| 020000116 |
East Bay Post-Acute |
020009140 |
B |
15-Mar-12 |
LZWC11 |
7499 |
T22 DIV5 CH3 ART5-72520(a) Bed Hold (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and that insurance may or may not cover such costs. 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. The facility is in violation of the above regulations by its failure to: 1. Readmit the patient when a psychiatrist cleared the patient to be safe and stable to return to the facility. 2. Give Patient 1 reasonable advance notice for discharge when he could no longer pay for his stay in the facility. The facility admitted Patient 1 on 3/9/08 with multiple health problems including, but not limited to end stage renal disease. Patient 1 went for dialysis treatment three times a week outside the facility.Patient 1 was known to have gone out to a liquor store across the facility for alcohol.According to the records and staff interview with the DON on 3/3/11 at 1:05 p.m., after the first incident on 1/07/11 the patient promised he would not drink or have a similar incident again. On 1/07/11, Patient 1 eloped, went to a liquor store, missed the dialysis treatment and ended up in a hospital due to alcohol intoxication. During the interview on 3/3/11 at 1:05 p.m., the DON (Director of Nursing) said that on 3/2/11 at around 11:00 a.m. or noon time, Patient 1 came from a liquor store and was waiting for transportation to take him to the dialysis center. CNA 1 saw alcohol in the bag that Patient 1 had at that time and reported it to the DON. The DON approached Patient 1 and asked if he had alcohol. Patient 1 threw a soda can towards the DON's direction. The can landed in a garbage can. The DON described Patient 1's behavior as volatile and determined him to be unsafe for himself and staff. The DON said that Patient 1, "medicated himself with alcohol." The facility called the police, declared a 5150 hold and transferred Patient 1 to GACH 1, an acute psychiatric hospital for evaluation. A 5150 hold is a situation when a person was determined to be a threat to self, others and gravely disabled. A person is gravely disabled when he does not have the ability to take care of himself.Review of the Interdisciplinary Progress Notes dated 3/2/11 at 1600 (4:00 p.m., inconsistent of the time stated in the interview) showed the documentation of the events that led Patient 1 being taken by ambulance to GACH 1. The documentation showed that Patient 1 was volatile while the police attempted to remove the bag (with alcohol) from the patient. GACH 1 medically cleared Patient 1. The ambulance transferred Patient 1 to GACH 2 for a psychiatric evaluation. Review of the Intake Evaluation and Progress Evaluation Note dated 3/3/11, written by the psychiatrist at GACH 2 showed that Patient 1 was uncooperative, irritable, anxious and disoriented during the initial assessment of the mental status. The examination showed that Patient 1 was gravely disabled, but was not a danger to self or others. The initial evaluation was completed on 3/3/11 at 6:20 a.m. The plan was to observe Patient 1 for disorganization, falls and seizure precaution while at the psychiatric emergency services. According to Progress Evaluation Note dated 3/3/12 at 12:48 p.m., Patient 1 improved and the psychiatrist cleared the patient as stable and called the skilled nursing facility to transfer the patient back. The psychiatrist's notes indicated that the nurse manager at the facility refused to take the patient back due to the patient's assaultive behavior and inability to pay fees.The Progress Note-Social Services dated 3/3/11 at 4:47 p.m. at GACH 2 showed that LCSW 1 spoke with the Administrator of the facility who said that the "5150 is like an eviction" notice. The Administrator confirmed with the LCSW 1, the social worker who interviewed Patient 1 that the facility did not serve Patient 1 an eviction notice and they just did not want the patient back. LCSW 1 documented that the Administrator was aware that a fine would be given, but would take the consequence of not taking the patient back.The PES Exit Disposition, the patient record from GACH 2 documented that the patient was calm and cooperative. Patient very much wanted to return to his home, the facility. Patient 1 was not threatening, psychotic and stable to return home.GACH 2 sent Patient 1 for dialysis treatment and made arrangement with the ambulance to take the patient back to the skilled nursing facility after treatment. The skilled nursing facility refused to take Patient 1 back and told the police present that Patient 1 would not be readmitted. The police report dated 3/3/11 at 7:29 p.m. showed that the Administrator told the police by phone that the Board of Directors of the facility had made the determination not to allow Patient 1 to return to the facility due to his "behavioral problems" in the past. The