry dressing (sterile pad or compress applied to a wound to promote healing and protect the wound) twice a day for 14 days.
A review of Resident 37's plan of care, titled "At risk for further development of pressure ulcer," dated 1/13/17, indicated Resident 37 would have no further development of pressure ulcers. The plan of approach included for the certified nursing assistants (CNAs), not a licensed nurse, to check the resident's skin condition during routine care, sponge baths or perineal ([private parts] the area in front of the anus extending to the vulva [vagina] in the female and to the scrotum in the male) care with special attention to the resident's bony prominences every shift and to notify the charge nurses of any skin changes, and it should be reported to the physician.
A review of Resident 37's Pressure Ulcer Assessment, dated 1/13/17, and titled, "Braden Scale for Predicting Pressure Score Risk," indicated Resident 37 had a score of 13. According to the assessment tool, a total score ranging 13 to 14 represented moderate risk for developing pressure sores.
A review of Resident 37's weekly pressure ulcer record, dated 2/13/17, indicated Resident's 37 response to treatment was observed to be a Stage II wound (from a Stage I) on the left buttock with beefy tissue with a secondary area reddened/pink in color.
On 2/16/17 at 9:08 a.m., during Resident 37's wound care observation and a concurrent interview, a licensed vocational nurse (LVN 12), who was performing the wound care treatment, stated Resident 37 had Stage 1 pressure ulcers on admission. When asked if the Stage I pressure ulcers were measured, LVN 12 stated, "I don't measure Stage I pressure ulcers." During the treatment, Resident 37 was observed to have three large wounds with some areas of deep black tissue (diseased/dead tissue), and not two wounds, as LVN 12 had indicated. LVN 12 stated Resident 37's two pressure ulcers were two Stage II wounds. LVN 12 was asked not to dress Resident 37's wounds until the registered nurse came to assess the wounds. LVN 12 was asked to measure the three wounds. LVN 12 was observed measuring the wounds without measuring the depth of the wounds and stated the following measurements:
1. Wound 1, on the right buttocks, was 1.3 cm in length (L) by 1 cm width (W).
2. Wound 2, on sacral (a triangular-shaped bone at the bottom of the spine) area,
was 3.5 cm in L by 4.1 cm in W.
3. Wound 3, on the left buttocks, was 2 cm in L by 1.8 cm in W.
During a concurrent interview, LVN 12 stated she had not previously assessed Resident 37's sacral wound, because she thought there were only two wounds on the buttocks and not three.
At 9:12 a.m., on 2/16/17, RN 1 was called to Resident 37's bedside. During a concurrent interview, RN 1 was asked to stage the pressure ulcers. RN 1 stated the wound located superior to wound one and two was a Stage III (full thickness tissue loss; subcutaneous [under skin fat] may be visible but does not know the depth of tissue loss). Wound (1), located on the right buttock, was a Stage II, and Wound (2), located on the coccyx (tailbone) was unstageable (full thickness tissue loss in which the base of the wound is covered by slough [dead tissue usually cream or yellow in color] and/or eschar [dry, black, hard dead tissue] in the wound bed; Wound (3), located on the left buttock, was a Stage III. RN 1 stated since the wound was a Stage III she will call a wound specialist today. RN 1 stated, " If I was not called to the resident's bedside to reassess the resident's (Resident 37's) wound, the nurse (LVN 12) would have probably continued to stage the wounds as a Stage II and the physician would not had been notified for a change in wound care."
On 2/16/17 at 9:24 a.m. during an interview, CNA 6 and LVN 12 both stated Resident 37 should be turned every two hours.
On 2/16/17 at 11:30 a.m., during an interview, RN 1 stated measurements are not assessed for Stage I wounds.
A review of Resident 37's Admission Nursing Assessment, dated 1/12/17, under "Summary of Problems," indicated Resident 37 had redness to both left and right buttocks (without size measurements).
A review of Resident 37's untitled care plan, dated 1/13/17, for the resident being at risk for further development of pressure ulcer, indicated Resident 37 required an extensive assistant to being totally dependent with all activities of daily living (ADLs) with contributing factors such as thin/fragile skin; incontinent of bowel and bladder (having no voluntary control over urination [release of urine from bladder] or defecation [discharge of feces from the body]).The nursing approaches included to observe the need for pressure relieving device while the resident was in the bed, notify the physician for any skin changes; keep the resident clean and dry at all times, and to reposition Resident 37 at least every two hours and/or as needed.
A review of Resident 37's Weekly Pressure Ulcer Record, dated 1/23/17, for the right and left buttocks wound, indicated the wounds had progressed to a Stage II with bleeding, measuring 2.0 cm by 1.5 cm in size on the right buttocks and the left the measurements were 5.0 cm by 2 cm, no depth indicated. The Pressure Ulcer Record under, "Date Notified," for dietary, physician and/or family were left blank and did not indicate they were notified of Resident 37's wound changes.
A review of the Resident 37's Physician's Order Summary Report, indicated an order, dated 1/27/17, to cleanse Resident 37's right and left buttock Stage II pressure ulcers with normal saline, pat dry, apply bactroban ointment (an antibiotic that prevents bacteria from growing on the skin) to the wound bed and calmoseptine (ointment used to treat minor skin irritation) on the peri-wound and cover with dry dressing every day and evening shift for 14 days.
A review of Resident 37's Treatment Records for the months of 1/2017 (starting on 1/23/17) and 2/2017, indicated the LVNs for dayshift and evening shift nurses were signing to indicate Resident 37's wound care treatment was being done twice a day
A review of Resident 37's nurse's notes, dated 2/16/17, and timed at 10:08 a.m., indicated Resident 37's wound was re-assessed and re-evaluated by another LVN (LVN 10) and noted a right and left buttock wounds extending to Resident 37's coccyx area. The nurse's note indicated the following:
1. Left buttock wound extending to coccyx/sacral area measuring 2.1 cm. in L by 1.4 cm in W (no depth measurements)
2. Left buttock wound measuring 3.5 in L by 4 cm in W (no depth measurements) with no drainage, no odor, wound bed reddish in color with bridge and some dark spots on some areas.
3. Right buttock wound measuring 1.2 in L by 1 cm in W (no depth measurement) with wound bed red in color, no drainage, discharge, or odor noted.
4. Continue current treatment until seen by a wound specialist.
On 2/16/17 at 2 p.m., during an interview, while at Resident 37's bedside, Resident 37's significant other stated she visits the resident three-four times a week and stays approximately four hours. She stated and understood how important it was for the staff to turn Resident 37 and would hope they (staff) would turn him every two hours.
A review of Resident 37's wound assessment done by a wound care specialist (a physician [Physician 5]), titled "Multi Wound Chart Details," dated 2/16/17, indicated the following:
1. A Stage II pressure ulcer on the right buttock measuring 2.2 cm in L by 1.0 cm in W by 0.1 cm in depth ([D] which included depth measurements).
2. An unstageable pressure ulcer on the coccyx measuring 4.5 cm in L by 3.6 cm in W by UTD (undetermined depth).
3. A Stage III pressure ulcer on the left buttock measuring 3.0 cm in L by 2.0 cm by 0.1 cm in D (which LVN 12 was staging as a Stage II).
According to Physician 5's note, a new treatment plan of medications was ordered for Resident 37's wound healing.
A review of the facility's policy titled, "Pressure Ulcer Treatment," with a revision date of 10/ 2010, indicated the pressure ulcer interventions for residents with Stage III ulcers with no drainage included to irrigate the wound with normal saline or other designated wound cleanser; use a syringe (a device used to inject fluids into or withdraw them from something) to apply hydrogel (a gel mostly made of water that was non-adhesive; essential in wound care and healing, especially in infected wounds, that allows the body to rid itself of the necrotic tissue) to the wound's cavity (an empty space within a solid object).
According to a NPUAP (National Pressure Ulcer Advisory Panel) article titled, "Pressure Injury Prevention Points," to inspect the resident's skin at least daily for signs of pressure injury, especially non-blanchable erythema area (redness or rash of the skin); repeat the risk assessment at regular intervals and with any change in conditions, as specified for a skilled nursing facility weekly for four weeks then quarterly; avoid positioning an individual on an area of erythema or pressure injury area; turn and reposition the resident at risk for pressure injury and avoid positioning on the body areas with pressure injury (www.npuap.org).
At 2/16/17 at 4:30 p.m., the director of nursing (DON) stated the LVN (LVN 12) did not know that the wound should have been assessed as three wounds because it was only one wound at first.
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 37's pressure ulcers.
2. Failure to implement the facility's policy, revised on 10/2010, and titled, "Pressure Ulcer treatment."
3. Failure to follow Resident 37's plan of care in pressure sore prevention in turning every two hours and reporting changes to the physician.
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. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013058 |
A |
29-Mar-17 |
LBXN11 |
11189 |
?483.20(k) Comprehensive Care Plans
(1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident?s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:
(i) The services that are to be furnished to attain or maintain the resident?s highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and
(ii) Any services that would otherwise be required under ?483.25 but are not provided die to the resident?s exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(b)(4).
?483.25(d) Accidents
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible;
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
?483.75(f) Proficiency of Nurse Aides
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents? needs, as identified through resident assessments, and described in the plan of care.
?483.75(i) Medical Director
(1) The facility must designate a physician to serve as medical director.
(2) The medical director is responsible for ?
(i) Implementation of resident care policies; and
(ii) The coordination of medical care in the facility.
On 12/20/16, at 1:10 p.m., an unannounced visit was made to the facility to investigate an injury of unknown origin dated 12/18/16. Resident 1 was found with a swollen left ankle with a purple discoloration. The X-ray result indicated a fracture of the left distal shafts of the tibia and fibula (a break in the two long bones of the left lower leg).
Based on interview and record review, the facility failed to ensure Resident 1 did not sustain a left ankle fracture by failing to:
1. Transfer Resident 1 on 12/17/16 at 6:30 p.m., from a wheelchair to bed by two or more staff assistants as indicated in the Minimum Data Set (MDS, a standardized comprehensive assessment and care-screening tool) and/or the use of a mechanical lift (Hoyer lift, assistive device that allows a resident to be transferred from the bed to the chair or other similar resting places) per facility?s protocol.
2. Ensure that Resident 1?s Activity of daily living (ADL) care plan interventions specified a need to use a mechanical lift for transfer.
3. Ensure that certified nursing assistants/direct care staff was provided an in-service training regarding Resident 1 requiring two or more staff assistants and use of a mechanical lift for transfer.
4. Ensure that the facility has a system in place, and/or policy and procedures for facility staff to identify a resident who required two or more staff assistants and a need to use a mechanical lift for transfer.
As a result, on 12/18/16 at 6:15 a.m. Resident 1 was found with a swollen left ankle and had a purple discoloration to his lower shin. The X-ray results indicated comminuted (The bone shatters into three or more pieces) fractures of the left distal shafts of the tibia and the fibula bone, and a non-displaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture of the proximal (end of a bone) fibula. Resident 1 was transferred to a general acute care hospital (GACH), where a left lower leg cast was applied.
A review of Resident 1's Record of Admission indicated that the resident was an 87 year-old male admitted to the facility on XXXXXXX 12 with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), and cerebral infarction (stroke).
A review of Resident 1's MDS dated 12/1/16 indicated that the resident's cognitive skills for daily decision-making were severely impaired. The MDS indicated that the resident was totally dependent on two or more staff assistants for all activities of daily living including transfer.
A review of Resident 1's Plan of Care, initiated on 3/2/12, and titled, "Activity of daily living (ADL) deficit: required total assistance with bed mobility, transfers, ambulation, locomotion, eating, dressing, toileting, personal hygiene, and bathing," The Plan of Care did not indicate a need to use a Mechanical lift for transfer.
A review of Resident 1?s Nurses Notes dated 12/18/16 at 6:15 a.m. indicated that CNA 1 reported that the resident?s left ankle was swollen and had a purple discoloration to his lower shin. The Nurses Notes indicated that Resident 1?s left ankle and the entire foot to the toes were swollen, had a purple discoloration and limited range of motion (the full flexion and extension movement potential of a joint). The Nurses Notes indicated that the resident had facial grimacing when the left foot was touched. At 6:30 a.m. the physician was notified and an order was received for an X-ray of the foot and left ankle.
A review of Resident 1's left ankle X-ray result dated 12/18/16 indicated acute (new) angulated (bent) moderately displaced comminuted fractures of the distal shafts of the tibia and fibula bones.
A review of the Nurses Notes dated 12/18/16 at 1:30 p.m., indicated that Resident 1 was transferred to a GACH for acute displaced left ankle fractures.
A review of Resident 1?s GACH Discharge Summary dated 12/19/16 indicated a left fibula and tibia fracture in cast. The notes indicated that Resident 1?s family member did not want the resident to return to the facility, as the family member questioned why and how would a non-ambulatory resident sustain ankle fractures.
A review of CNA 1?s written statement dated 12/18/16 indicated that on 12/17/16, Resident 1 did not have a problem with the left foot or left ankle. CNA 1 indicated that the next day 12/18/16, she noticed that the resident?s left foot was swollen and was reported right away to an LVN.
During an interview on 12/20/16 at 2:06 p.m., CNA 1 stated she was assigned to take care of Resident 1 on 12/18/16 on the 7 a.m. - 3 p.m., shift. CNA 1 stated between 6:00 a.m. and 6:15 a.m., and while providing care to Resident 1 she noticed that the resident's left ankle area was red and purple. CNA 1 stated that she notified the charge nurse.
During an interview on 12/20/16 at 3:40 p.m., CNA 2 stated she was assigned to Resident 1 on 12/17/16 from the 3 p.m. to the 11 p.m. shift. CNA 2 stated on 12/17/16 at 6:30 p.m., she transferred Resident 1 from a wheelchair to bed by herself.ΓΏ
A concurrent record review of Resident 1's Plan of Care titled, Activity of daily living (ADL) deficit and interview with the director of nursing (DON) on 12/20/16 at 4:35 p.m., indicated that Resident 1 required total assistance with bed mobility, transfers, ambulation, locomotion, eating, dressing, toileting, personal hygiene, and bathing. The DON stated that Resident 1's Plan of Care should have indicated that Resident 1 needed two or more staff assistants during transfers.ΓΏThe DON stated that Resident 1 required two or more staff assistants and use of Mechanical lift as facility protocol during transfers.
During an interview on 2/21/17 at 12:28 p.m., the MDS nurse stated that if the resident was assessed as requiring two or more persons-transfer then, the information would have been communicated to the director of staff development (DSD). The MDS nurse stated that the DSD would then communicate to the staffs (LVNs and CNAs) that the resident required two or more person-transfer during stand-up meetings and in-services.
During an interview on 2/21/17 at 1:19 p.m., the DSD stated she gets her information of residents who require two or more person-transfer and needing a Mechanical lift from the DON. The DSD stated that she gives in-services to staff about this information and the residents are identified by green stickers on their foot board.
During an interview on 12/21/16 at 2:33 p.m., LVN 1 stated she was assigned to Resident 1 on 12/18/16 on the 11 p.m. - 7 a.m. shift as the charge nurse. LVN 1 stated that Resident 1 was in bed the whole night and on 12/18/16 at 6:10 a.m. to 6:15 a.m., CNA 1 reported to LVN 2 that Resident 1's left ankle was swollen.ΓΏ
On 2/21/17 at 3:34 p.m., during an interview, CNA 2 stated she did not receive in-service or report that Resident 1 was to be transferred with two or more person-assist. CNA 2 also stated that she was not aware that Resident 1 required the use of Mechanical lift during transfer.
During an interview with the DON and concurrent record review on 2/22/17 at 1:16 p.m. of the facility's Training Record on topics titled, "proper transfer to resident (patient)," and/or "transferring using Mechanical (Hoyer) lift," dated 11/28/16, 12/21/16, and 2/15/17, indicated that CNA 2 was not in the attendance during any of the in-services. The DON stated the green sticker to identify residents needing two or more staff assistants and use of a Mechanical lift for transfer had not been in place for at least 3 years. The DON stated that the facility had no policy and procedures regarding the use of the Mechanical lift.
According to the American Academy of Orthopedic surgeons dated March 2010, indicated that high-energy collisions, such as an automobile or motorcycle crash, are common causes of tibia shaft fractures. In cases like these, the bone can be broken into several pieces (comminuted fracture). Sports injuries, such as a fall while skiing or running into another player during soccer, are lower-energy injuries that can cause tibia shaft fractures. These fractures are typically caused by a twisting force and result in an oblique or spiral type of fracture.
The facility failed to ensure Resident 1 did not sustain a left ankle fracture by failing to:
1. Transfer Resident 1 on 12/17/16 at 6:30 p.m., from a wheelchair to bed by two or more staff assistants as indicated in the MDS and/or the use the Mechanical lift per facility?s protocol.
2. Ensure that Resident 1?s Activity of daily living care plan interventions specified a need to use a Mechanical lift for transfer.
3. Ensure that certified nursing assistants/direct care staff was provided an in-service training regarding Resident 1 requiring two or more staff assistants and use of a mechanical lift for transfer.
4. Ensure that the facility has a system in place, and/or policy and procedures for facility staff to identify a resident who required two or more staff assistants and a need to use a mechanical lift for transfer.
As a result, on 12/18/16 at 6:15 a.m. Resident 1 was found with a swollen left ankle and a purple discoloration to his lower shin. The X-ray results indicated comminuted fractures of the left distal shafts of the tibia and the fibula bone, and a non-displaced fracture of the proximal fibula. Resident 1 was transferred to a GACH, where a left lower leg cast was applied.
These violations presented a substantial probability of death or serious physical harm to Resident 1. |
| 940000040 |
DEL RIO CONVALESCENT CENTER |
940013210 |
A |
26-May-17 |
TAV211 |
19721 |
F309
Based on observation, interview, and record review, the facility failed to provide effective intervention to prevent three of eight sampled residents (Resident 1, 2, and 3) with dementia (decline in mental ability severe enough to interfere with daily life) from wandering into other residents? rooms by failing to:
a. Assess Residents 1, 2 and 3's behaviors of wandering inside other residents' rooms.
b. Conduct an interdisciplinary team meeting (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) according to the administrator, to discuss and develop interventions to manage the wandering behaviors of Residents 1, 2, and 3.
c. Establish appropriate and effective interventions that included the development of a policy on wandering, develop care plans and effective supervision to prevent Residents 1, 2, and 3 from entering other residents' rooms so as to prevent resident-to-resident altercations, that may result in injuries to wandering residents and residents whose rooms were visited by the wandering residents and,
F323
d. Ensure that the resident?s environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent ensure that 1, 2, and 3 did not wander into Residents 4, 5, 6, and 7?s rooms. Residents 4, 5, 6, and 7 indicated their displeasure about wanderers that enters their room uninvited and indicated the potential assaultive actions that may result from the residents? wandering actions.
On 4/5/17 at 12 p.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding residents? safety.
On 4/5/17 at 12:20 p.m., during a tour of the facility with the ADON, the evaluator noted that the facility had four residents? halls. Halls 3 and 4 had rooms designated for female residents and Hall 2 and 5 had rooms designated for male residents. Resident 1 (a male resident) was observed on 4/5/17 at 12:20 p.m., propelling his wheelchair independently in Hall 3 designated for female residents. Resident 1 resided in Hall 2.
During a concurrent observation, the ADON stated that male residents were not supposed to be in halls designated for female residents and likewise, female residents were not to be in halls designated for male residents.
During the concurrent observation, Resident 1was observed in his wheel chair stuck between 2 chair benches and was not able to move. A CNA purposely put him in between the two chair benches to restrict him from wandering in a corner in his wheel chair to prevent him from wandering away because it was time to eat lunch. CNA 1 stated that Resident 1 did not understand instructions because he was confused and neither could he understand not to propel himself in his wheelchair all over the facility especially during lunch time. CNA 1 stated that Resident 1 went inside other male and female residents' rooms daily, and many times a day (CNA 1 did not state the exact number of times)
The ADON stated that Resident 1 was confused and he had a daily tendency to go inside other residents' rooms (male and female residents) ever since he was admitted to the facility and that the facility staff would redirect him back to the main (central) hall, where the nursing station was located.
On 4/5/17 at 2:25 p.m., during an interview, the ADON stated that Resident 1 did not have an individualized care plan to address the resident's wandering behavior for going in and out of other residents' rooms.
During an interview on 4/12/17 at 4:50 p.m., a licensed vocational nurse (LVN 3) stated that Resident 1 had the behavior of going inside other residents' rooms since his admission to the facility and that other residents had gotten upset when Resident 1 went inside their rooms uninvited.
A review of Resident 1's face sheet (admission record), indicated Resident 1 was first admitted to the facility on XXXXXXX 16 and was re admitted on 2/14/17 with diagnoses of dementia and Alzheimer's disease (an irreversible and progressive disorder that damages and destroys brain cells, inducing memory loss and negatively impacting cognitive abilities, such as thinking skills and reasoning).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/28/17, indicated that Resident 1 had severe impairment for daily decision making, unable to walk, used a wheelchair for mobility, and required limited assistance (staff provide guided maneuvering or other non-weight bearing assistance) for locomotion off unit (how resident moved to and returned from areas such as the dining room, and activity room) with the assistance of one person.
A review of Resident 1's record titled "Initial Psychosocial Assessment," dated 2/16/17, indicated that Resident 1 was able to propel himself in the wheelchair and had poor safety awareness and wandered in and out of the halls.
A review of Resident 1's record titled "Nurses Notes," dated 2/17/17, and timed at 11 p.m., indicated that Resident 1 propelled himself in the hallways.
During an interview on 4/12/17 at 1:51 p.m., LVN 1 stated that Resident 2 (a female resident) was a confused resident. LVN 1 stated that Resident 2 was able to propel her wheelchair independently and had wandered into the male and female halls. LVN 2 stated that there was a potential risk for other residents to get upset if Resident 2 enters their rooms uninvited. LVN 1 further stated that there was no care plan in place to manage Resident 2's wandering behavior.
During an interview on 4/12/17 at 4:03 p.m., Resident 2 was propelling her wheelchair independently through a male residents' hall.
During an interview on 4/12/17 at 4:48 p.m., CNA 1 stated that Resident 2 went in and out of male and female residents? rooms since she was admitted.
On 4/14/17 at 3:52 p.m., during an interview, the ADON stated that the facility did not have an individualized care plan to manage Resident 2's wandering behaviors of going in and out of other residents' rooms.
A review of Resident 2's face sheet indicated that the resident was admitted to the facility on 4/25/13 with diagnoses of dementia with behavioral disturbance and hypertension (high blood pressure). Resident 2 resided in Hall 4.
A review of Resident 2's MDS dated 1/23/17 indicated that Resident 2 had severe impairment in cognitive skills, was unable to walk, used a wheelchair for mobility, and required supervision while in locomotion off the unit.
A review of Resident 2's record titled "Progress Note," dated 4/1/17, indicated that Resident 2 had a history of removing things that are not hers.
During an observation on 4/12/17 at 4:01 p.m., Resident 3 (female resident) was observed propelling her wheelchair independently in a male residents' hall. A facility staff re-directed Resident 3 to the TV room.
During an interview on 4/12/17 at 4:48 p.m., CNA 1 stated that Resident 3 had been in and out of other male and female residents' rooms since she was admitted (on 11/2/16).
During an interview on 4/12/17 at 4:06 p.m., LVN 2 stated that Resident 3 did not have a care plan to address Resident 3's wandering behavior of going in and out of other residents' rooms.
A review of Resident 3's face sheet indicated that the resident was admitted to the facility on 11/2/16 with diagnoses of Alzheimer's disease and paranoid schizophrenia (delusions [false beliefs] that a person or some individuals are plotting against them.) Resident 3 resided in Hall 4.
A review of Resident 3's MDS dated 2/15/17 indicated that Resident 3 had severe impairment in cognitive skills, unable to walk, used a wheelchair for mobility, and was able to move independently between locations on and off the unit.
A review of Resident 3's record titled "Progress Notes," dated 4/1/17, indicated that Resident 3 was confused and had a history of wandering into other residents' rooms and taking things, which appeared more related to confusion than actual malice.
During an interview on 4/12/17 at 12:44 p.m., Resident 4 (a male resident residing in Hall 2) stated that Resident 1 (who resided in Hall 2), Resident 2 (who resided in Hall 4), and Resident 3 (who resided in Hall 4), had wandered inside his (Resident 4's) room daily, and approximately three to four times a day in the past several months without permission and touched his personal belongings. Resident 4 stated that Resident 1 wandered inside his room on 4/11/17 in the evening. Resident 4 stated that he used his call light to call a facility staff to remove Resident 1 from his room and the staff took more than 15 minutes to come to his (Resident 4's) room to remove Resident.
During the interview on 4/12/17 at 12:44 p.m., Resident 4 stated that Resident 1, 2, and 3 made him very angry every time they (Resident 1, 2, and 3) wandered in to his room. Resident 4 stated that he felt like hitting Resident 1 when Resident 1 wandered inside his (Resident 4) room because Resident 1 was a man. Resident 4 stated that he had to yell very loudly at Resident 1 so that Resident 1 would leave his (Resident 4) room. Resident 4 stated that Resident 2 and 3 made him angry when they touch his things.
A review of Resident 4's record titled, "Record of Admission," indicated the resident was admitted to the facility on 3/26/15 with diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms) and major depressive disorder (causes a persistent feeling of sadness and loss of interest).
A review of Resident 4's MDS dated 1/9/17 indicated that the resident was alert and cognitively intact for daily decision making.
During an interview on 4/12/17 at 1:33 p.m., Resident 5 (a female resident) stated that Resident 1 went inside her room three to four times a day every day. Resident 5 stated that Resident 1 last went inside her room on 4/11/17. Resident 5 stated that she used the call light to request facility staff to get Resident 1 out of her room. Resident 5 stated that she had to wheel Resident 1 out of her room because the facility staff took about half an hour to respond to the call light. Resident 5 stated that she felt violated and scared when Resident 1 stared at her while Resident 1 was inside her room.
A review of Resident 5's record titled, "Record of Admission," indicated the resident was admitted to the facility on 2/7/14 with diagnoses of Parkinson's disease (long-term movement disorder) and osteoporosis (a medical condition in which the bones become brittle and fragile). Resident 5 resided in Hall 4.
A review of Resident 5's MDS, dated 11/16/16, indicated that the resident was cognitively intact for daily decision making and had no limitations in range of motion (the full movement of the joints) in her upper extremities (shoulder, elbow, wrist, and hand).
During an interview on 4/12/17 at 12:59 p.m., one of two family members (FAM 1) stated that Resident 1 and other confused female residents (FAM 1 did not identify the female residents) went inside Resident 6's room (a female resident's room located in Hall 4) and that they (FAM 1, FAM 2, and Resident 6) were scared because they did not know what Resident 1 and the other confused residents were capable of doing.
During the interview, FAM 1 stated that the facility staff was aware that Resident 1 entered Resident 6's room daily. FAM 1 stated Resident 1 last entered Resident 6's room on 4/8/17 and FAM 1 and FAM 2 wheeled Resident 1 out of Resident 6's room and left him outside in the hall (Hall 4). FAM 1 and FAM 2 saw Resident 1 entered other female resident's room.
A review of Resident 6's face sheet indicated the resident was admitted to the facility on XXXXXXX 14 and was readmitted on XXXXXXX17 with diagnoses of Alzheimer's disease and dementia.
A review of Resident 6's MDS dated 2/5/17, indicated that the resident had severe impairment for daily decision making and required extensive (staff provide weight-bearing support) to total assistance from staff for activities of daily living (ADLs).
During an observation on 4/5/17 at 12:32 p.m., Resident 7 (a female resident) was awake and lying in bed inside her room. Resident 7 stated during an interview, that a male resident (Resident 7 could not remember the male resident's name) usually wandered in to her room in a wheelchair daily without permission and that the last time the male resident came in her room was on 4/4/17 after lunch time. Resident 7 stated that she was scared and concerned. Resident 7 stated that she reported the male resident to the facility staff (Resident 7 could not remember the staff's name) every time the male resident came inside her room and that the staff would take 10-15 minutes to remove the male resident from her room. Resident 7 stated that she had a wooden stick hidden inside her room and that she was planning to use it to hit any resident who came inside her room uninvited. |
| 940000017 |
DOWNEY CARE CENTER |
940013309 |
A |
23-Jun-17 |
ZN1K11 |
26757 |
42 CFR 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
42 CFR 483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
42 CFR 483.45(d) Unnecessary Drugs-General.
Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
42 CFR 483.45(f) Medication Errors.
The facility must ensure that its-
(f)(2) Residents are free of any significant medication errors.
42 CFR 483.45(a) and (b)(1) Pharmacy Services
(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--
(1) Provides consultation on all aspects of the provision of pharmacy services in the facility
42 CFR 483.70(i) Medical records.
(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are?
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
(5) The medical record must contain?
(i) Sufficient information to identify the resident;
(ii) A record of the resident?s assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and
determinations conducted by the State;
(v) Physician?s, nurse?s, and other licensed professional?s progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under
?483.50.
Based on interview and record review, the facility failed to provide residents with 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, and failed to 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:
1. Failure to ensure Resident 1, who had severe kidney disease, was given a medication with adequate monitoring, and to discontinue a medication if contraindicated to the resident?s impaired kidney.
2. Failure to assess and monitor Resident 1 for adverse consequences after the licensed vocational nurse (LVN 1) administered Morphine Sulfate (a narcotic medication used to treat moderate to severe pain).
3. Failure to re-assess Resident 1 and notify the resident?s attending physician when a change in condition (an altered mental condition) was identified and reported to LVN 1 at the time the resident was to be transported from the facility to the dialysis center.
4. Failure to coordinate pharmaceutical services and nursing services to identify that the newly ordered metformin (a generic name of a drug product comparable to the brand product called Glucophage, a medication used to help control blood sugar levels), had a black box warning that metformin was contraindicated to Resident 1, who had Stage 5 chronic kidney disease ([CKD], end stage kidney disease or kidney failure)
5. Failure to identify and monitor the adverse consequence of metformin administration to Resident 1.
6. Failure to ensure Resident 1 was free from a significant medication error (an error that jeopardizes the resident?s health and safety).
7. Failure to communicate to the dialysis center the medication change for Resident 1.
8. Failure to document accurately and completely on Resident 1?s medical record the treatment and services provided to the resident.
Resident 1 received one (1) dose of Morphine Sulfate on 1/23/17 at 2:40 a.m., prior to her transport to the dialysis center at 4:05 a.m. According to the Morphine Sulfate Tablet label information, the principal actions of therapeutic value of morphine are analgesia (pain reliever) and sedation (a state of sleepiness). Release of histamine (a substance that dilate blood vessels) can occur and may contribute to narcotic-induced hypotension (low blood pressure). The licensed nurse, who administered the morphine, did not reassess Resident 1 for possible side effects of the medication, which included hypotension and sedation. On 1/23/17, a transportation staff (TS 1) from the dialysis center notified LVN 1 that Resident 1, ?did not look normal.? LVN 1 did not reassess Resident 1 and inform the physician of the resident?s altered mental status or change of condition. LVN 1 did not document the time Resident 1?s blood pressure was taken on 1/23/17 prior to the arrival of the transporter. The licensed nurses did not document a reassessment of Resident 1?s health condition, such as presence or absence of side effects, after administering a dose of Morphine Sulfate.
Resident 1, who had Stage 5 chronic kidney disease, also received one (1) dose of the 1,000 mg (1,000 mg is equal to 1 Gram) of metformin on 1/19/17 and two (2) doses on 1/20/17, 1/21/17, and 1/22/17, for a total of seven (7) doses. The attending physician did not know the laboratory result regarding Resident?s 1 kidney function. The facility failed to ensure the attending physician received the most current laboratory result of the resident?s kidney function prior to prescribing the metformin; the dispensing pharmacy failed to alert the prescriber and nursing services of the black box warning for metformin; the facility failed to ensure its licensed nurses were aware of Resident 1?s kidney function and the potential adverse effects prior to the administering of metformin. The facility failed to inform the dialysis center that Resident 1 was started on metformin on 1/19/17. The hospital did not receive information that Resident 1 was started on metformin for appropriate diagnosis and treatment, and determination of cause of death.
According to Glucophage (brand name for metformin) label information, Glucophage carried a contraindication for patients with severe renal (kidney) impairment. Glucophage carried a black box warning (a warning in the US Food and Drug Administration (FDA)-approved labeling of prescription drugs when there is reasonable evidence of an association of a serious hazard [danger or risk] with the drug) of lactic acidosis and the risk factors included renal impairment.
These deficient practices resulted in delayed intervention when Resident 1 had an altered mental status. Resident 1 developed hypotension and was transferred to a general acute care hospital (GACH 2) on XXXXXXX17 from the dialysis center (the dialysis center called the paramedics at 5:25 a.m.). Resident 1 died on XXXXXXX17 at 10:48 a.m. at the hospital.
A review of Resident 1's record titled, "Admission Record," indicated Resident 1 was a 64-year-old female, who was admitted to the facility on XXXXXXX16, and was readmitted on XXXXXXX16, with diagnoses that included Stage 5 chronic kidney disease, hemodialysis status (a procedure for removing waste products or toxic substances and excess fluids from the bloodstream), diabetes mellitus (a disorder that affects the body's ability to use blood sugar resulting to high levels of sugar in the blood), old myocardial infarction (heart attack), presence of aortocoronary bypass graft (a heart surgery that improves blood flow to the heart), endocarditis unspecified (inflammation/infection of the heart), and methicillin resistant staphylococcus aureus (MRSA) infection.
A review of Resident 1's record titled, "History and Physical Examination," dated 12/20/16 indicated that Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's laboratory report from GACH 1, dated 1/2/17, indicated Resident 1's glomerular filtration rate (GFR) was low at 13 mL/min/1.73m2 (reference range should be above 59 mL/min/1.73m2 [milliliters per minute per body surface area]).
A review of Resident 1's clinical record titled "Order Review Report" for 1/1/2017 to 1/31/2017 indicated the resident was to receive hemodialysis treatments outside the facility three days a week at 5 a.m. and the scheduled transportation time was at 4 a.m.
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool)," dated 1/13/17, indicated that Resident 1 was receiving dialysis; her cognition (ability to think and reason) was intact; she was able to make her needs known and understand others; she required extensive assistance (resident performed part of the activity; staff provided support with bearing weight) from staff with toilet use; and she had frequent bladder incontinence (loss of bladder control).
A review of Resident 1's record titled, "Laboratory and Pathology Test Results," dated 1/13/17 indicated that, a high level of glycated Hemoglobin A1C (HgbA1C, a blood test for diabetes that reflects the average blood sugar levels for the past two to three months) of 7.5 percent (normal reference range 4.3-6.1 percent). A handwritten physician's order at the bottom of the test result indicated to administer "Metformin 1000 mg BID (twice a day)," dated and signed on 1/19/17.
A review of Resident 1's record titled, "Medication Administration Record (MAR)," for January 2017 indicated Resident 1 received seven doses of 1000 mg per dose of metformin from 1/19/17 to 1/22/17 (one dose on 1/19/17 and two doses each on 1/20/17, 1/21/17, and 1/22/17). The MAR indicated also that Resident 1 received 17 doses of Morphine Sulfate 15 mg tablet from 1/6/17 to 1/23/17 for pain level between 6/10 to 8/10 (zero being no pain, level 1 to 4 is mild pain, level 5 to 9 is moderate pain, and level 10 is severe pain).
A review of Resident 1?s care plans did not include the information that the resident was taking metformin and how the facility staff should monitor the metformin?s associated risks, such as lactic acidosis. There was no care plan developed on how the facility staff should monitor Resident 1 for adverse consequences of a narcotic medication, such as morphine, post administration.
During a telephone interview, on 3/31/17, at 2:40 p.m., the Registered Nurse (RN 1) was asked if she knew the black box warning for metformin. RN 1 was unable to answer the question related to the black box warning that the FDA mandated for metformin. RN 1 stated she did not know how the facility addresses (to direct the attention of) the concerns or issues of black box warnings in a new medication order. RN 1 stated she did not check the pharmacy website for contraindications (to advise against or indicate the possible danger of) or side effects of metformin. RN 1 stated she could not find a care plan developed for Resident 1?s use of metformin.
During a telephone interview, on 4/28/17, at 3:45 p.m., the facility's Pharmacy Consultant (PharmD) stated the usual starting dose of metformin for a resident with normal kidney function is 500 milligrams (mg) twice daily with meals or 850 mg once daily. PharmD stated that the initiation of metformin to residents with GFR (glomerular filtration rate) between 30-45 mL/min/1.73m2 (milliliters per minute per body surface area) is not recommended. PharmD stated that metformin should be discontinued if a resident?s GFR falls below 30 mL/min/1.73m2.
A review of the Resident 1?s Progress Notes, dated 1/23/17 at 2:40 a.m., indicated LVN 1 documented that she administered Morphine Sulfate 15 mg to Resident 1. At 3:15 a.m., LVN 1 documented that the morphine administered was effective. At 4:05 a.m., LVN 1 documented that the resident?s transportation to the dialysis center was in the facility. LVN 1 documented that the resident was alert, sleeping most of the time, no respiratory distress, able to verbalize needs, and was in stable condition.
A review of Resident 1?s record titled ?Dialysis Care Communication/Coordination (an interchange communication tool between the facility and the dialysis center during dialysis days),? dated 1/20/17 and 1/23/17 indicated a medication change section for the facility to complete to communicate medication changes to the dialysis center. The facility did not provide information to the dialysis center that Resident 1 was started on a new medication, metformin, on 1/19/17. The Dialysis Care Communication/Coordination form, dated 1/23/17, indicated LVN 1 took Resident 1?s blood pressure and it was 118/69 mmHg. LVN 1 did not document the time she took the resident?s blood pressure.
During a telephone interview, on 6/20/17 at 3 p.m., the Dialysis Care Communication/Coordination form, dated 1/23/17, which indicated that Resident 1?s blood pressure was 118/69 mmHg, was discussed with the director of nursing (DON). The DON was not able to verbalize what time LVN 1 took the blood pressure of 118/69 mmHg because LVN 1 did not document the time she took the resident?s blood pressure. The DON stated the time the blood pressure was taken should be documented and the blood pressure should be taken at least within an hour prior to transporting the resident to the dialysis center. The DON stated that LVN 1 stated that she took the resident?s blood pressure of 118/69 mmHg on 1/23/17 forty five (45) minutes to one hour prior to transporting the resident to the dialysis center.
During a telephone interview, on 1/27/17 at 1 p.m., the dialysis patient care technician (PCT 1) stated that the transportation staff (TS 1), who transported Resident 1 to the dialysis center, stated that he (TS 1) was worried about Resident 1 when he (TS 1) picked up Resident 1 from the facility because Resident 1 did not look normal. PCT 1 stated that according to TS 1, he asked LVN 1 multiple times if it was okay to transport Resident 1 and LVN 1 stated Resident 1 was ?Okay to go? to the dialysis center.
During a telephone interview, on 1/27/17 at 12:40 p.m., the dialysis registered nurse, DRN 1 stated, "Around 5:05 a.m. (on 1/23/17), I saw the resident (Resident 1) looked 'drugged' and was sleepy." DRN 1 stated Resident 1 could not answer where she was (location). DRN 1 stated 9-1-1 was called immediately and came within five minutes and took Resident 1 to the hospital.
During a telephone interview, on 1/27/17 at 1:15 p.m., the dialysis patient care technician (PCT 2), who received Resident 1 from the facility on XXXXXXX 17, stated, "I received her (Resident 1) with a consistently low blood pressure." PCT 2 stated that upon Resident 1's arrival to the dialysis center, the resident was not alert, was confused, and was just making sounds, and could not speak very well and then would black out (to undergo a temporary loss of vision, consciousness, or memory). PCT 2 stated Resident 1 was able to say her name but could not answer any other questions. PCT 2 stated Resident 1 was very sleepy.
A review of the dialysis progress note report, dated 1/23/17, indicated that Resident 1's condition worsened upon arrival at the dialysis center. The resident's level of consciousness was altered and the blood pressure (the pressure of circulating blood on the walls of blood vessels) reading was 57/72 mmHg (normal range is less than 120/80 mmHg or milliliters of mercury. A blood pressure reading of 90/60 mmHg is considered low blood pressure or hypotension) between 5:10 a.m. to 5:15 a.m. At 5:20 a.m., the dialysis registered nurse (DRN 1) at the dialysis center called the facility to ask if any medication was given to Resident 1 before sending the resident to the dialysis center. A licensed nurse in the facility informed DRN 1 that Resident 1 received 15 milligrams of morphine by mouth due to complaints of pain. DRN 1 documented that between 5:22 and 5:25 a.m. on 1/23/17, the paramedics were called for assistance. The resident was subsequently transferred to the acute hospital via 9-1-1 emergency services.
During a telephone interview, on 3/31/17, at 3:30 p.m., DRN 1 was asked if the dialysis center was made aware that Resident 1 was started on metformin four days (on 1/19/17) before Resident 1 was transferred to the acute hospital via 9-1-1 (on 1/23/17). DRN 1 stated the dialysis center was not made aware that Resident 1 was started on metformin and that it would be helpful if the dialysis center knew of any new medication Resident 1 was taking. DRN 1 was asked if he was knowledgeable of the precautions with the use of metformin. DRN 1 stated he knew that metformin should not be given to residents with severely impaired renal function. DRN 1 stated that traces of metformin stays in the body even after hemodialysis.
A review of Resident 1's GACH 2?s record titled, "Emergency Department (ED) Reports," dated 1/23/17, no time specified, indicated Resident 1 arrived in the hospital at 5:55 a.m. with altered mental status and poorly responsive, hypotension, acute (sudden) distress (physical or mental suffering), and was unable to verbalize what was wrong. The ED report indicated Resident 1 was given 15 mg of morphine at the facility prior to being dropped off at the dialysis center.