ambulance took Patient 1 to another skilled nursing facility, SNF 2, an affiliate of the former skilled nursing facility. SNF 2 was farther away from Patient 1's dialysis clinic, family and friends.During a phone interview on 3/7/11 at 12:50 p.m. and 2:32 p.m., the Administrator said that Patient 1 was not eligible for Medicaid on 3/1/11 and the facility was to assist Patient 1 get reinstated for Medicaid. On 3/7/11 at 2:19 a.m., SSD said, there was no follow-up when Patient 1 left on 5150.In a phone interview on 3/8/11 at 9:20 a.m., Patient 1 said, the new facility was way far from his family; he could not sleep because his roommate was yelling and wanted to go back to the former skilled nursing facility.Therefore, the facility failed to: 1. Observe Patient 1's right to return to the facility after the psychiatrist determined the patient to be safe and stable. 2. Observe Patient 1's right to be given an advanced notice of discharge when the patient could no longer pay for his stay in the facility. The above violations had a direct or immediate relationship to the health, safety or security of patients. |
| 020000128 |
Elmwood Care Center |
020010860 |
B |
14-Jul-14 |
L6Z311 |
3792 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESF323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation by failing to provide adequate supervision or a monitoring device (bed/chair alarm) to prevent Resident 3 getting out of bed unassisted on 8:20 p.m. on 4/18/14, sustaining a right hip dislocation. Resident 3 was admitted with a broken right hip on 4/17/14 and was at high risk for falls. On 4/18/14 at 8:19 AM, the night nurse recommended that the day nurse get an order for a bed alarm because Resident 3 was attempting to get out of bed. A bed alarm was not obtained and Resident 3 fell out of bed at 8 at 8:20 PM sustaining a right hip dislocation.Record review on 4/29/14 showed Resident 3 was admitted to the facility on 4/17/14 with diagnoses which included fracture of femur, hypertension, and dementia.Resident 3's fall risk evaluation record, dated 4/17/14, showed a score of 10 which represents Resident 3 was at high risk for falls. Resident 3's physician admission orders, signed 4/18/14, showed Resident 3 does not have capacity to make healthcare decisions. The nurses' notes ,dated 4/18/14 at 8:19 a.m., showed Resident 3 was alert and responsive with unclear speech, a fall risk with precautions in place, endorsed to day shift licensed nurse to get an order for a bed alarm because Resident 3 attempted to get out of bed without assistance on night shift.The nurses notes, dated 4/18/14 at 11 p.m., showed Resident 3 had an unwitnessed fall at 8:20 p.m. Resident 3 was found on the floor and put back to bed. Resident 3 told staff she slid off the bed while trying to use the bed pan. The nurses' notes showed that family came in after being notified of fall, and asked why Resident 3 did not have a bed alarm and the charge nurse informed the family there were no bed alarms available at this time. Resident 3 complained of pain at 10:45 p.m. and the physician was notified with an order for stat x-ray of right hip. The x-ray was done around 2 a.m. and the results were received around 3 a.m. and Resident 3 was sent to hospital and treated for dislocation of the right hip prosthesis. The orthopedic consultant report on 4/19/14 at the hospital showed Resident 3 had "a simple dislocation despite hardware, recommends attempting bedside reduction under sedation, usual technique, may need operating room (OR) if unable." On 5/8/14 at 2 p.m., RN (Registered Nurse) 1 stated Resident 3 was on fall precautions and the bed was lowered. RN 1 stated she did not believe there was a bed alarm and that the evening Shift had looked for an alarm, given her report, she looked for an alarm, and there was no alarm available. On 5/9/14 at 2:45 p.m., CNA (certified nurse aide) 1 stated she was instructed that Resident 3 was a fall risk and to keep the bed low. CNA 1 stated Resident 3 did not have a bed alarm and when Resident 3 family left the facility, Resident 3 made an attempt to get out of bed.The facility's policy, "Fall Prevention, "9/1/08 showed", the purpose was to prevent accidents by providing an environment that is free from hazards over which the facility has control. "All residents shall be assessed for being at risk for falls and any resident identified as "at risk" for falls shall have an individual plan of care that includes interventions to prevent falls for occurring." The policy showed "a licensed nurse will assess all residents on admission and quarterly for risk factors for falls and will initial a care plan for all residents at risk for falls."The above violation has a direct relationship to the health, safety or security of patients |
| 020000116 |
East Bay Post-Acute |
020011101 |
B |
04-Nov-14 |