A review of Resident 1?s GACH 2?s record titled, ?Emergency Department Notes,? dated 1/23/17 at 6:14 a.m., indicated the hospital was not aware that Resident 1?s current medications included metformin.
A review of Resident 1's GACH 2?s laboratory results, dated 1/23/17, at 7:05 a.m., indicated the resident?s lactic acid level was 21.6 millimoles per liter ([mmol/L], reference range is 0.5-2.2 mmol/L) and her GFR indicated "Low" 7 mL/min)/1.73m2.
A review of Resident 1's GACH 2?s record titled, "History and Physicals," dated 1/23/17, indicated Resident 1 died on 1/23/16 at 10:48 am.?
A review of Resident 1?s GACH 2?s record titled ?Consult Note Nephrology,? dated 1/23/17 at 11:08 a.m., indicated all information was based on the medical record, which did not include metformin that was started on 1/19/17 (four days ago), no family at bedside.
During a telephone interview, on 5/4/17, at 3:25 p.m. Resident 1?s attending nephrologist (Nephrologist 1) in the acute hospital stated he did not know Resident 1 was taking metformin. Nephrologist 1 stated ?If I see lactic acidosis and the resident was on metformin, then I would assume that (metformin- associated lactic acidosis) too. It is evidence-based that metformin has been known to cause lactic acidosis and it could also sometimes lead to death.? Nephrologist 1 stated Resident 1 should not receive metformin. Nephrologist 1 stated, ?Metformin is definitely contraindicated especially in dialysis patients. That is a medical error. I?m surprised it was even given to her (Resident 1). She should not have it at all.?
A review of Resident 1's GACH 2?s record titled, "Discharge Summaries Notes," dated 1/23/17, at 4:17 p.m., indicated Resident 1 was pronounced dead on 1/23/17 at 10:48 a.m. and "Cause of Death: Preliminary (initial) cause of death: Lactic acidosis.
During a telephone interview on 4/3/17, at 3:15 p.m., the facility's Pharmacy Consultant (PharmD) stated the next scheduled medication regimen review for the month of January 2017 was due on 1/27/17. PharmD stated that metformin was not recommended for residents who are renal-impaired (kidney failure) and with creatinine clearance (a test used to estimate the glomerular filtration rate or GFR) below 30 mL/minute/1.73m2. PharmD stated that the physician should have known of the risks of this medication and should not have ordered it for Resident 1 without first obtaining a creatinine clearance. PharmD stated, "Unfortunately, the dispensing pharmacist did not have direct access to the laboratory results of the residents in the facility and had no way of finding out the creatinine clearance of a resident."
During the interview, PharmD stated the facility staff (licensed nurses) should have checked the resident's laboratory result and notified the dispensing pharmacist. PharmD stated the facility should have a list of medications with black box warnings and should have reviewed new medication orders for warnings, make a clinical assessment, and call the physician or pharmacist to clarify the medication order.
During a telephone interview, on 4/4/17, at 4:58 p.m., Resident 1's attending physician (MD 1) in the facility stated that he ordered the metformin for Resident 1 because according to RN 1, Resident 1 had a high HgbA1C on the laboratory report dated 1/13/17 and because metformin was the first line of medication for diabetes. MD 1 stated he was not near the computer (electronic medical record) during that time so he did not have all the information/facts with him, such as, laboratory results (e.g. creatinine clearance) before he prescribed the metformin. MD 1 stated he did not know there was a black box warning for the metformin but if he had been told, "I would not have prescribed it."
During a telephone interview, on 4/5/17 at 8:35 a.m., the DON stated the facility pharmacy provided a manual of medications with black box warnings for nurse?s reference and the manual was located in the facility?s nursing station. The DON stated metformin was included in the manual. The DON stated the facility did not have a policy and procedure that would guide licensed nurse what to do when an order for a new medication with a black box warning was received from the physician.
During a telephone interview, on 4/5/17 at 9:30 a.m., LVN 1 stated the electronic medical record system did not have the capacity to indicate if a medication had black box warnings.
A review of a signed declaration form by a family member (FAM 1), dated 6/21/17, indicated that FAM 1 requested the nurse in charge several times to suspend the administration of morphine because the medication made Resident 1 sleepy. FAM 1 stated the nurses were not noticing Resident 1?s change of condition because they thought the resident was just sleepy.
During a telephone interview, on 6/20/17 at 3:13 p.m., the licensed nurses? documentation after administering Morphine Sulfate to Resident 1 was discussed with the DON. The DON stated the licensed nurses would follow-up within 60 minutes with Resident 1 and document if the Morphine Sulfate that was administered (for pain management) was effective. The DON stated the licensed nurses do not take the resident?s blood pressure after administering the morphine. The DON was unable to provide a policy and procedure regarding what the licensed nurse should do post administration of a narcotic medication, such as morphine.
During the interview, the DON stated she did not expect LVN 1 to retake Resident 1?s blood pressure after the transportation staff (TS 1) informed LVN 1 that Resident 1 did not look normal because LVN 1 followed the facility?s protocol by taking Resident 1?s blood pressure within one (1) hour prior to transporting the resident to the dialysis center. The DON stated the during the transport of Resident to the dialysis center, LVN 1 was talking to TS 1 because Resident 1 was mumbling and TS 1 could not understand what the resident was mumbling. The DON stated LVN 1 translated to TS 1 that Resident 1 stated that she was sleepy because she just had a dose of morphine.
The facility failed to provide residents with 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, and failed to 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:
1. Failure to ensure Resident 1, who had severe kidney disease, was given a medication with adequate monitoring, and to discontinue a medication if contraindicated to the resident?s impaired kidney.
2. Failure to assess and monitor Resident 1 for adverse consequences after the licensed vocational nurse (LVN 1) administered Morphine Sulfate (a narcotic medication used to treat moderate to severe pain).
3. Failure to re-assess Resident 1 and notify the resident?s attending physician when a change in condition (an altered mental condition) was identified and reported to LVN 1 at the time the resident was to be transported from the facility to the dialysis center.
4. Failure to coordinate pharmaceutical services and nursing services to identify that the newly ordered metformin (a generic name of a drug product comparable to the brand product called Glucophage, a medication used to help control blood sugar levels), had a black box warning that metformin was contraindicated to Resident 1, who had Stage 5 chronic kidney disease ([CKD], end stage kidney disease or kidney failure)
5. Failure to identify and monitor the adverse consequence of metformin administration to Resident 1.
6. Failure to ensure Resident 1 was free from a significant medication error (an error that jeopardizes the resident?s health and safety).
7. Failure to communicate to the dialysis center the medication change for Resident 1.
8. Failure to document accurately and completely on Resident 1?s medical record the treatment and services provided to the resident.
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. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013375 |
A |
27-Jul-17 |
4UJK11 |
8042 |
42 CFR ?483.25(d) Accidents.
(d) The facility must ensure that ?
(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
On 6/2/17, an unannounced abbreviated survey was conducted to investigate two complaints and one entity reported incident regarding Resident 22 being a victim of an assault by Resident 11.
Based on observation, interview, and record review, the facility failed to provide adequate supervision to Resident 11 by failing to:
1. Provide a one-on-one supervision (one staff dedicated to be present with one resident at all times) to Resident 11 in accordance with the plan of care.
Resident 11, who was identified as needing a one-on-one supervision due to his aggressive behavior, hit Resident 22 (his roommate) on his head when he (Resident 11) was left unsupervised inside his room on 5/28/17.
This deficient practice resulted in Resident 22?s transfer to the hospital and the resident was found to have sustained subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain). Resident 22 was admitted to the intensive care unit ([ICU], the department of a hospital that is designed and equipped for monitoring, care, and treatment of seriously ill or injured residents).
A review of Resident 11's record titled, "Face Sheet (admission record)," indicated Resident 11 was a 64 year-old male, who was admitted to the facility on XXXXXXX16, with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) with behavioral disturbances and schizophrenia (a deterioration of mental function and disturbance in which a split from reality existed and disordered thinking is present).
A review of Resident 11's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 12/21/16, indicated Resident 11 was moderately impaired in cognitive skills (ability to think and reason) for daily decision making and was independent with locomotion (how resident moves between locations).
A review of Resident 11's record titled, "Interdisciplinary Team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) Notes," dated 4/25/17, indicated the IDT recommended Resident 11 to be on a one on one supervision.
A review of Resident 11's record titled, "Incident Accident Short Term Care plan, dated 4/25/17, indicated Resident 11 was agitated and was verbally and physically aggressive. The interventions included to provide one-on-one supervision.
A review of Resident 11's record titled, "Nurses Notes," dated 5/28/17 at 3 p.m., indicated Resident 11 was slightly agitated and a staff (not identified in the notes) found Resident 11 (on the floor) with his wheelchair tipped over. The Nurses Notes indicated that at 3:50 p.m., Resident 11 had bloody hands and Resident 22's face and hands were covered in blood.
During an interview, on 6/5/17, at 9:16 a.m., Registered Nurse 1 (RN 1) stated that Resident 11 had a history of aggressive behaviors and was supposed to be on a one-on-one monitoring since the last IDT meeting (4/25/17). RN 1 stated Resident 11 was left unsupervised and that the incident between Resident 11 and Resident 22 should have been prevented.
During a telephone interview, on 6/6/17 at 2:30 p.m., Licensed Vocational Nurse 2 (LVN 2) stated that Resident 11 had an unwitnessed fall on 5/28/17, and Resident 11 was agitated. LVN 2 stated he (LVN 2) and RN 2 took Resident 11 back to his room after the fall and "we left him alone." LVN 2 stated the staff did not do neuro checks (a close observation and assessment of brain functions and level of consciousness) to Resident 11 after the fall.
According to an article titled, ?Neurological checks for head injuries,? retrieved from Long Term Care Nursing Library at http://www.hcpro.com, dated 1/8/13, neurological checks for head injuries included assessment of the resident for changes in level of consciousness, observation of injuries including lacerations, and performing frequent neurological assessments every:
15 minutes for two hours
30 minutes for two hours
60 minutes for four hours
Eight hours for 16 hours
Eight hours until at least 72 hours have elapse and resident is stable.
During an interview, on 6/6/17, at 3:06 p.m., Certified Nurse Assistant 2 (CNA 2), who worked the 3 p.m. to 11 p.m. shift, stated Resident 11was able to walk on his own and was supposed to be on a one-on-one supervision at all times. CNA 2 stated on 5/28/17, around 4 p.m., she heard moaning sounds coming from Resident 11?s and Resident 22's room. CNA 2 stated she saw Resident 11 standing by Resident 22's right side of the bed. CNA 2 stated she saw Resident 11 with blood on his hands and Resident 22 had blood on his face. CNA 2 stated she tried to stop Resident 11 from hitting Resident 22 and Resident 11 lifted his hands up trying to hit her (CNA 2) then continued to hit Resident 22. CNA 2 stated she left the room to call for help. CNA 2 stated that Resident 22 looked "scared."
During an interview, on 6/6/17, at 3:21 p.m., RN 2 stated Resident 11 was supposed to be on a one on one supervision due to Resident 11's aggressive behaviors. RN 2 stated that on 5/28/17, Resident 11 was not on a one on one supervision because the facility was short of staff. RN 2 stated Resident 11 hit Resident 22 in the face and arms on 5/28/17, inside their shared room. RN 2 stated Resident 22 "looked very scared." RN 2 stated Resident 22 was bedbound and was not able to call for help.
A review of RN 2's declaration, dated 6/6/17, indicated Resident 11 fell on 5/28/17; he was taken to his room and that 15 minutes later, RN 2 came back to the room and found Resident 22's face covered in blood and Resident 22 was shaking.
A review of Resident 22's Face Sheet indicated Resident 22 was an 87 year-old male, who was admitted to the facility on XXXXXXX16, with diagnoses that included dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and cataracts (cloudy areas in the lens of the eye that could cause changes in vision).
A review of Resident 22's MDS, dated 11/8/16, indicated Resident 22 had severe cognitive impairment and was totally dependent on staff with activities of daily living, including bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed).
A review of Resident 22's untitled general acute care hospital (GACH) record, dated 5/29/17, at 3 a.m., indicated Resident 22 was assaulted by another resident (Resident 11) at the facility and Resident 22 had facial trauma (injury to the face). The GACH record indicated a computerized tomography ([CT], an x ray images taken from different angles) scan of his head taken on 5/29/17, showed diffused (spread) bilateral (both) frontal (relating to the forehead or front part of the skull) small amount of subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain). The GACH record indicated Resident 22 was placed in the ICU.
A review of Resident 22?s Nurses Notes, dated 5/31/17, indicated Resident 22 was readmitted to the facility. The resident had multiple scratches on the forehead, discoloration (purple in color) surrounding both eyes, bruises on both hands, and skin tears on both hands.
During an observation, on 6/2/17, at 7:23 a.m., Resident 22 had multiple scratches and bruises to his face and both arms. Resident 22 had facial grimacing.
The facility failed to provide adequate supervision to Resident 11 by failing to:
1. Provide a one-on-one supervision (one staff dedicated to be present with one resident at all times) to Resident 11 in accordance with the plan of care.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013376 |
B |
27-Jul-17 |
4UJK11 |
5892 |
42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 15 sustained a right pelvic fracture (the large bony structure near the base of the spine was broken).
2. Report the results of the investigation to the Department within five working days, from the time the injury of unknown origin was reported to the administrator/designee.
These deficient practices had the potential for Resident 15 to further sustain unexplained injuries.
On 9/15/16, the facility sent a report to the Department that Resident 15 was sent to a general acute care hospital (GACH) for an evaluation of a right pelvic fracture. There was no evidence Resident 15 had fallen in the facility. The Department did not receive a result of the facility's investigation regarding how Resident 15 sustained the pelvic fracture.
A review of Resident 15's face sheet indicated Resident 15 was an 81-year-old female, who was admitted to the facility on XXXXXXX16 with diagnoses of Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior).
A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/22/16, indicated Resident 15 was severely impaired in cognitive skill for daily decision making; she required extensive assistance (resident involved in activity; staff provide weight-bearing support) with transfers with the assistance of one person; and she was totally dependent on staff with personal hygiene, dressing and toilet use with the assistance one person.
A review of Resident 15's Diagnostic Laboratories report, dated 9/14/16, indicated that Resident 15 had an acute displaced fracture (the bone breaks in two or more pieces and is no longer correctly aligned) of the right superior pubic ramus (a part of the pelvic or hip bone).
A review of Resident 15's GACH's records, dated 9/15/16 and timed at 4:47 p.m., indicated that Resident 15 was discharged back to the facility on XXXXXXX16 (same day) with a closed fracture (the broken bones do not break the skin) of right superior (upper) pubic ramus (pelvis) and that Resident 15 was supposed to follow up with her primary care within two to three days (9/17/16 or 9/18/16).
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated he did not know how Resident 15 sustained the fracture. The ADM stated that he (ADM) did not complete a thorough investigation and he did not send the final report (results of the investigation) within 5 days to the Department.
A review of the facility's policy and procedure titled, "Incident Management," dated 6/6/13, indicated that the facility required staff to initiate an investigation report for injuries of unknown origin. The policy indicated that the facility required staff to interview individuals who witnessed the incident, or have knowledge of the incident and that the safety committee reviewed the trend analysis to assist in the identification of trends, patterns, and establishment of preventative measures into action plans.
A review of the undated facility?s policy and procedure titled ?Policy on Abuse Prevention,? indicated that upon completion of the investigations, the administrator and or designee would send the final investigation outcome to the appropriate agencies within five days.
The facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 15 sustained a right pelvic fracture (the large bony structure near the base of the spine was broken).
2. Report the results of the investigation to the Department within five working days, from the time the injury of unknown origin was reported to the administrator/designee.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 15. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013377 |
B |
27-Jul-17 |
4UJK11 |
7094 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 7 and 19.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 9/24/16, the facility sent a report to the Department about an alleged abuse incident involving an altercation between Resident 7 and 19, which happened on 9/23/16 at 8:50 p.m. Resident 19 scratched Resident 7 on the chin and neck. The Department did not receive the result of the facility's investigation.
A review of Resident 19's face sheet indicated Resident 19 was a 58 year-old female, who was admitted to the facility on XXXXXXX13 with diagnoses of hemiplegia (paralysis of one side of the body) and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).
A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/18/16, indicated Resident 19 was moderately impaired in cognitive skills for daily decision making, unable to ambulate, and required extensive assistance (resident involved in activity; staff provide weight bearing support) with one person assist for bed mobility, toileting, and dressing.
A review of Resident 7's face sheet indicated Resident 7 was a 47 year-old female, who admitted to the facility on XXXXXXX13 with diagnoses of extrapyramidal and movement disorder (are drug-induced movement disorders), and schizoaffective disorder.
A review of Resident 7's MDS, dated 7/15/16, indicated Resident 7's cognition for daily decision making was intact and the resident was independent with activities of daily living (ADLs).
A review of Resident 7's Nurses Notes, dated 9/24/16, and timed at 9 p.m., indicated that Resident 7 had a scratch to the right side of her chin and neck.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated he did not send the final report (results of the investigation) within 5 days to the Department.
During an interview, on 6/7/17 at 3 p.m., the ADM, assistant administrator, director of nursing (DON), and a registered nurse (RN 1) stated that the incident was not investigated properly.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 7 and 19.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 7. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013378 |
B |
27-Jul-17 |
4UJK11 |
6939 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 3 and 4.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 12/1/16, the facility sent a report to the Department about an alleged abuse incident involving an altercation between Resident 3 and 4, which happened on 11/30/16 at 2:30 p.m. Resident 3 hit Resident 4 on his right eye while he was sitting outside the facility?s building. The Department did not receive the result of the facility's investigation.
A review of Resident 3's face sheet (admission record) indicated Resident 3 was a 58 year-old female, who was admitted to the facility on XXXXXXX13 with diagnoses of morbid obesity (a complex disorder involving an excessive amount of body fat).
A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/25/16, indicated Resident 3's cognitive skills was intact for daily decision making and she was independent with locomotion on and off the unit.
A review of Resident 3's Social Work Progress Notes, dated 11/30/16 (untimed), indicated Resident 3 struck Resident 4 on his right eye.
A review of Resident 4's face sheet indicated Resident 4 was an 89 year-old male, who was admitted to the facility on XXXXXXX15 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and Alzheimer's disease (a progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks).
A review of Resident 4's MDS, dated 9/23/16, indicated Resident 4's cognition was severely impaired for daily decision making and he required extensive assistance (resident involved in activity; staff provide weight bearing support) with two people assist with transfer and locomotion off unit.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated that he did not complete a thorough investigation and he did not send the final report (results of the investigation) within 5 days to the Department.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated that an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 3 and 4.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 4. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013380 |
B |
27-Jul-17 |
4UJK11 |
7173 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 12 and 13.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 10/14/16, the facility sent a report to the Department about an alleged abuse incident involving Resident 12 and 13, which happened on 10/14/16 at 2:30 p.m. The facility report indicated Resident 13 was found by a staff member locked in the restroom of his room. Resident 12 locked Resident 13 in the restroom. The Department did not receive the result of the facility's investigation.
A review of Resident 12's face sheet (admission record) indicated Resident 12 was a 58 year-old male, who was admitted to the facility on XXXXXXX15 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and cataracts (cloudy areas in the lens of the eye that can cause changes in vision).
A review of Resident 12's Minimum Date Set (MDS, a standardized assessment and care planning tool), dated 9/14/16, indicated Resident 12's cognition for daily decision making was intact and the resident was independent with locomotion on and off the unit.
A Review of Resident 12's Nurses Notes, dated 10/14/16 and timed at 2:30 p.m., indicated that Resident 12 locked a peer (Resident 13) in the restroom.
A review of Resident 13's face sheet indicated Resident 13 was an 81 year-old male, who was admitted to the facility on XXXXXXX 11 with diagnoses of dementia and generalized muscle weakness.
A review of Resident 13's MDS, dated 7/1/16, indicated Resident 13's cognition was severely impaired for daily decision making and he required extensive assistance (resident involved in activity; staff provide weight bearing support) with one person assist with transfer and locomotion off the unit.
During an interview, on 6/5/17 at 7:27 a.m., Resident 12 stated that he locked Resident 13 in the restroom because Resident 13 was "yelling."
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated he did not send the final report (results of the investigation) within 5 days to the Department.
During an interview, on 6/7/17 at 3 p.m., the ADM, assistant administrator, director of nursing (DON), and a registered nurse (RN 1) stated that the incident was not investigated properly.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated that an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 12 and 13.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 13. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013381 |
B |
27-Jul-17 |
4UJK11 |
6219 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on observation, interview and record review the facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 11 sustained a left hip fracture.
2. Report the results of the investigation to the Department within five working days, from the time the injury of unknown origin was reported to the administrator/designee.
These deficient practices had the potential for Resident 11 to further sustain unexplained injuries.