B58Y11 |
4896 |
483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.The facility violated the aforementioned regulation by failing to protect Resident 18 from physical abuse by Resident 24.On 8/27/14, Resident 24 was in an electric wheelchair and ran into Resident 18, knocking him off his wheelchair and on the next day, 8/28/14, Resident 24 punched Resident 18 on the face resulting in Resident 18 feeling unsafe in the facility.Record review on 9/8/14 showed Resident 18 was admitted on 8/12/14 for wound care and rehabilitation following a below the knee amputation.In an interview on 9/9/14 at 1:00 p.m., Resident 18 was asked about his care at the facility and replied that he did not, "Feel safe here." Resident 18 described an incident when another resident, (Resident 24), came into his room in an electrically powered wheelchair and ran him, "Off of his wheelchair and onto the railing of the balcony," outside of his room. Resident 18 stated that he reported this to the staff but felt that the staff "Swept the incident under the rug." Resident 18 stated that there was a second incident the next day with Resident 24. Resident 24 was involved in a verbal and physical argument with Resident 25 in the hallway directly next to Resident 18's room. Resident 18 had been outside having a cigarette. He was trying to get past Resident 24 and 25 so he could enter his room and as he passed, Resident 24 "Hit me in the face." In an interview on 9/9/14 at 12:05 p.m., the Social Services Coordinator, (SSC) was asked to describe the sequence of events regarding Resident 18. The SSC stated that Resident 18 had been, "Run off of his chair by another resident in a powered wheelchair on August 27th, 2014. The Director of Nursing did not find out about it until August 28th. We told both residents to stay away from each other. They were told to stay on each other's side of the building since their rooms are on opposite sides." The SSC was then asked to describe the incident regarding Resident 18 getting hit in the face by Resident 24. The SSC stated that, at approximately 9:30 p.m. on August 28, 2014, there was a physical and verbal fight between Resident 24 and another resident in the hallway. Resident 24 was still in her electric wheelchair. At that same time, Resident 18 was coming down the hall trying to get into his room. As Resident 18 passed by, Resident 24 punched him in the face." The SSC was then asked why Resident 24 was at that end of the hall since she had been told not to enter that area. The SSC stated that she "Did not know. She, (Resident 24), was still in the electric wheelchair." The SSC was then asked to describe the steps in place to prevent Resident 24 from moving to the opposite side of the building and potentially injuring other residents. The SSC stated that Resident 24 is currently unable to, "Use her wheelchair as a weapon. We gave her a manual wheelchair which she cannot use without assistance from staff. We took the electric wheelchair away on August 31, 2014." The SSC was asked why it took 3 days before staff removed the electric wheelchair. The SSC stated "I do not know." In an interview on 9/10/14 at 8:30 a.m., the Director of Nursing, (DON), was asked to describe the steps taken following the first incident when Resident 24 ran into Resident 18 with her wheelchair. The DON stated that, following the first incident, she met with Resident 24 and, "Discussed the policy regarding electric wheelchair use." The DON was then asked why it took 3 more days for staff to replace the electric wheelchair with a manual one. The DON stated that she believed the first incident happened on a Friday and she was, "Off on Saturday and Sunday. I think we took it away that Friday but I am not sure."Record review of the facility's policy and procedure titled, "Electric Wheelchair", and dated May, 2008, showed that, if a resident is not able to safely operate and maneuver the electric wheelchair as evidenced by related accidents or incidents, then attempts will be made immediately by the facility administrator and Director of Nurses or designees to regulate the use of the electric wheelchair. Record review of the facility's policy and procedure titled, "Abuse and Neglect": Measures to Prevent, showed that, if the suspected abuser is another resident, staff would separate residents and ensure the safety of the affected resident; and monitor residents closely to prevent a reoccurrence. Therefore the facility failed to prevent Resident 24 from physically abusing Resident 18. The above violation has a direct or immediate relationship to patient health, safety or security of residents. |
| 020000116 |
East Bay Post-Acute |
020011104 |
B |
04-Nov-14 |
B58Y11 |