On 4/1/17 at 5:31 p.m., the facility sent a report to the Department that Resident 11 was sent to a general acute care hospital (GACH) for an evaluation of an acute left femoral neck (hip) fracture. The Department did not receive a result of the facility's investigation regarding how Resident 11's sustained the left hip fracture.
A review of Resident 11's Nurses Notes, dated 4/1/17 and timed at 5:30 a.m., indicated Resident 11 kicked a certified nursing assistant (CNA 7). At 7:45 a.m., Resident 11 complained of pain to his left knee while a CNA (not identified in the nurses? notes) was attempting to change Resident 11's disposable brief.
A review of Resident 11's Diagnostic Laboratories report, dated 4/1/17, and timed at 3:57 p.m., indicated that Resident 11 had an acute (sudden onset) left subcapital femoral neck fracture (broken bone of the neck of the femur or hip) with mild displacement.
A review of Resident 11's GACH records titled, "Discharge Summary," dated 4/5/17 and timed at 1:26 p.m., indicated that Resident 11 underwent general anesthesia (medically induced coma) for a left hip hemiarthroplasty (the top of the thigh bone [femur] is replaced by a metal implant).
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated he did not know how Resident 11 sustained the fracture. The ADM stated he should had completed the investigations and sent the final report (results of the investigation) within 5 days to the Department.
During an interview, on 6/13/17 at 12:47 p.m., a registered nurse (RN 1), the former director of nursing (DON), stated that she did not know what happened during the night shift (11 p.m. to 7 a.m. shift) on 4/1/16.
A review of Resident 11's face sheet (admission record), indicated Resident 11 was a 64-year-old male, who was admitted to the facility on XXXXXXX 16 with diagnoses of dementia with behavioral disturbances (a decline in mental ability severe enough to interfere with daily life) and schizophrenia (a serious mental illness characterized by incoherent or illogical thoughts, bizarre behavior and speech, and delusions or hallucinations, such as hearing voices).
A review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/21/16, indicated Resident 11 was moderately impaired in cognitive skills (ability to think and reason) for daily decision making; he was independent during transfers and locomotion. The MDS indicated that Resident 11 required limited assistance (resident highly involved in activity; staff provide guided-maneuvering of limbs or other non-weight bearing assistance) in walking in the corridor.
A review of the facility's policy and procedure titled, "Incident Management," dated 6/6/13, indicated that the facility required staff to initiate an investigation report for injuries of unknown origin. The policy indicated that the facility required staff to interview individuals who witnessed the incident, or have knowledge of the incident and that the safety committee reviewed the trend analysis to assist in the identification of trends, patterns, and establishment of preventative measures into action plans.
A review of the undated facility?s policy and procedure titled ?Policy on Abuse Prevention,? indicated that upon completion of the investigations, the administrator and or designee would send the final investigation outcome to the appropriate agencies within five days.
The facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 11 sustained a left hip fracture.
2. Report the results of the investigation to the Department within five working days, from the time the injury of unknown origin was reported to the administrator/designee.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 11. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013382 |
B |
27-Jul-17 |
4UJK11 |
7120 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Report the injury of unknown origin within 24 hours to the Department.
2. Thoroughly investigate how Resident 23 sustained the fracture of the right arm.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
4. Report the results of the investigation to the Department within five working days, from the time the injury of unknown origin was reported to the administrator/designee.
These deficient practices had the potential for Resident 23 to further sustain unexplained injuries.
On 5/30/17, the facility sent a report to the Department that Resident 23 had a bruise on the right upper arm measuring 7 centimeter or cm (length) by 7 cm (width). The bruise was noticed by a staff member on 5/27/17 during a shower. On 5/28/17, the x-ray result showed Resident 23 had a fracture (broken bone) involving the neck of the humerus (the bone connecting to the shoulder). The physician ordered to immobilize Resident 23?s arm with an arm sling and to refer the resident for an orthopedic (the branch of medicine concerning the deformities of the muscles and bones) consult. The facility reported the injury of unknown origin to the Department three days after the discovery of the injury.
A review of Resident 23's face sheet (admission record) indicated Resident 23 was admitted to the facility on XXXXXXX12 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and unspecified bone disorder (disease that cause various abnormalities or deformities of bone).
A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/7/17, indicated Resident 23 was moderately impaired in cognitive skills for daily decision making and was totally dependent from two or more staff with transfers, bed mobility, and bathing.
A review of Resident 23's nurses' notes, dated 5/27/17, indicated an x-ray was performed to Resident 23's right humerus after a bruise was found on 5/27/17 during a shower.
A review of Resident 23?s Radiology Report indicated that on 5/28/17, there was a fracture involving the resident's neck of the humerus with medial (middle) displacement (the moving of something from its place or position).
A review of the facility?s final investigation result, which was received by the Department on 6/5/17 (six days after the facility sent the initial report), indicated that the facility was unable to determine the cause of the fracture due to Resident 23 was unable to verbalize how he (the resident) sustained the fracture.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated that he did not complete a thorough investigation, and that he should have completed the investigations and sent the final report (results of the investigation) within 5 days to the Department.
A review of the facility's policy and procedure titled, "Incident Management," dated 6/6/13, indicated that the facility required staff to initiate an investigation report for injuries of unknown
origin. The policy indicated that the facility required staff to interview individuals who witnessed the incident, or have knowledge of the incident and that the safety committee reviewed the trend analysis to assist in the identification of trends, patterns, and establishment of preventative measures into action plans.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
The facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Report the injury of unknown origin within 24 hours to the Department.
2. Thoroughly investigate how Resident 23 sustained the fracture of the right arm.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
4. Report the results of the investigation to the Department within five working days, from the time the injury of unknown origin was reported to the administrator/designee.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 23. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013383 |
B |
27-Jul-17 |
4UJK11 |
5789 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 18 sustained bruise on his left inner knee and left upper hip, which was discovered on 7/10/16, and a dark purple discoloration to his abdomen, which was discovered on 9/23/16.
2. Report the results of the investigation to the Department within five working days, from the time the injuries of unknown origin was reported to the administrator/designee.
These deficient practices had the potential for Resident 18 to further sustain unexplained injuries.
A review of Resident 18's face sheet (admission record) indicated Resident 18 was a 53 year-old male, who was admitted to the facility on XXXXXXX14 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and cataracts (a clouding of the lens in the eye which leads to a decrease in vision).
A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/1/16, indicated Resident 18's cognitive skills for daily decision making was intact and that the resident was independent on transfers, bed mobility, and walking in the room and corridor.
a. A review of Resident 18's Nurses Notes, dated 7/10/16, and timed at 3:41 p.m., indicated Resident 18 had a bruise on his left inner knee measuring 5.5 centimeter (cm in length) by 9 cm (width) and a bruise to his left upper hip measuring 6 cm (length) by 2 cm (width), and that Resident 18 did not know how the bruises occurred.
On 7/11/16, the facility sent a report to the Department that Resident 18 had unexplained bruises to his left upper hip and inner knee. The Department did not receive the result of the facility's investigation.
b. A review of Resident 18's Nurse Notes, dated 9/23/16, and timed at 4:30 p.m., indicated Resident 18 was noted with a dark purple discoloration that measured 12.5 cm (length) by 6 cm (width) to his right side of the abdomen.
On 9/23/16, the facility sent a report to the Department that Resident 18 had unexplained bruises to his right lower abdomen. The Department did not receive the result of the facility's investigation.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated he did not know how Resident 18 sustained bruises on different occasions. The ADM stated that he (ADM) did not complete a thorough investigation and he did not send the final report (results of the investigation) within 5 days to the Department.
A review of the facility's policy and procedure titled, "Incident Management," dated 6/6/13, indicated that the facility required staff to initiate an investigation report for injuries of unknown
origin. The policy indicated that the facility required staff to interview individuals who witnessed the incident, or have knowledge of the incident and that the safety committee reviewed the trend analysis to assist in the identification of trends, patterns, and establishment of preventative measures into action plans.
A review of the undated facility?s policy and procedure titled ?Policy on Abuse Prevention,? indicated that upon completion of the investigations, the administrator and or designee would send the final investigation outcome to the appropriate agencies within five days.
The facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 18 sustained bruise on his left inner knee and left upper hip, which was discovered on 7/10/16, and a dark purple discoloration to his abdomen, which was discovered on 9/23/16.
2. Report the results of the investigation to the Department within five working days, from the time the injuries of unknown origin was reported to the administrator/designee.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 18. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013385 |
B |
27-Jul-17 |
4UJK11 |
6817 |
F225 ? 42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
F226 - 42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 20 and 21.
2. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 5/18/17, the facility sent a report to the Department about an alleged abuse incident involving an altercation between Resident 20 and 21, which happened on 5/17/17 at 1:45 p.m. Resident 21 hit Resident 20 on the face. Resident 20 did not sustain any injuries. The final investigation report was received by the Department on 5/23/17 with no root cause analysis of why Resident 21 attacked Resident 20.
A review of Resident 20's face sheet (admission record) indicated Resident 20 was admitted to the facility on XXXXXXX16 with diagnoses of generalized osteoarthritis (occurs when the protective cartilage on the ends of your bones wears down over time), and hypertension (high blood pressure).
A review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/22/16, indicated Resident 20's cognition was intact for daily decision making and the resident required extensive assistance (resident involved in activity; staff provide weight bearing support) for locomotion on the unit.
A review of Resident 21's face sheet indicated Resident 21 was admitted to the facility on XXXXXXX16 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior).
A review of Resident 21's MDS, dated 1/23/17, indicated Resident 21 was moderately impaired in cognitive skills for daily decision making and required limited assistance (resident highly involved in activity; staff provide guided-maneuvering of limbs or other non-weight bearing assistance) from one staff for locomotion on the unit.
A review of nurses' notes, dated 5/17/17, indicated a facility staff (not identified in the notes) reported that Resident 21 hit Resident 20 on the right side of the face, by the eye, with a closed fist.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated that he did not complete a thorough investigation and that he should had completed the investigations.
During an interview, on 6/8/17 at 12:18 p.m., a licensed vocational nurse (LVN 2) stated that Resident 21 had being verbally aggressive towards Resident 20 different occasions but the incidents were not reported to the ADM. LVN 2 stated that the incident between Resident 20 and 21 on 5/17/17 could had been prevented if LVN 2 had notified the ADM regarding Resident 21's verbal aggressions towards Resident 20.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 20 and 21.
2. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 20. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013391 |
B |
27-Jul-17 |
4UJK11 |
6373 |
42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on observation, interview and record review the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged staff to resident physical abuse (rough handling during care) of Resident 9 by a certified nursing assistant (CNA 1).
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
During an observation, on 6/2/17 at 9:47 a.m., a certified nursing assistant (CNA 1) was changing Resident 9's disposable adult brief. CNA 1 pulled the resident's draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress to cover the area between the person's upper back and thighs, often used by medical professionals to move patients) fast and hard despite the resident asking CNA 1 to stop. Resident 9 told CNA 1, "Stop, don't hurt me, don't hurt me, ouch." The administrator (ADM) was notified of the observation made by the surveyor.
During the observation, CNA 1 did not notify Resident 9 regarding the changing process and CNA 1 continued to pull hard on the draw sheet and the adult brief during care. Resident 9 had a Stage IV pressure sore (a full thickness tissue loss with exposed bone, tendon or muscle) on the coccyx area.
A review of the facility's CNA Schedule for June 2017 indicated that CNA 1 worked on 6/3/17, 6/4/17, and 6/5/17.
During an interview, on 6/6/17 at 4:49 p.m., the administrator (ADM) stated that he did not believe that rough handling was an act of abuse and that he did not investigate the roughness during care of CNA 1 to Resident 9. The ADM stated that he did not think that he was supposed to send a final conclusion letter of his investigation to the Department.
A review of Resident 9?s Admission Record indicated that Resident 9 was an 81 year-old male, who was admitted to the facility on XXXXXXX11 with diagnoses of dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and major depressive disorder.
A review of Resident 9?s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/16/17, indicated that Resident 9 required extensive assistance for bed mobility requiring on person to assist and was totally dependent with toilet use requiring one person to assist.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged staff to resident physical abuse (rough handling during care) of Resident 9 by a certified nursing assistant (CNA 1).
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 9. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013392 |
B |
27-Jul-17 |
4UJK11 |
7047 |
42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 1 and 2.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 11/11/16, the facility sent a report to the Department about an alleged abuse incident involving an altercation between Resident 1 and 2, which happened on 11/11/16 at 8:30 a.m. A facility staff witnessed Resident 1 hit Resident 2 on his right arm. Resident 2 did not sustain any injuries. The Department did not receive the result of the facility's investigation.
A review of Resident 1's face sheet (admission record) indicated Resident 1 was a 55-year-old male, who was admitted to the facility on XXXXXXX16 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and mood disorder.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/5/16, indicated Resident 1's cognition for daily decision making was intact and was independent with activities with daily living (ADLs).
A review of Resident 2's face sheet indicated Resident 2 was a 75year-old male, who was admitted to the facility on XXXXXXX15 with diagnoses of Alzheimer's disease (a progressive brain disease that slowly destroys memory and thinking skill, and eventually even the ability to carry out the simplest tasks) and dementia.
A review of Resident 2's MDS, dated 8/26/16, indicated Resident 2 was severely impaired in cognitive skills for daily decision making and was total dependent for transfers (how resident moves between surfaces) and locomotion off unit (how resident moves to and from of the unit) requiring one person assist.
A review of a QA (Quality Assurance) report, dated 11/11/16, indicated Resident 1 became aggressive towards staff and the residents. The QA report did not identify what was the root cause of Resident 1 becoming aggressive towards staff and residents.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated that he did not complete a thorough investigation and that he should had completed the investigations and sent the final report (results of the investigation) within 5 days to the Department.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated that an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 1 and 2.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 2. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013394 |
B |
27-Jul-17 |
4UJK11 |
7235 |
42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 1 and 24.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 5/27/17, the facility sent a report to the Department about an alleged abuse incident involving an altercation between Resident 1 and 24, which happened on 5/26/17 at 1:30 p.m. Resident 24 went to the nursing station to report that Resident 1 hit him at the side of his mouth. The alleged incident was not witnessed. Resident 24 did not sustain any injuries. The Department did not receive the result of the facility's investigation.
A review of Resident 1's face sheet (admission record) indicated Resident 1 was a 55-year-old male, who was admitted to the facility on XXXXXXX16 with diagnoses of dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and mood disorder.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/5/16, indicated Resident 1's cognition for daily decision making was intact and was independent with activities with daily living (ADLs).
A review of Resident 24's face sheet indicated Resident 24 was a 71 year-old male, who was admitted to the facility on XXXXXXX16 with diagnoses of generalized muscle weakness and dementia.
A review of Resident 24's MDS, dated 4/14/17, indicated Resident 24's cognition was intact; and was total dependent on staff (two people assist) for transfers. The same MDS indicated that Resident 24 did not ambulate and needed limited assistance with one staff for locomotion using his wheelchair.
A review of Resident 24?s nurses' notes, dated 5/26/17, indicated Resident 24 was hit on the right side face by the mouth by Resident 1.
A review of the QA report, dated 5/26/17, indicated the incident was unwitnessed and no further investigation was conducted.
During an interview, on 6/2/17 at 2:42 p.m., License Vocational Nurse (LVN) 7 stated that the incident happened in the activity room while the residents were unsupervised. LVN 7 stated that the residents should be supervised at all times.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated that he did not complete a thorough investigation and that he should had completed the investigations and sent the final report (results of the investigation) within 5 days to the Department.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated that an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 1 and 24.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 24. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013400 |
B |
27-Jul-17 |
4UJK11 |
5784 |
42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 2 sustained a bruise to the right rib cage and the surrounding area of his right eye.
2. Report the results of the investigations to the Department within five working days, from the time the injuries of unknown origin were reported to the administrator/designee.
These deficient practices had the potential for Resident 2 to further sustain unexplained injuries.
A review of Resident 2's face sheet (admission record) indicated Resident 2 was a 75 year-old male, who was a admitted to the facility on XXXXXXX15 with diagnoses of Alzheimer's disease (a progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks) and dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior).
A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool,) dated 8/26/16, indicated Resident 2 was severely impaired in cognitive skills for daily decision making and was totally dependent for transfers (how resident moves between surfaces) and locomotion off unit (how resident moves to and from of the unit) requiring one person assist.
a. On 10/14/16, the facility sent a report to the Department that Resident 2 had an unexplained bruise on the right side of his rib cage. The Department did not receive the result of the facility's investigation.
A review of the facility's Quality Assurance (QA) report, dated 10/14/16, indicated Resident 2 was found with an unexplained bruise to the right side of his rib cage during a shower. The report indicated that the facility was unable to determine the cause of the bruise due to Resident 2 was unable to verbalize how it occurred.
b. On 5/23/17, the facility sent a report to the Department that Resident 2 had an unexplained bruise to the outer corner of his right eye. The Department did not receive the result of the facility's investigation.
A review of Resident 2's Nurses Notes, dated 5/23/17 and timed at 6:20 p.m., indicated that Resident 2 was noted to have a bruise to the surrounding area of his right eye and the resident did not know how he sustained the bruise.
During an interview, on 6/7/17 at 2:50 p.m., the administrator (ADM) stated he did not know how Resident 2 sustained the bruises. The ADM stated that he did not complete a thorough investigation (for the two injuries of Resident 2) and he did not send the final report (results of the investigations) within 5 days to the Department.
A review of the facility's policy and procedure titled, "Incident Management," dated 6/6/13, indicated that the facility required staff to initiate an investigation report for injuries of unknown
origin. The policy indicated that the facility required staff to interview individuals who witnessed the incident, or have knowledge of the incident and that the safety committee reviewed the trend analysis to assist in the identification of trends, patterns, and establishment of preventative measures into action plans.
A review of the undated facility?s policy and procedure titled ?Policy on Abuse Prevention,? indicated that upon completion of the investigations, the administrator and or designee would send the final investigation outcome to the appropriate agencies within five days.
The facility failed to implement its policy and procedure for investigating and reporting injuries of unknown origin by failing to:
1. Thoroughly investigate how Resident 2 sustained a bruise to the right rib cage and the surrounding area of his right eye.
2. Report the results of the investigation to the Department within five working days, from the time the injuries of unknown origin was reported to the administrator/designee.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 2. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013401 |
B |
27-Jul-17 |
4UJK11 |
9582 |
42 CFR ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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, andif the alleged violation is verified appropriate corrective action must be taken.
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review the facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 11 and 22.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
These deficient practices had the potential for abuse incidents to recur.
On 5/29/17 at 10:11 a.m., the facility sent a report to the Department about an alleged abuse incident, which involved an altercation between Resident 11 to Resident 22, which happened on 5/28/17 at 3:50 p.m. On 5/30/17 at 1:31 p.m., the Department received a complaint regarding Resident 22 being a victim of an assault by another resident (Resident 11).
A review of Resident 11's face sheet (admission record), indicated Resident 11 was a 64-year-old male, who was admitted to the facility on XXXXXXX 16 with diagnoses of dementia with behavioral disturbances (a decline in mental ability severe enough to interfere with daily life) and schizophrenia (a serious mental illness characterized by incoherent or illogical thoughts, bizarre behavior and speech, and delusions or hallucinations, such as hearing voices).
A review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/21/16, indicated Resident 11 was moderately impaired in cognitive skills (ability to think and reason) for daily decision making; was independent during transfers (how resident moved between surfaces including to or from bed, chair, wheelchair) and locomotion (how resident moves between locations in his room). The MDS indicated that Resident 11 required limited assistance in walking in the corridor.
A review of Resident 22's face sheet indicated Resident 22 was an 87-year-old male, who was admitted to the facility on XXXXXXX16 with diagnoses of dementia and cataracts (cloudy areas in the lens of the eye that can cause changes in vision).
A review of Resident 22's MDS, dated 5/28/17, indicated Resident 22's cognition was severely impaired and the resident was totally dependent on staff with his activities of daily living (ADLs).
A review of Resident 11?s Nurses Notes, dated 5/28/17 at 3:50 p.m., indicated a certified nursing assistant (CNA 2) reported Resident 11 walking away from peer (Resident 22) with bloody hands and the peer (Resident 22) was covered in blood over his face and hands. The police was called and Resident 11 was left in the room with two CNAs watching him.
A review of Resident 22's untitled general acute care hospital (GACH) records, dated 5/29/17, and timed at 3 a.m., indicated that Resident 22 was assaulted by another resident (Resident 11) at the facility and that Resident 22 had facial trauma (injury on the face). Resident 22's Computed Tomography ([CT], combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues) scan of his head showed diffused (spread) bilateral (both) frontal (relating to the forehead or front part of the skull) small amount of subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) and that Resident 22 was in the intensive care unit (ICU). Resident 22 returned to the facility on 5/31/17.