3341 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the aforementioned regulation by failing to follow physician's order and apply a seat belt to (Resident 15 while up in a wheelchair, resulting in Resident 15 falling out of her wheelchair and sustaining a facial abrasion and being sent to the hospital.On 9/10/14, at approximately 9:00 a.m., observation showed Resident 15 was lying on the corridor floor near her wheelchair in close proximity of Nursing Station 2. Resident 15 had a facial laceration. LVN 1 and others were in attendance to the resident. There was no seat belt observed on the chair or in close proximity to the resident. The resident was later transferred to the acute care hospital for subsequent care and evaluation. Review of the Nurse's Notes, dated, 9/10/14 at 9:00 a.m. showed, "Resident alert and verbally responsive was up on w/c...near to Nurse's Station II outside across to her room and fell from her w/c. Resident hit her head with the floor and got laceration. Checked for any neck and back injuries. Kept on the floor with head on pillow and waited on EMT's to assist. Resident sent to hospital." Review of the facility's record showed the facility admitted Resident 15 to the facility on 7/1/13 with diagnoses that included cerebral (brain) degeneration. Review of the "Evaluation" section dated, 6/4/14 of the "Occupational Therapy Discharge Summary" (services from 6/2/14 - 6/20/14) showed, "Patient demonstrates total assist for ongoing/frequent supervision and [reposition] in w/c [wheelchair] d/t [due to]...R/L [right/left] trunk leaning resulting in increased risk of fall..." The review of the current "Functional Status "section of the quarterly MDS (assessment tool) dated, 7/1/14 and Weekly Summary dates, 9/9/14 showed the resident was totally dependent on staff for ADL (activities of daily living) that included transfer and ambulation. The review of current monthly orders dated, September, 2014 showed orders that included, "Seat belt while in wheelchair for safety and prevention on unassisted transfers On 9/11/14 at 9:45 a.m., during an interview, LVN 1 was asked about the "seat belt" application order. LVN 1 indicated that the resident was supposed to have the "lap belt" on when up in the chair because "she [Resident 15] likes to lean forward to adjust her pants and fidgets around." LVN 1 further stated she did not see it applied to the resident on the date of the fall incident.On 9/11/14 at 9:55 am, Housekeeping Technician stated she witnessed the resident fall approximately 10 steps away from her while she (Housekeeping Technician) was vacuuming the corridor floor carpet near the nurse's station. Housekeeping Technician stated she saw Resident 15 lean forward and fall on the floor. There was no seat belt on the resident. Therefore the facility failed to follow the physician's order to apply a seat belt on Resident 15 when up in the wheelchair resulting in Resident 15 falling out of the wheelchair and sustaining a facility abrasion.The above violation has a direct or immediate relationship to patient health, safety or security of residents |
| 020000116 |
East Bay Post-Acute |
020011858 |
B |
19-Nov-15 |
CZML11 |
5509 |
F 323 483..25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation by failing to provide supervision and a smoking apron for Resident 10 on 6/26/15 while he was smoking in the smoking area resulting in Resident 10 sustaining a second degree burn (the first layer and some of the second layer of the skin are burned) to his left thigh. The facility failed to ensure the Interdisciplinary Team (IDT) conducted an investigation on how Resident 10 sustained a burn from smoking and failed to update the smoking care plan thereby placing Resident 10 at further risk of cigarette burns. Review of the clinical record, on 7/10/15, showed that Resident 10 was admitted in 2010 with multiple diagnoses that included airway obstruction, diabetes, chronic heart disease, muscular wasting and disuse atrophy (shrivel), difficulty walking, and paralysis of the non-dominant lower limb due to cerebrovascular (refers to a group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to the affected areas of the brain.) A "Change of Condition Assessment" form, dated 6/26/15 at 9 a.m., indicated that Resident 10 was found with a hole in his pants on the left thigh and a partial thickness burn wound to his left thigh measuring, "2 cm (centimeters) x 1.7 cm x 1 cm". (2.54 cm equals 1 inch.) During an interview on 7/10/15 at 9:50 a.m., Licensed Vocational Nurse 4 (LVN 4) stated she was the charge nurse for Resident 10 on 6/26/15. LVN 4 said Resident 10 was brought into the facility from the smoking area and she saw a hole in Resident 10's pants. LVN 4 stated, "looks like from cigarette, "and found the burn wound on the left thigh.Review of Resident 10's Smoking Care Plan, dated 5/28/15, showed that Resident 10 "may smoke under supervision." The goal was "Resident will smoke safely in accordance with Facility policy," with a projected goal date of 8/2015. The listed interventions included: assist Resident 10 to and from the smoking area and use a smoking apron. A review of Resident 10's "Safe Smoking Assessment," dated 5/30/15, indicated Resident 10 was not able to hold a cigarette without endangering others and he was not able to safely extinguish the cigarette and place it in the proper receptacle. On 7/6/15 at 10:15 a.m., in an interview, the Environmental Services Coordinator (ESC) stated, "The smoking aprons were kept in my office. During interviews on 7/6/15 at 10:16 a.m. and 4:20 p.m. respectively both LVN 3 (Licensed Vocational Nurse 3 and CNA 6 (Certified nurse aide) said that residents should be supervised and wear smoking aprons while outside smoking but neither one knew where the smoking aprons were kept. During observations and concurrent interview on 7/7/15 at 9:45 a.m. and 10:00 a.m., Residents 5 and 9 were smoking on the facility's back porch/designated smoking area without staff supervision and no smoking apron. When asked if they are aware of the smoking apron, Residents 5 and 9 both stated, "We were not offered a smoking apron." Resident 5 stated," We were not aware that we are supposed to wear an apron while smoking, I never saw one, and I was never offered a smoking apron." On 7/10/15 at 9:55 a.m., the Environmental Service Coordinator (ECS) stated the maintenance department is assigned to sit with Resident 10 in the smoking area at 9 a.m. ECS stated he documents on the log (Smoking Watch Log) when he supervises residents in the smoking area. There was no documentation on the log indicating any of the residents were supervised, on 6/26/15, or that smoking aprons were provided. ECS stated he missed that day and was not aware Resident 10 was burned.During an interview, on 7/10/15 at 10:15 a.m., the Director of Nursing Services stated there was no investigation done by the IDT and no smoking reassessment after Resident 10 sustained a burn on his thigh, on 6/26/15, because she was not aware there was an incident.During an interview on 7/10/15 at 4:30 p.m., Registered Nurse 3 (RN 3), also the Nurse Consultant, reviewed Resident 10's Smoking Care Plan dated 5/28/15, and stated it is Resident 10's current smoking care plan and it was not updated after the 6/26/15 incident. Review of the facility's undated policy "Smoking," included the direction that the IDT will ensure the smoking assessment is completed upon admission, quarterly, annually and upon significant change and include interventions related to safe smoking. In addition, staff will make reasonable accommodation to supervise residents identified as unsafe to smoke. Review of the facility's 2013 policy "Interdisciplinary Team Meeting Standard" indicated that the meeting process allows the team to review residents' care risk areas, ensure compliance with policy and procedure and determine root cause and effective intervention. Review of the facility's 10/14 policy "Care Plan Interdisciplinary" indicated that the Interdisciplinary team will review care plan and update individual care plan as necessary. Therefore the facility failed to provide supervision and a smoking apron for Resident 10, on 6/26/15, resulting in a 2nd degree, partial-thickness burn to his left thigh and failed to ensure the IDT investigated the incident and updated the care plan to ensure no further burns would occur. |
| 020000116 |
East Bay Post-Acute |
020011859 |
B |
19-Nov-15 |
CZML11 |
5889 |
F 309 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the aforementioned regulation by failing to give the prn (give as necessary) MS (morphine sulfate is a controlled substance to treat moderate to severe pain) as ordered for breakthrough pain resulting in Resident 12 having unrelieved pain. Resident 12 received MS 5 mg (milligrams) every 6 hours around the clock which did not completely relieve his pain and had an order for MS 20 mg. liquid for breakthrough pain. Resident 12 had unrelieved pain which was not assessed and his prn order for MS 20 mg was only given once in 10 days. On 7/9/15, review of the clinical record showed that Resident 12 was admitted with multiple diagnoses that included end stage congestive heart failure (when heart muscle is weak and doesn't pump blood as well as it should), and Multiple Myeloma (cancer that starts in the bone marrow plasma cells). The diagnosis of Multiple Myeloma was considered terminal and Resident 12 was on hospice care. A comprehensive assessment tool of cognitive, functional and psychosocial status), dated 6/03/15, showed that Resident 12 was able to recall information, able to reason, and able to understand communication.Review of Physician Orders, dated 7/1/15, showed that Resident 12 had two orders for MS to be given for pain: 1) MS 5 mg sublingually (underneath the tongue) around the clock every 