During an interview, on 6/5/17 at 10:32 a.m., the administrator (ADM) stated that he did not conduct a thorough investigation regarding Resident 11's and Resident 22's altercation on 5/28/17. The ADM stated that he did not know that Resident 11 was left unsupervised on 5/28/17 and that he (the ADM) did not ask the staff as to what exactly happened before the altercation.
During an interview, on 6/6/17 at 3:06 p.m., CNA 2 stated that Resident 11 was able to walk on his own and that Resident 11 was supposed to be on a one-on-one supervision (one staff to be present with Resident 11 at all times). CNA 2 stated that on 5/28/17, she (CNA 2) heard moaning sounds coming from Resident 11 and Resident 22's shared room; she (CNA 2) saw Resident 11 standing over Resident 22's right side of the bed; and she (CNA 2) saw Resident 11 having blood on his hands and Resident 22 having blood on his face. CNA 2 stated that she tried to stop Resident 11 from hitting Resident 22 but Resident 11 lifted his hand and tried to hit her (CNA 2) and then continued to hit Resident 22. CNA 2 stated that Resident 22 looked "scared."
During an interview, on 6/6/17 at 3:21 p.m., RN 2 stated that Resident 11 was supposed to be on a one-on-one supervision due to Resident 11's aggressive behaviors. RN 2 stated that on 5/28/17, Resident 11 was not on a one-on-one supervision because the facility was short of staff.
During an interview, on 6/7/17 at 2:50 p.m., the ADM stated that he (ADM) should have completed the investigations and send the final report (results of the investigation) within 5 days to the Department.
A review of the facility's undated policy and procedure titled, "Policy on Abuse Prevention," indicated an internal investigation will be initiated by the facility in addition to notification within 24 hours of the Department of Health Services, local ombudsman, and other agencies as indicated. To complete the investigation, the administrator within 5 days of the incident, will notify in writing the appropriate agencies. The administrator or designee analyzes the investigation outcomes, and events through the Quality Assurance Committee to determine what actions are necessary to avoid recurrence.
The facility's policy and procedure was not updated to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). The facility's undated policy and procedure was not able to satisfy both the Federal and State laws and regulations on mandated reporting for abuse.
A review of the facility's undated policy and procedure titled "Resident to Resident Altercation," indicated steps for a facility staff to do when two residents are involved in an altercation, which included but not limited to: identifying what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and reviewing the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; making any necessary changes in the care plan approaches to any or all of the involved individuals.
A review of the undated facility's policy and procedure "Abuse Prohibition, Patient," indicated an immediate investigation of the incident would begin with the aim of concluding the investigation within five days and submit to the appropriate agencies.
The facility failed to implement its policy and procedure for abuse prevention, investigation, and reporting by failing to:
1. Thoroughly investigate an alleged physical abuse, involving a resident to resident altercation between Resident 11 and 22.
2. Report the results of the investigation to the Department within five working days, from the time the allegation of abuse was reported to the administrator.
3. Revise the facility's abuse reporting policy and procedure to include the time frames for mandated reporting according to the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA).
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 22. |
| 630013546 |
Downey Adult Home Care III |
960010301 |
A |
30-Jan-14 |
BYHB11 |
8939 |
Title 22 ?76918. Client's Rights. Each client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550, Title 17. California Administrative Code. NOTE: Authority cited: Sections 208.4 and 1267.7, Health and Safety Code. Reference: Section 1276, Health and Safety Code.W & I Code 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, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.On April 10, 2012, an unannounced visit was made to the facility to conduct an initial certification survey.Based on observation, interview and record review, the facility staff failed to ensure Client 2 was free from harm and unnecessary physical restraint by:1. Restraining the client in a wheelchair while waiting in the doctor?s office to be seen by the doctor despite the client?s non-verbal disapproval of being in the wheelchair and pounding on the wheelchair's arm rest. As a result the client sustained a lower arm fracture.A review of the client's medical record indicated Client 2 was admitted to the facility October 8, 2011 with diagnoses that included profound developmental disability (cognitive ability that was markedly below average level). According to the Consumer Developmental Evaluation Report dated July 19, 2011, Client 2 communicated non-verbally through movement, smiling, making eye contact and the like. She also needed assistance with personal care activities.On April 10, 2012 at 5:55 a.m., during observations, Client 2 was sitting in the living room on the sofa with her left lower arm in a cast and a sling was applied to the cast.On April 11, 2012 at 4:15 p.m., during observations, the client returned home from the day program with her left arm and part of her hand in a pink cast, without a sling.On April 11, 2012 at 6:30 p.m., during an interview, while Staff B was assisting the client with her game card and game pieces, Staff B stated the client was left handed and had to do things with her right hand because of the injury to the left arm.On April 10 and 11, 2012, during meal observations, the client was fed by staff and was able to express her dislikes non- verbally with her movements. A review of the occupational therapy assessment dated November 21, 2011, prior to the injury, indicated the client feed herself and required assistance to slow down.On April 10, 2012 at 7:40 a.m., during an interview, Staff A stated, the client was usually placed in a wheelchair for long walks and appointments.On March 8, 2012, the client had an appointment with the neurologist. The client was transported by the facility?s van and was placed in the wheelchair at the doctor's office. While the client was seat belted in the wheelchair she became agitated and pounded the wheelchair with her upper limbs. The client did not see the physician that day because the appointment was canceled after they had waited.Staff A stated the fracture was self-inflicted.On August 1, 2013 at 1 p.m., during an interview with Staff A, she stated Client 2 was buckled in the wheelchair with a seatbelt at the neurologist office.On April 10, 2012 at 9:15 a.m., during an interview, the qualified intellectual disabilities professional (QIDP) stated the client had a behavior of pounding her arm when she does not want to do something.However, there was no supportive documentation provided by the facility that a plan was in place when the client bangs her arm.A review of the client?s behavior plans dated December 2011, indicated the client had two behaviors. One plan was to decrease disrobing behaviors in public areas of the residence. The other plan was to eliminate self- injurious behavior of hitting/ slapping her temporal (side of her head) with both fists. Staff was to tell Client 2 she was okay using a calm voice and gentle physical prompts to bring her hands to her lap, and then re-directing her to prior activities when she was calmer. There was no behavior plan in place that addressed the client?s behavior of banging her arm on the wheelchair when she did not want to do something as stated by the QIDP.On April 10, 2012 at 9:20 a.m., during an interview, regarding the incident on March 8, 2012, the licensee/ administrator stated to prevent that behavior and injury, staff should encourage the client to do things that do not trigger her behavior such as putting their hands in the way of the client pounding and re-direct the client. She stated the client should have been in a regular chair and not left in the wheelchair to prevent the client from injuring herself.A review of the facility's incident report dated March 9, 2012 indicated; the client had a history of self-abusive behaviors and was agitated while sitting in her wheelchair waiting for a neurology visit (March 8, 2012). The client pounded her wheelchair's arm rest as she hated the long wait and sitting in the wheelchair. ?She must have obtained the fracture at that time (self-inflicted).? She was re-directed a few times when she was pounding the wheelchair's arm rest and later she calmed down on her way to the day program after leaving the neurology office. During morning hygiene the following day (March 9, 2012), staff noticed a difference between the client?s wrists that the left wrist was swollen.The client was taken to the doctor's office for evaluation and x-ray which revealed a distal ulna fracture (lower arm fracture). The client was then taken to a medical center emergency room where she received a splint to her left wrist and was discharged. The facility concluded that the client?s lower arm fracture was possibly self-inflicted.On April 12, 2012 at 3:38 p.m., an interview with Staff A continued regarding what she did to prevent the client from hurting herself in the wheelchair in the waiting room.Staff A stated she re-directed the client by holding her hands and by telling the client "don't do that and stop it for the first few hours.? She stated the client remained in the wheelchair banging her arm until she was out of the wheelchair, sitting in the transportation vehicle, on her way to her day program.On October 17, 2013 at 9:45 a.m., during a telephone interview with the neurologist office worker, she stated the office did not have sign sheets for April 2012; however, the neurologist?s assistant may be able to give further information.On October 29, 2013 at 2 p.m., during a telephone interview with the neurologist?s assistant, she stated Client 2 had an appointment scheduled March 8, 2012 at 9:15 a.m. A record review of the day program?s sign in sheet dated March 8, 2012, indicated Client 2 was signed in, by Staff A, at 10:10 a.m. A review of the physical therapy annual assessment dated November 18, 2011, indicated the client utilizes a wheelchair for long distance community mobility only and to continue to walk at home for mobility with assistance as needed.A review of a physician's report dated April 6, 2012 indicated the client was status post left ulnar (lower arm) fracture, that was a self-imposed trauma by the client flinging her arms. The report further indicated the client was being followed by an orthopedist (orthopedic, surgeons specializing in muscular skeletal injuries, disorders and disease) and had a short arm cast of the left upper extremity. A review of the direct care person job description signed by staff July 19, 2011indicated staff was responsible for respecting and promoting the individual rights of the clients.Upon transportation, staff was to supervise and assist the client to maintain adequate safeguards for client protection during outings.The facility staff failed to ensure Client 2 was free from harm and unnecessary physical restraint. 1. Restraining the client in a wheelchair while waiting hours in the doctor?s office to be seen by the doctor despite the client?s non-verbal disapproval of being in the wheelchair and pounding on the wheelchair's arm rest.As a result the client sustained a left ulnar (lower arm) fracture, pain and decreased ability to feed herself as a result. 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. |
| 960002567 |
DELHAVEN COMMUNITY HOME |
960011152 |
B |
05-Dec-14 |
YMCU11 |
6425 |
Title 22, Division 5, Chapter 8.5, Article 4, 76918 (a) Client?s Rights. Each Client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550, Title 17, California Administrative Code.Welfare and Institution Code 4502 (b) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:(b) A right to dignity, privacy, and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports shall be provided in natural community settings.Based on observation, interview and record review, the facility staff failed to ensure Clients 3, 4 and 5?s right to privacy by failing to: 1. Close the bathroom door while Client 3 sat on the toilet. 2. Close the bathroom door and shower curtain while Client 5 was nude in the shower. 3. Ensure privacy during care of personal needs for Clients 4 and 5. Client 4 was brushing his teeth while Client 5 was in the shower and the bathroom door was opened. A review of Client 3?s clinical record on March 5, 2014, indicated he was admitted to the facility on April 12, 2004 with diagnoses that included moderate developmental delay (developmentally functions below chronological age and can learn elementary health and safety habits) and depression (a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer).A review of Client 4?s clinical record on March 5, 2014, indicated he was admitted to the facility on June 20, 2004 with diagnoses that included moderate developmental delay and Down?s syndrome (condition - result of an extra copy of chromosome 21- with several symptoms, including a characteristic body type, intellectual disability, increased susceptibility to infections, and various heart and other organ abnormalities). A review of Client 5?s clinical record on March 5, 2014, indicated he was admitted to the facility on October 5, 2009 with diagnoses that included moderate developmental delay and psychotic disorder [causes a loss of contact with reality that usually includes: False beliefs about what is taking place or who one is (delusions); Seeing or hearing things that aren't there (hallucinations)]. During an observation on March 4, 2014, at 5:38 a.m., Staff B exited the bathroom and left the door wide open revealing Client 5 as he stood nude, with his genitals in full view, in the shower with the curtain open.Staff B stood at the cabinet outside the bathroom for several minutes gathering supplies with the bathroom door open.During an observation on March 4, 2014, at 6:08 a.m., Client 4 was in the bathroom brushing his teeth, with the door open, while Client 3 was being showered by Staff B.Staff B left Client 3 in the shower and went outside the bathroom to get a new toothbrush from the hall cabinet for Client 4, with the door remaining open. During an observation on March 5, 2014, at 5:08 p.m., Staff B stood outside the opened bathroom door, while Client 3 was sitting on the toilet, with his pants down, in full view of anyone who passed by the hallway. Staff B stated, ?I can see (Client 3).? During an interview and signed declaration with Staff B, on March 5, 2014, at 5:55 p.m., he stated he watches Client 3 outside the bathroom because the client could fall down on the floor. He stated he leaves the door open just a little. Regarding Client 5, Staff B stated the client opened the shower curtain and he (Staff B) left the bathroom door open so he could see what the clients were doing.He stated he went in the cabinets outside the bathroom in order to obtain deodorant, lotion, electric shaver, towels and toothbrushes which were all kept in that cabinet.Staff B stated, Client 4 was brushing his teeth while the other client was showering because there was limited time in the mornings to get ready for the bus. He stated he had some privacy training, but he could not stop Client 4 from brushing his teeth when Client 5 was showering.During an interview and signed declaration with the qualified intellectual disabilities professional (QIDP), on March 5, 2014, at 6:08 p.m., she stated sometimes Client 4 walks into the bathroom when someone is in the bathroom, however, he should wait his turn. She stated staff should not leave the door open when a client is toileting or being showered. She stated, ?They should respect their right to privacy.?Regarding Client 3, the QIDP stated the door should be cracked so Staff B could hear, but no one walking in the hallway should be able to see the client.She stated Staff B would previously take everything needed in the bathroom before he went in there with the client. The QIDP stated, staff should remind Client 4, it is not his turn when someone else is using the bathroom.She stated under no circumstance are both clients to be in the restroom at the same time.The QIDP was unable to present any privacy training in the past year and then stated staff reviewed client rights when they were hired.The undated facility policy and procedure titled ?Clients Rights? indicated clients had the right to dignity, privacy and humane care, including privacy in treatment and in care for personal needs. The facility staff failed to ensure Clients 3, 4 and 5?s right to privacy by failing to: 1. Close the bathroom door while Client 3 sat on the toilet. 2. Close the bathroom door and shower curtain while Client 5 was nude in the shower. 3. Ensure privacy during care of personal needs for Clients 4 and 5. Client 4 was brushing his teeth while Client 5 was in the shower and the bathroom door was opened.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 960002685 |
DORE HOME |
960012567 |
A |
23-Sep-16 |
3V1M11 |
18320 |
Title 22: 76918 Clients Rights (a)Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code. 4502(h) Welfare and Institutions Code Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. Based on interview and record review, the facility?s administrative staff failed to protect Client 1 from sexual abuse by the alleged perpetrator (someone who has committed a crime or wrongful act), Direct Care Staff (DCS 1). According to Client 1, she wanted to move out of the facility because DCS 1 came into her room multiple times and abused her sexually. Client 1 became pregnant. The client's pregnancy was complicated with severe morning sickness (nausea in pregnancy, typically occurring in the first few months), dehydration and weight loss. As the result, the client's pregnancy had to be terminated. A review of Client 1's clinical record indicated the client was admitted to the facility on 8/12/2010 with diagnoses that included moderate intellectual disability (noticeable developmental delays) and psychogenic tremors (unwanted muscle movement such as a spasm or tremor that is caused by an underlying psychological condition). A review of the Regional Center Service Coordinator's (RCSC) report, dated 6/29/16, indicated on 6/29/16, the RCSC met Client 1 at the facility. Client 1 told the RCSC she tried to call the RCSC a couple of times, but the RCSC did not answer the phone and Client 1 did not leave messages. Client 1 stated she wanted to move out of the facility because while she was listening to music and watching TV, one of the staff, the guy with the Virgin Mary tattoo and wears an earring, came into her room, kissed her breasts and her vaginal area. Client 1 stated this happened when everyone was asleep. Client 1 then pointed at other female client who lives in the facility and stated "Why doesn't he go into her room?" Client 1 had history of fabricating stories, so the RCSC asked the client three times if she was lying. Client 1 stated "No." Client 1 stated "if I was lying, I would be laughing (Client 1 would do a nervous laugh when she was caught in a lie). Client 1 continued to state that she wants to cry, she does not want to live at the facility anymore and she wants to move. During an interview with Direct Care Staff 2 (DCS 2), on 7/6/16, at 7:55 a.m., she stated Client 1 was transferred to another facility on 6/29/16. DCS 2 stated around the second week of June 2016, in the morning, during breakfast, Client 1 told her there was a tall guy with tattoos who came into her bedroom at night, pulled her blouse down and touched her breasts. DCS 2 stated Client 1 did not mention the name of the tall guy with tattoos because the client had problems with memorizing people?s name. DCS 2 stated when Client 1 told her about the tall guy with tattoos, she knew the Client 1 was talking about DCS 1 because DCS 1 was tall and he had tattoos on his arms. DCS 2 stated DCS 1 lives in the facility and he sleeps in the small room in the converted garage at night. DCS 2 stated she reported the alleged sexual abuse to the Former Administrator (FA) in person on the same day when the FA visited the facility. DCS 2 stated the FA spoke to Client 1 regarding the sexual abuse allegation. DCS 2 stated after the FA spoke to Client 1, he told DCS 2 that Client 1 told him the same thing, "a tall guy with tattoo came into my room at night and touched my breasts." DCS 2 stated after Client 1 spoke to the FA, every morning, the client would tell the same story over and over again. During an interview with DCS 3, on 7/6/16, at 9:25 a.m., he stated on the second week of April 2016, while waiting for the van to pick up the clients to go to the day program, Client 1 spoke loudly in broken English and Spanish, with lot of hand gestures, stating at night, a tall guy with tattoos on his arms, came into her room, undressed her, touched and kissed her breasts. DCS 3 stated Client 1 also said something about the tongue and pointing to her butt and her vaginal area. DCS 3 stated when he first heard the story from Client 1; he thought the client was fabricating the story. DCS 3 stated sometime in May 2016 (he does not remember the exact date), he witnessed Client 1 tell the facility's FA the same story. DCS 3 stated after Client 1 told the FA the same story, the FA questioned the client "Are you sure, there was staff here at night." DCS 3 stated when he heard Client 1's story; he knew the client was talking about DCS 1 because DCS 1 was the only male in the facility that has tattoos on his arms. DCS 3 stated DCS 1 lived in a small room in the garage. DCS 3 stated DCS 1 does not have his own apartment and his family lives in another country. In addition, DCS 3 stated that during the second week of February 2016, the facility's administrative staff switched DCS 3's assignment with DCS 1 due to a female employee filing a sexual harassment grievance against DCS 1. During an interview with the current administrator (ADM) on 7/6/16, at 11 a.m., she stated DCS 1 stayed overnight in the little room in the garage. The ADM stated the FA allowed DCS 1 to stay in the little room in the garage since January 2016. The ADM stated DCS 1 does not have his own home or apartment. During an interview with the FA, on 7/6/16, at 1:20 pm, he stated DCS 1 worked at the facility during night shift (7 pm to 5:30 am) and at a sister facility during day shift (6 am to 8 am and 2:30 pm to 7 pm). The FA stated DCS 1 worked 6 to 7 days a week with an average of 15 hours per day. The FA denied that he was aware of the sexual abuse allegations by Client 1. During an interview with DCS 5, on 7/7/16, at 6:30 am, he stated in the beginning of April 2016, he heard Client 1 talk about a man with tattoos on his arms and wears an earring, came into her room, took her clothes off, and touched her breasts and her vaginal area. DCS 5 stated Client 1 told the story in Spanish but he could understand the client because she used lot of hand gestures. DCS 5 stated there were too many details in the story so he asked Client 1 "Who?" The client pointed to both arms and stated tattoos and pointed to the ear lobe gesturing earring. DCS 5 stated he questioned himself, was Client 1 talking about DCS 1 because DCS 1 had tattoos on both arms and wears an earring. DCS 5 stated DCS 1 worked night shift at the facility. DCS 5 stated he works at 5 am and ran into DCS 1 at the facility a couple times because DCS 1 works night shift at the facility. DCS 5 stated he was so shocked about the details in Client 1's story; he discussed it with his coworkers (DCS 2 and DCS 3). DCS 5 stated about a week after he first heard the story from Client 1, he heard Client 1 tell the FA the same story. DCS 3 stated while Client 1 was telling the story to the FA, she pulled her blouse down, exposed her breasts, and started to rub her breasts to demonstrate to the FA what DCS 1 did to her. DCS 5 stated, the FA was aware of Client 1's sexual abuse allegation. DCS 5 stated sometime in May 2016, DCS 3 told DCS 1 that DCS 1 should be aware of Client 1's sexual abuse allegation against him. DCS 5 stated after the FA learned about the conversation, the FA held a meeting telling staff to report everything to him (the administrator only) and not to speak or confront other coworkers. During an interview with DCS 3 on 7/7/16, at 8:55 a.m., he stated Client 1's complaint was not the first time complaining about sexual abuse/harassment against DCS 1. DCS 3 stated about a year ago, Client 2 complained that DCS 1 touches her inappropriately, but a couple days later, the client changed her story. DCS 3 stated in February of this year (2016), a female staff filed a sexual harassment case against DCS 1 due to DCS 1 touching her inappropriately. DCS 