6 hours (12:00 midnight, 6:00 a.m., 12 noon and 6:00 p.m.) and 2) an older order, dated 2/27/15, for MS 20 mg liquid every 3 hours prn (give as necessary) for shortness of breath/pain. During an observation and concurrent interview on 7/9/15 at 7:50 a.m., Resident 12 was lying on his right side with the head of the bed elevated with a grimace on his face. Resident 12 stated, "I am hurting on my buttocks." When asked if he told the staff about his pain, Resident 12 stated, "I told the nurse."In an interview on 7/9/15 at 7:52 a.m., Licensed Vocational Nurse (LVN) 3 stated, "He had his pain medication at 6:00 a.m. He was on routine Morphine Sulfate for pain. I will check if he has pain medication that I can give." In an observation and concurrent interview on 7/10/15 at 7:25 a.m., Resident 12 was lying on his back with the head of the bed elevated. Resident 12 stated, "I am hurting so much, this people don't care." When Registered Nurse (RN) 1 was informed of Resident 12's complaint of pain, RN 1 stated, "He got his routine pain medication 30 minutes ago." In a follow up observation, on 7/10/15 at 8:20 a.m., while staff assisted Resident 12 with breakfast, Resident 12 complained about pain on his buttock. When RN 1 was asked about Resident 12's complaint of pain on his buttock, RN 1 said Resident 12 had an order for Morphine Sulfate administer 20mg/ml every 3 hours as needed for pain. RN 1 stated, "I did not give him pain medication because he just got his pain pill at 6:00 a.m. I want to check first if the pain medication given earlier was effective. I will call the Physician if he can give me stat order of pain medication."In an interview on 7/10/15 at 10:08 a.m., Certified Nursing Assistant (CNA) 2 stated, "Resident 12 was complaining of pain on his buttocks lately and more often when we turn him from side to side. Of course we notify the nurse, but he continues to complain of pain." In a follow up observation and interview on 7/10/15 at 10:30 a.m., Resident 12 stated, "I did not get my pain medication yet. I am hurting so much." When Resident 12 was asked about the severity of his pain, using a scale of 0-10 with ten being the worst, Resident 12 said his pain was "8".LVN 5 was again notified of Resident 12's pain and said, "You did not tell me that he is in pain. I will give him his pain medication now." In an interview on 7/10/15 at 12:15 p.m., Hospice Nurse stated, "I told them already, to give him [Resident 12] his PRN pain medication because he is hurting. How could I increase the dose of his pain medication if the staff is not assessing the pain?" In a follow up interview on 7/10/15 at 1:15 p.m., Resident 12 was awake on his right side. Resident 12 stated, "This sore in my buttocks is painful. I am tired hurting." Review of Resident 12's Care Plan "Altered Comfort (Pain)," and "Pain Assessment," dated 2/27/15, showed Resident 12 was in pain secondary to terminal illness. Care plan approaches included to monitor and report signs and symptoms of pain, i.e. flinching, moaning, crying, facial expression, position for comfort, allow for rest period, assess effectiveness of PRN medication and notify MD if needed, encourage resident to report pain, routine pain medication as ordered. Evaluate effectiveness on the MAR every shift and PRN medication as ordered. Review of facility's policy and procedure titled "Hospice Care," revised 10/14, showed that the "...licensed nurse will oversee that all medications, treatments, and other procedures are provided in accordance with standards of practice and as per order of the primary care physician..."Review of Resident 12's July "Medication Administration Record" (MAR) on 7/10/15, showed Morphine Sulfate 5mg was given every 6 hrs. as ordered, but the MS 20mg/ml prn every 3 hrs. was given once on 7/1/15.Review of the July "Pain Assessment Flow Sheet," on 7/10/15, showed there was no pain assessment between 7/1/17 and 7/10/15. There was no indication Resident 12 received the prn MS. Therefore the facility failed to give the prn Morphine Sulfate medication to Resident 12 as ordered by the physician resulting in Resident 12 having unrelieved pain.The violation had a direct relationship to the health, safety or security of residents. |
| 030000020 |
Eagle Crest |
030008848 |
B |
06-Jan-12 |
LSMP11 |
8916 |