3 stated now Client 1 complained that DCS 1 came into her room, touched and kissed her. During an interview with DCS 2, on 7/7/16, at 10:05 a.m., she stated prior to DCS 1 transferring to the sister facility, every time Client 1 saw DCS 1, she pointed her finger at his face and said "Tattoo came in my room." DCS 2 stated she confronted DCS 1 but he said every time Client 1 sees him Client 1 said that but it was not true. DCS 2 stated Client 1 did not tell the story in detail until April 2016. DCS 2 stated when she assisted Client 1 with a shower, Client 1 pointed her finger to her anus area and said tattoo. During an interview with Client 1, with a Spanish speaking staff on 7/7/16, at 12:05 pm, at a new residential home, Client 1 stated she was transferred to the facility for a week now because of a guy who put his middle finger and his penis inside her vagina and made her bleed. Client 1 stated, she told everybody about this but no one believed her. Client 1 stated she does not remember the guy's name, but he was skinny, tall, with dark skin, wears an earring on the right ear and has tattoos on both arms and a Virgin Mary tattoo on his right leg. Client 1 stated the guy works and sleeps in the facility where she previously lived. Client 1 stated DCS 1 worked at the facility by himself on the weekends. Client 1 stated whenever other clients were asleep and other staff left the facility, DCS 1 would take a shower, brush his teeth, apply the deodorant and enter her room. DCS 1 would disconnect her radio and her TV. Client 1 stated she would close her eyes and pretend that she was sleeping but DCS 1 used the flash light on his phone and shined the light into her eyes. Client 1 stated DCS 1 removed all her clothes and his clothes, touched himself and her. Client 1 stated she would cry so he would get out of her room, but he did not. Client 1 stated she was afraid so she used the sheet to cover her face but DCS 1 did not like it. Client 1 stated DCS 1 put her breasts into his mouth and put his penis in her vagina and anus. Client 1 stated DCS 1 also put his penis into her mouth and asked her to kiss his penis, but she refused. Client 1 stated when she refused; DCS 1 pinched her (use her hand gesture as pinching). Client 1 stated when she yelled ?get out of my room? DCS 1 would turn her face down against the bed and insert his penis inside her anus. Client 1 stated when DCS 1 inserted his penis into her vagina and anus, it hurt. Client 1 stated DCS 1 puts his saliva and cream into her vagina, open her legs and hurt her. Client 1 stated whenever she did not let him do that to her; he would get mad and spank her. Client 1 stated DCS 1 was really jealous. Client 1 stated DCS 1 showed her a gun and told her if she falls in love with a new guy, he will kill her and the new guy with the gun. Client 1 stated the gun was a toy gun. Client 1 stated she likes coffee with cream, popsicles, and pork skin with chili. Client 1 stated DCS 1 would buy them for her. Client 1 stated when she refused to eat what he brought her, he would get mad. Client 1 stated, after she eats his food, her stomach would hurt. Client 1 stated when the guy with the tattoos "do that to her," she told "mama? (referring to DCS 2). Client 1 stated since she repeats herself so many times, Mama did not believe her. Client 1 stated even the police did not believe her and the police thinks she was crazy. Client 1 stated she was two months pregnant and because of the pregnancy, she could not eat anymore. She vomits the food that she eats. Client 1 asked the surveyor to help her by arresting the guy and put him in jail. Client 1 stated the guy need to be in jail because a woman should not have a baby when she does not want to. When the surveyor asked if there were any other people who touched and kissed her, the client stated ?no" only one, the tall guy with tattoos. A review of the Regional Center's report, dated 7/5/16, indicated RC's staff observed a back room located by the washer and dryer. The report indicated the former administrator, other staff members and clients confirmed that DCS 1 slept in the back room. The FA reported that DCS 1 worked at the facility on 6/4, 6/5, 6/11, 6/12, 6/18, and 6/19/2016 from 10 pm to 6 am. The report indicated, the regional center staff observed a paint ball gun, in the back room, that was not locked. A review of the Former Administrator's statement, dated 6/30/16, indicated DCS 1 was a full time employee who spends his nights at the facility when he was not assigned to work at any other facility. The statement indicated during these times, DCS 1 was not paid with a time card since they had an agreement. The statement indicated DCS 1 was an alert staff and he slept at the facility at night. The facility's administrative staff did not charge any rent or utilities. DCS 1 did not use a time card when he was on duty at night at the facility due to the agreement with the facility's Former Administrator. A review of DCS 1's work schedule, from 1/14/16 to 6/28/16, indicated DCS 1 worked at the facility with an average of 50 to 60 hours a week from 1/14/16 to 3/24/16. DCS 1 also worked at the facility from 4/25/16 to 4/27/16. DCS 1's schedule did not include the 12 hours night shifts on the weekend that he slept in the facility at night. During an interview with the facility's Qualified Intellectual Disabilities Professional (QIDP) from the facility where Client 1 presently resides, on 7/7/16, at 2:15 p.m., she stated staff took Client 1 to the doctor's office, on 6/30/16, for blood test and the blood test came back on 7/1/16 as positive for pregnancy. A review of Client 1's laboratory report, dated 7/1/16, indicated the client's blood result showed she was pregnant. The blood results indicated the client's Human chorionic gonadotropin (HCG, a hormone the body makes during pregnancy that can be detected in the mother's blood or urine) was high (142120 milli international units per milliliter mIU/ml). A review of the ultrasound report, dated 7/4/16, indicated Client 1 was pregnant with a single live fetus at 7 weeks and 2 days gestation +/1 week. The report indicated the fetus's heart rate was 169 beats per minute. The report also indicated Client 1 had abdominal pain and vomiting. During a telephone interview with the registered nurse (RN) from the new facility where Client 1 was residing, on 7/26/16, at 9:30 am, she stated the client was hospitalized from 7/8/16 to 7/13/16 due to the client not eating or drinking anything and for hypoglycemia (low blood glucose). A review of Client 1's first hospitalization record, dated 7/13/16, indicated the client was admitted to the hospital on 7/8/16 with diagnoses that included hyperemesis gravidarum (HG: a complication of pregnancy that is characterized by severe nausea and vomiting such that weight loss and dehydration occur), hypoglycemia (low blood sugar). The Client was discharged from the hospital on 7/13/16. During a telephone interview with the Regional Center Service Coordinator (RCSC), on 8/4/16, at 2 pm, she stated Client 1 was admitted to the hospital due to electrolytes imbalance and weight loss. The RCSC stated the client had lost more than 20 pounds; the client could not keep any food or fluid in her stomach due to severe morning sickness. The RCSC stated Client 1's pregnancy was not only a threat to her baby's life but it was also a threat to Client 1's life. The RCSC stated the Dilatation and Curettage (D & C - a procedure to remove products of pregnancy from inside the uterus) procedure was scheduled for tomorrow (8/5/16, at 8 am). A review of the second hospitalization record, dated 8/9/16, indicated Client 1 was hospitalized from 8/2/16 to 8/9/16 for intractable nausea and vomiting, dehydration, starvation ketosis (a metabolic state in which the body breaks down fat and produces acids called ketones), weight loss of 15 to 20 pounds within 17 days and profound tachycardia (increased in heart rate). A review of the Operative Report, dated 8/5/16, indicated Client 1 was 12 weeks pregnant secondary to sexual assault. Client 1 was taken to the operating room where general anesthesia was induced for a Dilatation and Evacuation procedure (D&E a procedure to remove products of pregnancy from inside the uterus). The operative report indicated under the ultrasound guidance, Client 1's cervix was dilated and suction was applied and the amniotic fluid was drained, as well as products of conception (the fetus). Client 1 was taken back to the Intensive Care Unit (ICU, a unit in the hospital that is dedicated to the care of seriously ill patients). A review of the discharge instruction, dated 8/9/16 indicated, Client 1 was discharged back to the third facility, on 8/9/16. A review of the facility's policy and procedure, titled "Abuse Prevention Program," indicated the clients have the right to be free from abuse. The facility?s administrative staff failed to protect Client 1 from sexual abuse by the alleged perpetrator, Direct Care Staff (DCS 1). According to Client 1, she wanted to move out of the facility because DCS 1 came into her room multiple times and abused her sexually. Client 1 became pregnant. The client's pregnancy was complicated with severe morning sickness (nausea in pregnancy, typically occurring in the first few months), dehydration and weight loss. As the result, the client's pregnancy had to be terminated. 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. |
| 960002322 |
DOUGLASS HOME |
960012908 |
A |
17-Feb-17 |
KR5011 |
13862 |
Title 22: 76918 Clients Rights
(a) Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code.
4502(h) Welfare and Institutions Code
Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds.
It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:
(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
On 10/5/16, at 7:15 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Client 1 not receiving proper care and supervision from staff to manage the client's new Jejunostomy (JT: a plastic tube surgically inserted through the abdomen to deliver formula, water and medication into the small intestine).
The facility's nursing staff failed to develop nursing care plans for staff to carry out the interventions in caring for Client 1?s new JT placed on 8/17/16. Client 1 was readmitted to a General Acute Care Hospital (GACH) three times for JT replacement due to the JT being clogged (blocked with an accumulation of thick, wet matter) and/or dislodged (pull out of the small intestines) from 9/2/16 to 10/3/16. Failure of the facility to develop a care plan to aid the direct care staff in caring for Client 1 restricted the client?s right to be free from harm.
A review of Client 1's face sheet, indicated the client was admitted to the facility on XXXXXXX16 with diagnoses that included severe intellectual disabilities (considerable delays in development), Autism (a mental condition, present from early childhood, characterized by difficulty in communicating and forming relationships with other people) and spastic quadriplegia (limited movement due to muscle stiffness affecting both lower and upper extremities).
During an observation of the facility, on 10/5/16, at 7:30 am, Client 1 was not at the facility. A concurrent interview was conducted with Direct Care Staff (DCS 1) and she stated Client 1 was readmitted to the hospital on Monday XXXXXXX16 due to the client pulling his JT out.
During an interview with DCS 2, on 10/5/16, at 8:30 am, she stated Client 1 had behaviors of touching his private parts (masturbation) and pulling his JT out. DCS 2 stated when Client 1 tried to get his hands into his groin area for masturbation, his hands also rub against the JT site and that was how the JT dislodged. DCS 2 stated for the last two and a half months, Client 1 had pulled his JT out three to four times. When asked what preventive measure had staff been taken to prevent the JT from being pulled out by the client, DCS 2 stated when Client 1 returned from the hospital he had an abdominal binder to prevent the client from pulling his JT out. DCS 2 stated beside from the abdominal binder there was no other interventions from staff to prevent Client 1 from pulling his JT out. DCS 2 stated neither the nursing staff (the Licensed Vocational Nurse (LVN) and the Registered Nurse (RN) nor the Qualified Intellectual Professional (QIDP) had provided any training to staff on how to prevent Client 1 from pulling out his JT.
During an interview with the LVN, on 10/5/16, at 8:47 am, regarding the nursing care plan for Client 1's new JT management, the LVN did not respond to the question. The LVN walked away from the table and came back with Client 1's nursing care plans.
A review of Client 1's nursing care plans indicated there was no nursing care plan for the client's new JT management. When asked which staff was responsible to review Client 1's discharge instructions from the hospital, create a nursing care plan according to the client's needs and train staff on how to manage Client 1's new JT based on the nursing care plans, the LVN stated me and the RN.
During an interview with DCS 1, on 10/5/16, at 9:00 am, she stated Client 1 had a new JT placement in August, 2016. DCS 1 stated since then, the client had been readmitted to the hospital three times (XXXXXXX16, XXXXXXX16 and XXXXXXX16) for JT replacement.
During an interview with the RN, on 10/5/16, at 9:10 am, regarding the nursing care plan for Client 1's new JT, she stated since the JT management care plan was a long-term care plan, she was the one responsible to develop the nursing care plan. The RN reviewed Client 1's nursing care plans and stated Client 1 did not have a care plan for the new JT management. The RN further stated she did not do it.
During an interview with DCS 1, on 10/5/16, at 9:15 am, she stated last Monday (10/3/16) was the 4th time Client 1 pulled his JT out. DCS 1 stated the doctor at the hospital stitched the JT (stitched the JT into the abdominal wall) but the JT site was located at the area where Client 1 rubbed himself so the stitches came out. DCS 1 stated the staff at the hospital asked the facility staff why we did not put a restraint on the client, but the company had a restraint free policy. When asked had the administrative staff provided any measure to prevent Client 1 from pulling his JT out, DCS 1 stated "No". DCS 1 stated the client was hospitalized four times, first hospitalization was from 8/10/16 to 8/26/16, second hospitalization was from 9/2/16 to 9/3/16, third hospitalization was from 9/19/16 to 9/24/16, and the fourth hospitalization was on 10/3/16 and Client 1 was still in the hospital.
During an interview with the RN, on 10/5/16, at 9:30 am, regarding staff interventions to prevent the new JT from being pulled out, she stated the client was discharged home with a new JT on 8/26/16 without an abdominal binder to prevent the JT from being pulled out. The RN stated during that time the facility's staff did not know Client 1 would pull his JT out. The RN stated Client 1 first pulled his JT out on 9/2/16; the client was readmitted to the hospital for a new JT placement and was discharged back to the facility on XXXXXXX16 with an abdominal binder to prevent the client from pulling his JT out. The RN stated after 9/3/16, Client 1 was transferred to the ER two more times in September 2016 due to the client's JT being clogged, not dislodged; however, she did not remember the dates. RN stated on 10/3/16, Client 1 was transferred to the hospital again due to the JT slipping out from the stoma. The RN stated besides using the abdominal binder that was provided by the hospital, there was no other interventions to prevent the new JT from being pulled out. The RN stated on 9/21/16, at 10:45 am, she received a phone call from the surgeon at the hospital. The RN stated the surgeon was very angry and did not allow her to explain anything. The RN stated the surgeon stated the staff members at the facility were incompetent and we keep sending the client back with a JT that was clogged that needed to be replaced.
A review of the GACH's report from 8/10/16 to 8/26/16 indicated Client 1 had difficulty tolerating oral intake and failed the swallow study. A JT was placed for long term enteral access (The delivery of a nutritionally complete feed directly into the stomach, duodenum or jejunum). The JT was sutured into place, to the anterior abdominal wall and sterile dressings were applied. The client was discharged home on XXXXXXX16.
A review of the facility's nursing notes regarding the hospitalization from 8/10/16 to 8/26/16, indicated Client 1 was admitted to the hospital due to aspiration pneumonia (a lung infection that develops after someone inhales food, liquid, or vomit into the lungs). The client was discharged home with a new JT. The nurse's note did not indicate how the facility's staff should manage Client 1's new JT.
A review of the GACH's report, from 9/2/16 to 9/3/16, indicated Client 1 was readmitted for a JT replacement due to the client accidentally pulling his JT out. The JT was replaced, abdominal binder was recommended to prevent any accidental pulling out of the JT.
A review of the facility's nursing notes, dated 9/2/16 and 9/3/16, indicated that the facility's LVN walked in Client 1's room at 10 am and found the client's JT was pulled out. The client was transferred to a GACH at 11:27 am. Client 1 was returned to the facility on XXXXXXX16 with a new JT replacement and an abdominal binder around the JT site.
A review of the hospital emergency room's report, dated 9/10/16, indicated Client 1 was brought in the ER due to the client pulling the JT out. The physician replaced the JT and tacked it down to a figure of eight wrapping, tied it around the catheter, and placed another suture to the abdomen on the other side, and gauze dressing was applied and the client's abdominal binder was replaced.
A review of the facility's nursing notes, dated 9/13/16, indicated on 9/10/16, the RN received a call from the House Manager (HM) indicated the client's JT stitches came off from the constant friction rubbing, resulting in the JT coming loose with yellow exudates. The HM transferred the Client to a GACH Emergency Room for an X-ray to confirm the JT placement. The client returned home on the same day.
A review of the GACH report from 9/19/16 to 9/24/16 indicated the surgeon wrote a note on 9/21/16. The surgeon indicated Client 1 was mentally challenged, had multiple other developmental issues, and underwent placement of a JT, given the client anatomical issues. The client underwent a surgery on 8/27/16. At the facility, the client ended up having dislodgement of his JT within 2 weeks of his surgery. The surgeon indicated that he spoke to the facility's RN and aside from claiming that they did nothing wrong there was no explanation to why the client was unable to have help so he would stop pulling at the JT. The surgeon stated that the caretakers at the facility did not reveal any reason as to why the client was having these issues of dislodgement except for the fact that they noted that the client likes to pull things and they have not done adequate protection of the JT. The surgeon also indicated that he left a message with his cell phone number on the phone for the facility?s administrator to call back and after 24 hours, he has yet to receive any phone call back. According to the surgeon?s note, he recommended that the client not be sent back to the same facility that the client came from due to their extreme incompetence at managing the client with a JT or GT and their gross negligence.
A review of the facility's nursing notes, dated 9/19/16, indicated at 7 pm, when the LVN attempted to administer the medication, Client 1's JT was clogged. The client was transferred out to a GACH ER. The client was discharged back to the facility on XXXXXXX16.
A review of the GACH ER's report, dated 10/4/16, indicated Client 1 was brought to the ER for JT replacement. The client's JT could not be replaced at the bedside therefore the client was readmitted to the GACH for JT replacement.
A review of the facility's nursing notes, dated 10/3/16, at 8:50 pm, indicated when staff removed Client 1's abdominal binder, the staff noted Client 1's JT was displaced out of the stoma. The client was taken to a GACH ER.
A review of the surgeon's progress note from the GACH, dated 10/6/16, indicated the surgeon recommended that the client does not return to the same facility due to negligent care resulting in the client requiring inpatient hospitalization for feeding tube access and management. The surgeon also spoke to the client's mother who would like her son to be placed at a different facility. Due to the client's medical insurance, the options for other facilities were limited, however the surgeon believe that Client 1 will receive the same negligent care if the client return to the same facility and the client will be admitted yet again for the same problem.
During an interview with the RN, on 10/5/16, at 10:10 am, regarding how does the facility's staff know how to manage Client 1's JT without a nursing care plan for JT management, the RN stated the staff know how to manage the JT due to there was another client (Client 2) with a JT in the facility. The RN stated and she provided an in-service to staff regarding new JT management.
A review of the in-service record for Client 2 regarding Gastrojejunostomy tube (GJT), dated 9/16/15, indicated there will be three different ports as follows: (1) for gastronomy (2) jejunum and (3) balloon. All feedings should go directly into the JT port; all medication should go directly in the GT port. Do not aspirate or check for placement for jejunum tube. There was no information in the in-service indicating how to keep the JT from getting clogged or dislodged.
The facility's nursing staff failed to develop nursing care plans for staff to carry out the interventions in caring for Client 1?s new JT placed on 8/17/16. Client 1 was readmitted to a General Acute Care Hospital (GACH) three times for JT replacement due to the JT being clogged and/or dislodged from 9/2/16 to 10/3/16. Failure of the facility to develop a care plan to aid the direct care staff in caring for the Client 1 restricted the client?s right to be free from harm.
The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result.
ΓΏ
Select Narrative Text Document: |
| 940000040 |
DEL RIO CONVALESCENT CENTER |
940013662 |
B |
1-Dec-17 |
L97811 |
4484 |
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 hiring of all employees by performing a criminal background check prior to employment.
These failures resulted in Resident 1 being verbally abused by being told to stop talking and shut up by Certified Nursing Assistant 1 (CNA 1), which had the potential for emotional distress and psychological trauma.
On 7/28/17 at 1 p.m., an unannounced entity reported incident (ERI) investigation was conducted regarding Resident 1 being verbally abused by CNA 1.
A review of Resident 1's Admission Face Sheet indicated Resident 1 was a 45 year-old male who was admitted to the facility on May 5, 2008. Resident 1's diagnoses included multiple sclerosis (a disease that affects the brain and spinal cord), bipolar disorder (a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). According the face sheet, Resident 1 was self responsible.
A review of Resident 1's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 was totally dependent for transferring, mobility, dressing, eating, and hygiene.
On July 31, 2017 at 8:30 a.m., during a telephone interview, Certified Nursing Assistant 2 (CNA 2) stated, she heard CNA 1 tell Resident 1 to stop talking and to "shut up." CNA 2 stated, CNA 1 told Resident 1, "Shut up! Shut up! Shut up!" in an aggressive and loud manner.
A review of Resident 1's Licensed Nurses Note, dated July 9, 2017, and timed at 2 a.m., indicated that CNAs 2 and 3 overheard CNA 1 tell the resident to "shut up!" The note indicated Resident 1 was assessed by the licensed nurse on duty and denied pain, discomfort, or any physical injury.
On July 18, 2017 at 1:26 p.m., during an interview, Resident 1 stated CNA 1 told him to shut up and go back to his "country". Resident 1 stated he told CNA 1 not to insult him in his own room. Resident 1 stated he tried not tell on the staff because he knows how hard it was for them to find a job.
A review of CNA 1's employee file indicated that CNA 1 was hired February 13, 2017. A document titled "Employers Choice Screening," dated June 13, 2017, indicated that a National Federal Criminal search was conducted on June 13, 2017, which was four months after CNA 1 was hired. A form titled, "Termination Resignation Report," dated July 11, 2017, indicated CNA 1 was terminated for violation of the facility's policies/procedures due to verbal abuse toward a resident.
A review of the facility's policy and procedures titled, "Policy Regarding Hiring of All Employees and Criminal Background Check," with a revision date of August 29, 2016, indicated that the facility would utilize an independent company to perform criminal background checks on all non-certified, licensed or registered employees prior to their starting employment.
A review of the facility's undated policy and procedures titled, "Patient Abuse Prohibition," indicated the facility was committed to protecting the physical and emotional well-being of every resident. The policy indicated that all prospective employment candidates would be screened for whether they engaged in incidents of abuse, neglect and /or misappropriation of property.
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 hiring of all employees by performing a criminal background check prior to employment.
The above violation had a direct relationship to the health, safety, or security of the residents in the facility. |
| 940000040 |
DEL RIO CONVALESCENT CENTER |
940013552 |
B |
20-Oct-17 |
F2P111 |
3325 |
?F226
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.
Based on interview and record review, the facility by not:
Following its abuse policy in reporting abuse between two residents (Residents 1 and 2) to the Department of Public Health (DPH) within 24 hours.
This deficient practice resulted in the facility not adhering to its policy and had the potential to jeopardize the health and safety of residents who resided in the facility.
On 9/8/17 at 3 p.m., an unannounced visit to the facility was conducted for a self-reported event of a resident-to-resident altercation.
A review of the facility's Initial Investigation Report faxed to DPH, dated 7/3/17, and timed at 1:14 p.m., indicated the altercation between Residents 1 and 2 occurred, on 6/30/17 at 2:50 p.m. (72 hours prior to receipt of fax), while in the dining room.
A review of Resident 1's Admission Face Sheet indicated the resident was a 64 year-old female who was admitted to the facility on 8/28/13. Resident 1's diagnoses included schizophrenia (mental disorder affecting thought, emotion, and behavior, leading to inappropriate actions and a withdrawal from reality) and anxiety (feeling of worry, nervousness, or unease, about an imminent event).
A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 6/10/17, indicated the resident had the ability usually to understand and be understood by others. Resident 1 had a Brief Interview for Mental Status ([BIMS] a mental status assessment) score of 15 (a score of 13-15 = cognitively intact and interviewable). According to the MDS, Resident 1 was ambulatory and required extensive assistance from of a one-person physical assist with activities of daily living (ADLs), such as transferring.
A review of Resident 2's Admission Face Sheet indicated the resident was a 54 year-old female who was admitted to the facility on 10/22/14. Resident 2's diagnoses included dementia (disorder that affects a person's ability to think, feel, and behave clearly) and schizophrenia.
A review of Resident 2's MDS, dated 5/7/17, indicated the resident had the ability to understand and was understood by others. Resident 2's BIMS score was 10 (a score of 8-12 = moderately impaired and interviewable). According to the MDS, Resident 2 was ambulatory and did not require setup or physical help from staff.
During a concurrent telephone interview and record review of the facility's policy, on 9/13/17 at 8:09 a.m., the Director of Nursing (DON) stated the facility's practice, prior to 7/2/17, was to report on the Monday following any incidents that occurred over the weekend to the DPH.
A review of the facility's undated policy and procedure titled, "Abuse Prohibition, Patient," indicated that a written notification to DPH, local ombudsman, and other appropriate agencies would be made within 24 hours.
The above violation had a direct relationship to the health, safety, or security the residents. |
| 940000040 |
DEL RIO CONVALESCENT CENTER |
940013674 |
A |
7-Dec-17 |
C9IS11 |
6257 |
? F323
CFR 485.25(d) Accidents.
The facility must ensure that-
(1) The resident environment remains as free from accidents 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 provide 1:1 supervision for Resident 1 after sustaining a fall 12 days prior to a second fall.
2. Failure to follow and adhere to their policy regarding 1:1 supervision, revision of Resident 1?s plan of care after a change of condition, and implementing fall prevention measures.
These failures resulted in Resident 1 having two falls within 12 days of one another and sustaining blunt head trauma, with a forehead hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma), and a nasal fracture (broken bone to the nose), that required a transfer to the general acute care hospital (GACH).
On 8/21/17 at 3:52 p.m., an unannounced complaint investigation was conducted regarding Resident 1?s fall.
A review of Resident 1's Admission Record (face sheet) indicated Resident 1 was a 57 year-old female who was admitted to the facility on 5/5/16 with diagnoses including extrapyramidal movements (drug induced movement disorders) and pre-glaucoma (eye diseases which result in damage to the optic nerve and vision loss).
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 8/8/17, indicated Resident 1's cognition (thought process) was severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for toilet use and was dependent on a wheelchair for locomotion.
A review of Resident 1's care plan titled, "Incident/Accident Short Term-Fall," dated 8/7/17 indicated that Resident 1 would be free from falls with 1:1 observations for 72 hours.
On 8/21/17 at 4:26 p.m., during an interview, Certified Nurse Assistant 1 (CNA) stated Resident 1 was not on 1:1 supervision, because the facility was short of staff. CNA 1 stated Resident 1's assigned CNA did not show up to work on 8/19/17. CNA 1 stated that on 8/19/17, she heard a loud sound from Resident 1's room, and found the resident lying on the floor face up between her bed and the nightstand.
On 8/21/17 at 4:40 p.m., during an interview, Registered Nurse 1 (RN1) stated that Resident 1 was placed on 1:1 supervision after a fall that occurred on 8/7/17 (12 days prior), which resulted in the resident developing a hematoma. RN 1 stated the CNA assigned to Resident 1 on 8/18/17 on the 11 pm-7 am shift, was a "No show/no call" and stated a staff member should have been with the resident at all times.
A review of a Nurses' Progress Note, dated 8/19/17, and timed at 12:40 a.m., indicated Resident 1 was transfer to the GACH via an ambulance due to fall. The Note indicated Resident 1 was found on the floor, bleeding from the back of her head.
On 8/23/17 at 1:30p.m., during an interview, Registered Nurse 2 (RN) stated that they were not able to locate Resident 1's 1:1 Monitoring Log monitoring for 8/8/17 and 8/18/17, as requested.
A review of Resident 1's GACH Emergency Room Report, dated 8/9/17, and timed at 3:37 a.m., indicated the resident had an extra-cranial (located outside the skull) subcutaneous (under the skin) hematoma within the inferior frontal region of the brain.
A review of Resident 1's Nurses Progress Note, dated 8/9/17, and timed at 9 a.m., indicated Resident 1 returned to the facility from the GACH with facial swelling and bilateral (both sides) black eyes, with agitation (state of feeling irritated or restless).
A review of Resident 1' Nurses' Progress Note, dated from 8/9/17 through 8/19/17, indicated Resident 1 continued to display signs of agitation, and showed aggression towards staff and residents. The notes indicated Resident 1 continued to be on 1:1 observation due to the behaviors.
On 11/7/17 at 2:34 p.m., during a telephone interview, the Director of Nursing (DON) stated that Resident 1's care plan and the Interdisciplinary Team ([IDT] a group of disciplines working towards a common goal of a resident) plan were not revised after the 72-hour 1:1 monitoring order by Resident 1's Physician on 8/15/17.
On 11/8/17 at 8:19 a.m., during a telephone interview, the DON stated staff forgot to complete the assignment sheets for 8/17/17 and 8/18/17 on the 11-7 a.m. (night) shift. The DON stated that on the night of 8/17 and 8/18/17 there was two CNA's assigned to 99 residents.
A review of the facility's undated policy and procedure titled, "Care Plans-Comprehensive," indicated that care plans are revised as changes in the resident's condition dictates.
A review of the facility policy and procedure titled, "Fall Prevention and Management," dated 5/19/17, indicated that the IDT was responsible for assessing, treating, and implementing strategies for the prevention of resident falls.
A review of the facility's policy and procedure titled, "1:1 Supervision," dated 8/17/17, indicated that a resident that are physically aggressive would be placed on 1:1 supervision, and CNAs would fill and sign the "15 minute check" document and would make sure the resident was safe and needs are attended to promptly.
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 provide 1:1 supervision for Resident 1 after sustaining a fall 12 days prior to a second fall.
2. Failure to follow and adhere to their policy regarding 1:1 supervision, revision of Resident 1?s plan of care after a change of condition, and implementing fall prevention measures.
The above violation presented either an imminent danger that death or serious harm would result to Resident 1 or a substantial probability that death or serious physical harm would and did result to Resident 1. |
| 940000040 |
DEL RIO CONVALESCENT CENTER |
940013680 |
A |
8-Dec-17 |
None |
7071 |
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.
F353
?483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
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 provide the necessary supervision for Resident 1.
2. Failure to implement Resident 1's plan of care of providing one to one supervision.
3. Failure to follow their policy regarding residents who wander and needs 1:1 supervision.
This failure resulted in Resident 1 rapidly propelling herself within the facility resulting in Resident 2 tripping and falling sustaining a facial fracture (broken bone) and hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma) and being transferred to the general acute care hospital (GACH).
On 8/21/17 at 3:52 p.m., an unannounced complaint investigation was conducted regarding Resident 2's fall with injuries.
A review of Resident 1's Admission Record indicated the resident was a 75 year-old male who was admitted to the facility on 4/25/13 with a diagnosis of dementia (brain diseases that cause a long-term and often gradual decrease in the ability to think and remember).
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/26/17, and the Mini-Mental State Exam (MMSE) score of 3 (0-7: severe cognitive impairment) indicated Resident 1 was severely impaired of cognition. The MDS indicated Resident 1 required limited assistance from a one-person assist for locomotion off unit (how resident moves between locations such as dining are, activities and treatments), and was dependent on a wheelchair for locomotion.
A review of Resident 1's Assessment for Elopement ([AWOL] to leave the facility without permission)/Unsafe Wandering Risk, dated 4/13/17, indicated Resident 1 would wander into other resident's room and collect belongings. The Assessment for Elopement/Unsafe Wandering indicated that Resident 1 required frequent monitoring and constant observation.
A review of Resident 1's Care Plan titled, "Wandering," dated 4/13/17, indicated Resident 1 had a history of wandering behavior episodes, such as wandering around the facility, hallways, other residents' rooms, and would attempt to go in the nursing station. The staff interventions included placing Resident 1 on 1:1 supervision and monitoring while providing frequent visual checks.
On 8/23/17 at 3:09 p.m., during a concurrent interview and record review, the Assistant Administrator (AA) stated that frequent monitoring meant as soon as possible [sic]; and 1:1 supervision meant that the staff would monitor the resident at all times. AA stated that the resident's care plans did not specify the duration of the interventions to be implemented.
A review of the facility investigation, dated 8/9/17, indicated Resident 2 tripped over Resident 1's anti-tip bars causing resident to fall and have a bloody nose. The investigation report indicated that the facility failed to provide the 1:1 supervision for Resident 1 due to assigned staff not been present.
A review of Resident 2's Admission Record indicated the resident was a 57 year-old female who was admitted to the facility on 5/5/16 with diagnoses that included extrapyramidal movements and pre-glaucoma (a group of eye diseases which result in damage to the optic nerve and vision loss).
A review of Resident 2's Minimum Data Set, dated 7/14/17, indicated a brief interview for mental status (BIMS) score of 10 (8-12 moderately impaired in cognitive skills) and had no memory problems. The MDS indicated Resident 2 did not require assistance from staff to walk in the corridors and/or any mobility devices for ambulation.
On 8/23/17 at 1:30 p.m., during an interview, Registered Nurse 2 (RN 2) stated that they were not able to provide the nursing per hour per patient a day (NHPPD) and was unable to locate that the 1:1 monitoring log for 8/8/17.
On 8/23/17 at 3:11 p.m., during an interview, Registered Nurse 2 stated that Resident 1 wheeled herself out of the dining room and hit Resident 2 with the wheelchair's anti tip bars, causing Resident 2 to fall.
On 8/23/17 at 3:48 p.m., during an interview, Certified Nurse Assistant 2 (CNA) stated that Resident 1 had not been supervised because the facility had been short of staff. CNA 2 stated that CNA 1 was assigned to Resident 1 for 1:1 supervision.
A review of a "Nurses Progress Note," dated 8/7/17, and timed at 9:10 p.m., indicated Resident 2 was transfer to a GACH via ambulance.
A review of Resident 2's GACH report, dated 8/7/17, and timed at 10:57 a.m., indicated the resident had a displaced and non-displaced nasal fracture (broken nose) a hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma) on the forehead.
On 8/23/17 at 4:47 p.m., during an interview, Registered Nurse 1 (RN) stated that Resident 2's fall on 8/7/17 could had been prevented if they had enough staff to supervise Resident 1 as indicated in the resident's care plan.
A review of Resident 2's "Nurses Progress Note," dated 8/9/17, and timed at 9 a.m., indicated Resident 2 returned to the facility from the GACH with a swollen face, bilateral black eyes, and was agitated.
A review of facility's policy and procedure titled, "Unsafe Wandering," dated 6/5/17, indicated that any unsafe wandering/potential AWOL resident that are identified would be immediately placed on one to one.
A review of the facility's policy and procedure titled, "1:1 Supervision," dated 8/17/17, indicated that a resident that wanders would be placed on 1:1 supervision.
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 provide the necessary supervision for Resident 1.
2. Failure to implement Resident 1's plan of care of providing one to one supervision.
3. Failure to follow their policy regarding residents who wander and needs 1:1 supervision.
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 and did result to Resident 2. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013543 |
B |
12-Oct-17 |
None |
11152 |
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 protect five sampled residents (Residents 1, 2, 3, 4, and 5) from being hit by another resident (Resident 7).
1. - Resident 1 was hit on the left arm and felt unsafe around Resident 7.
2. - Resident 2 was hit on the back of his neck.
3. - Resident 3 was punched in her mouth and verbally abuse.
4. - Resident 4 was verbally attacked by Resident 7.
5. - Resident 5 was verbally attacked by Resident 7.
These deficient practices resulted in Residents 1, 2, 3, 4, and 5 being physically and/or verbally abused expressing mental anguish and fear of Resident 7, which had the potential to affect other residents, who resided in the facility and witnessed the abusive behavior.
On 8/16/17 at 7 a.m., an unannounced visit was conducted to the facility to investigate an entity report incident (ERI) of a resident?s (Resident 1) allegation of being abused by another resident (Resident 7).
A review of the Admission Record (Face Sheet) indicated Resident 7 was a 64 year-old male who was initially admitted to the facility on 4/12/16 and readmitted on 12/7/16. Resident 7?s diagnoses included major depressive (mental health disorder characterized by loss of interest in activities, causing significant impairment in daily life) disorder, alcohol use, and dementia (memory disorders, personality changes, and impaired reasoning).
A review of Resident 7's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 7/27/17, indicated Resident 7 was moderately impaired for daily decision- making and had no behaviors. The MDS indicated Resident 7 used a walker and wheelchair for ambulation and locomotion and had no impairments of the bilateral (both) upper and lower extremities.
A review of Resident 7's care plan, dated 6/17/17 and titled, "Long Term Care Plan-Mood,? indicated the goal was for the resident to not harm others. The staff?s interventions included to provide 1:1 observation.
During an observation on 8/16/17 at 7:17 a.m., Resident 7 was observed unsupervised with other five (5) residents watching television in the dining room.
During an interview on 8/16/17 at 7:30 a.m., Resident 2 stated that Resident 7 hit him on the back of his head with a close fist, but was unable to provide the exact date. Resident 2 stated he felt unsafe, due to his fear of Resident 7 hitting him again.
A review of Resident 2?s Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on 9/2/15. Resident 2?s diagnoses included major depressive (mental health disorder characterized by loss of interest in activities, causing significant impairment in daily life) disorder, alcohol use, and dementia (memory disorders, personality changes, and impaired reasoning).
A review of Resident 2's MDS, dated 7/15/17, indicated Resident 2?s cognition (thought process) and memory was intact for daily decision-making. The MDS indicated Resident 2 used a wheelchair for ambulation and did not require staff assistance for ambulation on/off unit.
During an interview on 8/16/17 at 7:34 a.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 7 hits other residents when he becomes agitated or he bumps the other residents? wheelchair.
On 8/16/17 at 8:10 a.m., during an interview, Resident 1 stated Resident 7 hit him on his left arm when we has on his way to the dining room and called him ?Mother F--ker? a week prior. Resident 1 stated he too felt unsafe having Resident 7 around him. Resident 1 stated once he saw Resident 7?s family member bring the resident a can of beer into the facility.
A review of Resident 1?s Admission Record (Face Sheet) indicated Resident 1 was a 55 year-old male who was initially admitted to the facility on 12/1/16 with diagnoses that included generalized muscle weakness and difficulty walking.
A review of Resident 1's MDS, dated 7/15/17, indicated Resident 1?s cognition and memory was intact for daily decision-making. The MDS indicated Resident 1 used a wheelchair as a mobility device and did not require of staff for ambulation on/off unit.
A review of a document titled, ?Social Services Notes? dated 8/14/17, indicated Resident 7 would be move to a different dining room. The Social Service Note, dated 8/16/17 indicated Resident 1 asked the Social Services Director (SSD 1) why Resident 7 was sitting in the same dining room.
During an interview on 8/16/17 at 8:15 a.m., Resident 4 stated Resident 7 was always cursing and hitting everyone. Resident 4 stated, ?I feel safe because if Resident 7 attempted to hit me, I will hit him back.?
A review of the Admission Record (Face Sheet) indicated Resident 4 was a 61 year-old male who was initially admitted to the facility on 10/31/16 with diagnoses that included weakness and unspecified pain in leg.
A review of Resident 4's Minimum Data Set (MDS), dated 8/11/17, indicated Resident 4?s cognition and memory were intact for daily decision-making. The MDS indicated Resident 4 was dependent of a wheelchair as a mobility device and did not require of staff for ambulation on/off unit.
During an interview on 8/16/17 at 8:20 a.m., Resident 7 stated he was not aware of any incidents with other residents. Resident 7 stated that when he goes out on pass (OOP) he drinks alcohol and returns back to the facility.
On 8/16/17 at 11:06 a.m., during an interview, with the Director of Nurses (DON) and Registered Nurse Supervisor (RN 1), they both stated that Resident 7 hits other residents when he becomes agitated and/or other residents are in his way. The DON stated, ?We should had taken action and move him to another facility; it seems like he likes hitting his peers.?
At 3:40 p.m., on 8/16/17, during an interview, Resident 3 stated that Resident 7 punched her in the face once and used to call her a ?B--ch.? Resident 3 stated the staff were all aware of the resident hitting her and she was scared that Resident 7 might hit her again.
A review of the Admission Record (Face Sheet) indicated Resident 3 was a 66 year-old female who was initially admitted to the facility on 12/10/16 with diagnoses that included hypertension (high blood pressure) and generalized arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age).
A review of Resident 3's MDS, dated 6/23/17, indicated Resident 3?s cognition and memory were intact for daily decision-making. The MDS indicated Resident 3 used a wheelchair as a mobility device for locomotion around the facility.
During an interview on 8/16/17 at 4 p.m., Resident 5 stated Resident 7 have been verbally abusive towards her, but stated she will hit Resident 7 if he attempts to hit her.
A review of the Admission Record (Face Sheet) indicated Resident 5 was a 61 year-old female who was initially admitted to the facility on 2/17/15. Resident 5?s diagnoses included major depressive disorder (mental health disorder characterized by loss of interest in activities, causing significant impairment in daily life) and anxiety (mental health disorder characterized by loss of interest in activities, causing significant impairment in daily life).
A review of Resident 5s Minimum Data Set, dated 6/16/17, indicated Resident 5?s cognition and memory were intact for daily decision-making. The MDS indicated Resident 5 was dependent on a wheelchair as a mobility device.
During an interview on 8/16/17 at 4:43 p.m., CNA 4 stated Resident 7 was calm when watching television, but would strike out at resident peers when they were in his way or they bump his wheelchair. CNA 4 stated that all the facility?s staff was aware of Resident 7?s striking out behavior.
During an observation on 8/16/17 at 5:23 p.m., Resident 7 was observed eating in the same dining room as Resident 1, which indicated the facility failed to follow the plan to keep Resident 1 and 7 separated, due to Resident 1?s fear of Resident 7.
On 8/17/17 at 7:15 a.m., during an observation, Resident 7 was observed in the dining room without 1:1 supervision, as part of the POA to provide 1:1 supervision.
On 8/17/17 at 7:55 a.m., during an interview, the SSD stated that 1:1 supervision meant that one staff member would remain with the resident at all times. The SSD stated Resident 7 should have been evaluated for his behavior of hitting others due to the possibility of harm to self and others.
A review of the document titled, ?11-7 Daily Assignment,? dated 8/17/17, indicated Resident 7 did not have a staff member for 1:1 supervision on the night shift.
During an interview on 8/18/17 at 6:58 p.m., CNA 5 stated that she was assigned on 8/17/17 on the 11-7 a.m. shift to five (5) rooms with a total of 11 residents including Resident 7. CNA 5 stated that she was not with Resident 7 at all times because he was sleeping and she had other assignments.
A review of a handwritten declaration, written by CNA 6, dated 8/16/17, and timed at 4:53 p.m., indicated Resident 7 hits other residents when they are in front of him moving slowly.
A review of a handwritten declaration, written by the facility?s Activity Coordinator (AC), dated 8/16/17 and timed at 4:46 p.m., indicated Resident 7 participated in activities and was calm until someone gets in his way or bumps him. The AC indicated that Resident 7 would strike out physically and become verbally abusive, depending on his mood.
A review of the facility's undated policy and procedure titled, "Abuse Prohibition, Patient,? indicated that when the facility had knowledge that an individual has a history of abuse, appropriate actions will be taken to decrease the possibility of an abuse act. The Interdisciplinary (IDT) team will assess, care plan and monitor patients with needs and behaviors that might lead to conflict or abuse situations, such as a history of aggressive behaviors. The policy also indicated that if it involves patient to patient abuse, the patients involved would be separated.
Based on observation, interview, and record review, the facility failed to protect five (Residents 1, 2, 3, 4, and 5) from being hit by another resident (Resident 7).
1. - Resident 1 was hit on the left arm and felt unsafe around Resident 7.
2. - Resident 2 was hit on the back of his neck.
3. - Resident 3 was punched in her mouth and verbally abuse.
4. - Resident 4 was verbally attacked by Resident 7.
5. - Resident 5 was verbally attacked by Resident 7.
The above violation had the direct relationship to the health, safety, or security of patients. |
| 940000041 |
DEL RIO GARDENS CARE CENTER |
940013579 |
B |
1-Nov-17 |
KJDL11 |
8750 |
42 CFR ?483.12(b) The facility must develop and implement written policies and procedures that:
(4) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Social Security Act. The policies and procedures must include but are not limited to the following elements.
(i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual?s obligation to comply with the following reporting requirements.
(A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility.
(B) Each covered individual shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.
(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.
(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and
(2) of the Act.
?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
During an unannounced visit to the facility, on 7/19/17 at 9:20 a.m., an investigation was conducted for a self-reported incident. A certified nursing assistant (CNA 4) reported on 7/2/17 that she heard Resident 2 teasing Resident 1 because of Resident 1?s last name.
Based on interviews and record reviews, the facility failed to implement its abuse prohibition policy and procedure by failing to:
1. Report an alleged resident-to-resident verbal abuse to the administrator immediately or within 24 hours.
A certified nursing assistant (CNA 4) witnessed Resident 2 calling Resident 1 a name of an animal on 7/2/17. CNA 4 reported the alleged verbal abuse to a registered nurse (RN 1) on 7/5/17, three days later. Two other CNAs (CNA 2 and 3) witnessed Resident 2 calling Resident 1 a name of an animal multiple times prior to June 2017 (dates and times were not specified). CNA 2 and 3 did not report the witnessed incidents.
This deficient practice had the potential to expose the residents of the facility in an environment of abuse and mistreatment if the entity does not observe the facility?s abuse reporting protocol.
A review of Resident 1's face sheet (admission record) indicated that the facility admitted Resident 1 on 3/10/17. Resident 1?s diagnoses included Alzheimer?s disease (a type of dementia that causes problems with memory, thinking, and behavior) and psychosis (a mental condition characterized by an impaired relationship with reality).
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 3/23/17, indicated that Resident 1?s cognition was severely impaired. The MDS indicated that Resident 1 had not exhibited any physical or verbal behavioral symptoms towards others such as hitting, scratching, threatening, or cursing.
A review of Resident 2's face sheet indicated that the facility admitted Resident 2 on 12/17/15. Resident 2?s diagnoses included major depressive disorder (a major depression characterized by a persistent feeling of sadness or a lack of interest in outside stimuli) and hypertension (high-blood pressure).
A review of Resident 2's MDS, dated 12/30/16, indicated that Resident 2?s cognition was intact. The MDS indicated that Resident 2 had not exhibited any physical or verbal behavioral symptoms towards others such as hitting, scratching, threatening, or cursing. The MDS indicated that Resident 2 used a walker and a wheelchair for mobility.
During a telephone interview, on 7/25/17 at 1:20 p.m., CNA 4 stated that on 7/2/17 at around 9:30 a.m., she heard Resident 2 make fun of Resident 1?s last name. CNA 4 stated that she did not report the incident to RN 1 until 7/5/17.
A review of the facility?s investigation report indicated that CNA 4 declared on her interview statement that she heard Resident 2 tease Resident 1 about his last name. CNA 4 stated that Resident 2 told Resident 1 to eat grass outside and called him an animal. CNA 4 stated that the incident happened on 7/2/17 at around 9:30 a.m. RN 1 stated that CNA 4 reported this incident to her on 7/5/17.
A review of the facility?s undated policy and procedure titled, ?Abuse Prohibition, Patient? indicated that person(s) observing an incident of resident abuse or suspected resident abuse must immediately protect the resident. After securing the resident?s safety, all such incidents must be reported to the charge nurse.
During an interview, on 7/19/17 at 10:50 a.m., Resident 2 said that he teased Resident 1 occasionally. Resident 2 stated that other residents and facility staff also teased Resident 1 when they were in the dining room. Resident 2 stated they would say something like, ?XXXX Baca. XXXX eat grass.? (XXXX is an animal name)
During an interview, on 7/19/17 at 11:14 a.m., CNA 1 stated that she heard Resident 2 and Resident 3 make fun of Resident 1?s last name in the dining room while Resident 2 and 3 were sitting at the same table and Resident 1 was sitting at an adjacent table. CNA 1 stated that the teasing incident happened at least twice on separate occasions. CNA 1 stated Resident 2 and 3 would tell Resident 1 in Spanish, ?Go outside eat grass since your last name means an animal.? CNA 1 did not specify the date and time she witnessed the incidents.
During the interview, CNA 1 stated that she told Resident 2 and 3 to stop teasing Resident 1 and that she reported the incident to the charge nurse. CNA1 could not recall the name of the charge nurse or the date when it happened. CNA 1 stated that she has not heard anyone else tease Resident 1 aside from those two residents.
During an interview, on 7/21/17 at 12:50 p.m., CNA 2 stated that she heard Resident 2 tell Resident 1 to pick up the food on the floor and eat it. CNA 2 stated that she witnessed that incident a couple of times in June 2017 in the dining room. CNA 2 stated that Resident 1 throws his food on the floor whenever he does not like it. CNA 2 stated that in her opinion, that was offending and was verbal abuse. CNA 2 stated that she did not report it to her supervisor because she thought she would be able to handle it herself.
During an interview, on 7/21/17 at 1:13 p.m., CNA 3 stated that on one occasion before June 2017, Resident 1 was in the dining room and sat at the table of Resident 2. Resident 2 told Resident 1, ?XXXX move to your table and sit there? and Resident 2 started laughing. CNA 3 stated that she thought that it was verbal abuse but she did not report it because she asked Resident 1 to move to his table and she had everything under control.
The facility failed to implement its abuse prohibition policy and procedure by failing to:
1. Report an alleged resident-to-resident verbal abuse to the administrator immediately or within 24 hours.
This deficient practice had the potential to expose the residents of the facility in an environment of abuse and mistreatment if the entity does not observe the facility?s abuse reporting protocol.
This violation had a direct relationship to the health, safety, or security of Resident 1. |
| 020000133 |
Driftwood Healthcare Center - Hayward |
020013416 |
B |
17-Aug-17 |
38YG11 |
5170 |
483.25(d)(1)(2) 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.
The facility failed to follow the aforementioned regulation by failing to ensure Certified Nurse Assistant (CNA 1) transferred Resident 2 to the bed with assistance, resulting in Resident 2 falling and sustaining a fracture on his rib.
Review of the Resident Face Sheet indicated Resident 2 was initially admitted to the facility on 12/1/16 and was re-admitted on 1/3/17.
Review of the admission Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/10/17, indicated Resident 2's Brief interview for mental status was 14 (indicated he was able to recall events and knew the correct year and month). The MDS also indicated Resident 2 was totally dependent and required total assistance of two plus persons when transferring to and from bed to wheelchair. Further review of the MDS indicated Resident 2's active diagnoses included muscle weakness.
During an interview with Resident 2 on 7/5/17, at 1:05 p.m., Resident 2 stated the sling broke on the Hoyer lift when CNA 1 was transferring him from the wheelchair to the bed on 6/12/17. Resident 2 stated he fell and hit the left side of his head and the left side of his trunk on the footboard of his roommate's bed. Resident 2 stated he was hurting and asked to go to the hospital.
During an interview with CNA 1 on 7/5/17, at 1:50 p.m., CNA 1 stated while transferring Resident 2 from the wheelchair to the bed on 6/12/17 one of the hooks on the sling came off the lift. When Resident 2 was lifted from the wheelchair, CNA 1 saw the sling come off the lift, and Resident 2 was leaning to the left. CNA 1 stated she moved Resident 2's wheelchair out of the way and the Hoyer lift was used to guide the sling down until Resident 2 reached the floor in a sitting position. CNA 1 stated she used the Hoyer lift without assistance. She stated she had been trained on how to use the lift before the incident, and she was aware two people were required when using the Hoyer lift.
Review of the facility's investigation summary dated 6/16/17, indicated CNA 1 was operating the Hoyer lift, and the sling loop came off from the mechanical lift's hook during transfer. Further review indicated Resident 2 slid down and ended in a sitting position on the floor.
During an interview on 7/5/17 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 3, he stated on 6/12/17, Resident 2 was on the floor in a sitting position when he entered the room after the fall. LVN 3 stated CNA1 told him Resident 2 had slid from the wheelchair to the floor. LVN 3 stated he assessed Resident 2 and with the help of facility staff, Resident 2 was transferred to bed using a sheet to lift him. LVN 3 stated Resident 2 complained of pain on his left side. He notified the physician, and Resident 2 was transferred to the acute hospital.
Review of Resident 2's Observation Report dated 6/12/17 at 9:44 p.m., indicated Resident 2 was transferred to the acute hospital.
Review of the acute hospital X-Ray report dated 6/13/17, indicated Resident 2 sustained a fracture to his left eighth rib.
Review of Resident 2's care plan "Self-care deficit", initiated on 12/2/16, indicated the staff should "Provide 2 person assist with Activities of daily living (ADL's) as needed."
Review of Resident 2's Physical Therapist Progress Discharge Summary dated 2/23/17, indicated Resident 2 required the assistance of two or more helpers for transfer.
Review of the facility's "Hoyer Lift/Mechanical Lift Procedures" training document for staff dated 6/14/17, indicated "Mechanical lifts require at a 2-person assist. Both caregivers will steady the resident as the lift is being moved. The second caregiver will guide the resident's body while the first caregiver moves the lift."
Review of the facility's "Resident Transfer: Mechanical Lift" policy and procedure dated 8/15/2002, revealed "Mechanical lifts require at least a 2-person assist."
Review of the "Manual/Electric Portable Patient Lift" manufacturer manual, under Transferring the Patient, indicated "The use of one assistant is based on the evaluation of a healthcare professional for each individual case...before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place...correct this problem-otherwise, injury or damage may occur...". The manual further indicated, when transferring resident to a wheelchair, one assistant will be behind the chair and the other operating the patient lift, "This will maintain a good center of balance and prevent the chair from tipping forward."
Therefore the facility failed to ensure CNA 1 transferred Resident 2 to the bed with assistance, resulting in Resident 2 falling and sustaining a fracture on his rib.
The above violation had a direct relationship to the health, safety or security of patients. |
| 630013020 |
DHK Manor |
030013528 |
B |
5-Oct-17 |
C55F11 |
2871 |
California Health and Safety code, section 1418.91
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within 24 hours.
(b) Failure to comply with the requirements of this section shall be a Class B Citation.
The following citation is written as a result of an allegation of abuse reviewed during a Fundamental Recertification Survey on 9/5/17 and 9/6/17.
The Department determined the facility failed to implement State law when an allegation of abuse was not reported to the Department within 24 hours.
Review of a "Special Incident Report" (SIR) on 9/5/17, disclosed Client 1 had accused Client 2 of inappropriate sexual touching. Client 1 reported to the Residential Service Provider (RSP) that Client 2 had "grabbed her [breast]." Client 1 also told the RSP that if Client 2 did it again, she "will hit him." The SIR indicated that Client 1 stated the incident occurred on 1/16/17 and was reported to facility staff on 1/19/17. Further review of the SIR revealed the allegation was not reported to the Department of Public Health within 24 hours.
Observations of Client 1 and Client 2 on 9/5/17 and 9/6/17 revealed neither was seated in close proximity to the other. Further observation revealed Client 1 possessed the capability to verbalize needs, whereas Client 2 primarily used gestures to communicate.
An interview was conducted with Client 1 on 9/6/17 at 6:30 a.m. Client 1 stated that she does not like people touching her person and she had pushed Client 2 away during the incident. Client 1 stated that Client 2 does not bother her anymore.
The facility's undated, abuse prevention policy, titled, "Subject: Mistreatment, Abuse & Neglect" read in pertinent part: "...All instances of mistreatment, abuse and/or neglect will be reported immediately using the guidelines discussed in this policy...Sexual abuse to include: sexual battery...Any person having knowledge of abuse, mistreatment, neglect abuse, or having reasonable cause to believe it is taking place will make an immediate report...Immediately upon learning of the incident, (within 24 hours) the QMRP [Qualified Mental Retardation Professional [now termed QIDP, Qualified Intellectual Disabilities Professional]/Administrator (or designee) will report the incident to:...- Department of Health Services (Licensing & Certification)..."
An interview was conducted with the Licensee on 9/5/17 at 8 a.m. The Licensee stated, "It should have been reported." An interview was conducted with the Facility Administrator on 9/6/17 at 8:30 a.m. The Facility Administrator stated, "I thought I reported it."
The Department determined the facility failed to implement State law when an allegation of abuse was not reported to the Department within 24 hours. |
| 120001440 |
Dinuba Healthcare |
120013600 |
A |
15-Nov-17 |
MLCW11 |
8866 |
T22 DIV 5 CH3 ART3-72311 (a)(3) B)-Nursing Services-General
(a) Nursing service shall include, but not be limited to, the following:
(3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of:
(B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.
On 10/9/17, at 9:30 AM, an announced recertification and relicensing was conducted at the facility.
Patient 15 was an 88-year-old female, originally admitted to the facility on 9/19/13, with diagnoses of 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), psychosis (severe mental disorder), high blood pressure, anxiety, major depression, osteoarthritis (disease that results in breakdown of joint cartilage), and osteoporosis ( disease in which the bones become weak and are more likely to break). The Minimum Data Set (MDS-an assessment tool), dated 9/18/17, indicated Patient 15 was cognitively severely impaired, never/rarely made decisions, and had short-term and long-term memory problems.
Patient 15 had a witnessed fall on 10/6/17, at 6:40 PM. Patient 15 was transferred to an acute hospital emergency department for evaluation on 10/11/17 at 1 PM. After being evaluated, Patient 15 was diagnosed with a right intertrochanteric fracture (hip fracture). An open reduction and internal fixation (ORIF) with cephalo-medullary nail was performed on 10/12/17 to repair the right hip fracture for Patient 15.
The Department determined that the facility failed to assess Patient 15 on multiple opportunities after the patient's fall incident. Such failure resulted in Patient 15's hip fracture to go unnoted for six days and sustained severe pain for six days.
During an observation on 10/09/17, at 10:20 AM, Patient 15 was in bed lying on her right side facing the wall. At 12 PM, the patient was in bed awake lying on her right side. Certified Nursing Assistant (CNA) 2 was at the bedside attempting to feed Patient 15 her lunch. Patient 15 refused lunch and pushed CNA 2's hand away. CNA 2 stated Patient15 had only eaten 50 percent of her breakfast, "I don't know why she refuses her food now."
The Nurses Notes, dated 10/6/17, at 6:49 PM, was reviewed. It indicated Patient 15 had a witnessed fall at 6:40 PM. Patient 15 had "lost her balance while stepping backwards and landed on her left side." Patient 15 sustained a skin tear to her right hand and was placed on a 72 hour monitoring (observing and checking any change in medical/mental condition and level of care) after the fall on 10/6/17. The clinical records indicated Patient 15 had no complaints of pain, but her behaviors of crying, yelling out, and restlessness prompted the staff to administer Ativan (anti-anxiety medication) for three consecutive days (10/7/17, 10/8/17, and 10/9/17). The clinical records also indicated Patient 15 had no episodes of these behaviors prior to the fall incident. There was no documented evidence during the behavior episodes, the physician was notified for further assessment and evaluation of Patient 15's change of condition.
During an interview with Restorative Nursing Assistant (RNA) 1, on 10/12/17, at 10:35 AM, she stated an attempt was made to transfer Patient 15 into a wheel chair for her scheduled weight on 10/9/17. RNA 1 stated, "She [Patient 15] was screaming during the process of getting up in the chair with one leg on the floor. She was in pain." RNA 1 stated she had reported the incident to the Director of Nursing (DON).
During an interview with Certified Nursing Assistant (CNA) 2, on 10/12/17, at 11:10 AM, she stated she worked with Patient 15 on 10/9/17, three days after the witnessed fall. CNA 2 stated Patient 15 was scheduled to be showered and would usually have no difficulty standing up for showers, but on 10/9/17, "She couldn't stand up, she was in pain. She was screaming, saying 'pain' and touching her right leg and then both legs. I think she was in a lot of pain that she didn't know where the pain was anymore." CNA 2 stated she had reported the incident to the nurse on duty.
During an interview with CNA 4 on 10/12/17, at 2:16 PM, she stated she worked with Patient 15 on 10/10/17, four days after the witnessed fall. CNA 4 stated it was unusual for Patient 15 to stay in bed all day, "She is usually up walking."
The Nurses Notes, dated 10/9/17, at 2:45 PM, was reviewed. The notes indicated "Upon entering room patient [Patient15] was in bed lying on right side with eyes closed, no apparent distress. Upon assessment of lower extremities, resident [patient] began to yell. . . Upon passive ROM (range of motion), resident [patient] started to cry out. When asked where the pain was resident [patient] did not reply only continued to cry." Patient 15 was placed on 72 hour monitoring for lower extremity pain.
During an interview with a Registered Nurse (RN) 2, on 10/12/17, at 2:29 PM, she stated, "She [Patient 15] was restless that morning [10/9/17], she was given Ativan. She was guarded when moving her lower extremities." RN 2 stated she notified the physician, and was given an order for Norco (pain medication) every 6 hours. RN 2 stated, "I told the doctor she was crying during passive range of motion, I didn't tell him she was guarding her lower extremities. No I didn't tell him she couldn't stand up."
The Rehab Referral note, dated 10/10/17, was reviewed. It indicated "Pt [patient 15] in bed-refused to follow any requests to get OOB (out of bed)-crying and very agitated-unable to assess at this time." The Nurses Notes, dated 10/11/17, at 11:44 AM, indicated "Writer and therapy assistant attempted to assess resident [patient] due to not wanting to ambulate, became upset, crying, holding right lower extremity. . . noted right knee to be slightly swollen. . . staff provides needed care with occ [sic] episodes of guarding her extremities and crying." The clinical records indicated Patient 15 was only given Norco on 10/9/17 at 1:31 PM.
During an interview with Licensed Vocational Nurse (LVN) 1, on 10/12/17, at 3:01 PM, she stated she observed Patient 15 on 10/11/17 (six days after the witness fall), in her room, lying in bed, her right side facing the wall, in a fetal position, holding both legs. LVN 1 stated, "She didn't let me assess her, she was crying, saying leave me alone. She wouldn't let me turn her or anything."
During further review of the Nurses Notes, dated 10/11/17, at 1:02 PM, it indicated Patient 15's attending physician was notified and gave an order for Patient 15 to be sent out to the hospital for "treatment and evaluation, due to resident [patient] diagnosis of dementia and history or [sic] refusing care." The radiology report from the hospital, dated 10/11/17, indicated Patient 15 had sustained a right intertrochanteric fracture (hip fracture). Patient 15 had a surgical operation done on 10/12/17 to repair the hip fracture.
During an interview with the Director of Nurses (DON), on 10/12/17, at 3:30 PM, she stated she was notified of the fall on 10/6/17. DON stated, "I was told she [Patient 15] fell and was able to move all extremities. I wasn't aware she was crying during the passive range of motion until I went through the notes on Monday [10/9/17]." DON stated she had not assessed Patient 15 after she was made aware of Patient 15's complaint of pain, crying, and pushing staff away. DON stated, "I was told she was crying, was able to move both legs, no one told me she was guarding her legs. That's new for her. Yeah, she should have been sent out sooner."
The facility policy and procedure titled "Change in a Resident's Condition or Status" undated, indicated "A significant change of condition is a decline or improvement in the resident's status that: Ultimately is based on the judgement of the clinical staff. . . Acute changes include: Incident with injury of any kind this includes skin tear, bruise or pain. Change in baseline condition. . . New behavior."
The policy and procedure titled "Pain Assessment and Management" undated, indicated "Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of jaw, etc.; c. Changes in gait; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Guarding, rubbing or favoring a particular part of the body; f. difficulty eating or loss of appetite; Review the resident's clinical record to identify."
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. |