72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 72311Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 7/9/10 at 9:20 a.m., an unannounced visit was made to the facility to investigate an entity self-report of a patient fall that resulted in a hip fracture. Based on interviews and record reviews, the facility failed to: 1. Assess a patient (Patient 1) for two days following an unwitnessed fall. 2. Promptly notify the physician following Patient 1's unwitnessed fall. Patient 1 was a 61 year old admitted to the facility on 2/25/10 with diagnoses that included left-sided paralysis.Review of Patient 1's clinical record revealed the following documentation: 1. A Social Services note in the Interdisciplinary Progress Notes, dated 6/16/10 (not timed), indicating that Patient 1's wife ". . . will be taking Res (resident) home on 6/30/10." 2. A weekly summary in the Interdisciplinary Progress Notes, dated 8:00 a.m. on 6/26/10, which indicated the patient had not experienced any falls that week. 3. A Change of Condition form dated 11 a.m. on 6/27/10 which noted the patient complained of persistent left knee and left hip pain described as an aching and stabbing pain, aggravated by mobility of the hip. The range of motion of the left leg could not be assessed due to pain, and an X-ray was ordered. 4. A Change of Condition form dated 4 p.m. on 6/27/10 which noted an X-ray had revealed the patient had sustained an acute (sudden onset) fracture of the left hip. The notes further added Patient 1 reported he had fallen a few nights earlier. 5. An X-ray report dated 6/27/10 which concluded the patient sustained an acute left hip fracture. The facility "Falls Management Program" policy, dated January 2008, included the following information: 1. "Reporting and Investigating Falls. A specific procedure is followed to report and investigate falls. This ensures that the resident receives appropriate care after a fall, that an investigation is begun, and that the resident's care plan is adjusted, as needed." 2. "When A Resident Falls. Notify the licensed nurse, who will: 1. Provide immediate care and first aid, including a complete head-to-toe evaluation. 2. Stay with the resident. 3. Complete a neurological evaluation, if the resident hit his or her head, or if the fall is not witnessed. 5. Notify the physician and the resident's responsible party." 3. "Post-Fall Documentation. After the resident has been cared for, the licensed nurse: 1. Completes an interdisciplinary note, including . . . the nursing evaluation, actions taken, who was notified, and the resident's condition (Licensed nurses continue to document the resident's condition in the Interdisciplinary Progress Notes during each shift for the next 24 hours, and daily for the next 72 hours, noting any changes of condition.) 2. Completes a Fall Evaluation to determine if there have been any changes in resident condition and to identify interventions that may help in preventing future falls. 4. Updates the care plan with the identified interventions. 6. Completes the 24-Hour report, to alert following shifts to the fall . . ." On 6/28/10 and 6/29/10 the facility conducted an investigation into the reported fall. The following information was included in the investigation: 1. An interview with Certified Nursing Assistant (CNA) 1 in which she reported to the facility that she had noticed the call light on to Patient 1's room at approximately 1 a.m. on 6/25/10. She went into the room and discovered the patient on the floor. The roommate had turned on his light to summon the staff. CNA 1 then called for Licensed Nurse (LN) 1 to come to the room. CNA 1 reported she heard LN 1 ask the patient what happened and heard the patient tell LN 1 that he was having hip pain. CNA 1 reported she did not see LN 1 assess the resident's ability to move his arms or legs. She then reported LN 1 told her the resident was fine and they asked CNA 3 to come to assist the patient back to bed. 2. An interview with CNA 3 in which CNA 3 reported he was called to the room to help transfer the patient from the floor to the bed. He reported LN 1 was in the room and was asking the patient how he fell. 3. An interview with CNA 2 in which CNA 2 reported she saw CNA 1, CNA 3, and LN 1 running to Patient 1's room. She reported she followed them and saw the patient on the floor. She reported she heard LN 1 ask Patient 1 if he was alright and the patient told her he was alright. LN 1 then told the CNAs the patient was alright and they transferred him back to the bed. CNA 1 noticed blood on the patient's hand and told LN 1. LN 1 observed the blood on the patient's hand and stated she would put something on it.In an interview with the Responsible Party (RP) for Patient 1 on 7/7/10 at 4:35 p.m., she reported that Patient 1 called her on the morning of 6/25/10 and told her he had experienced a fall that prior night. She went in to visit the patient that evening and spoke with LN 2 and asked LN 2 if anyone had assessed the patient as a result of the fall the prior evening. She reported LN 2 told her he was not aware of any fall and he would look into it. On 6/26/10 she was not able to see the patient, but she spoke to him by phone and he told her his leg hurt more than usual. She returned to the facility on 6/27/10 at approximately 8:00 a.m. She asked an unidentified staff if there had been any X-rays ordered to identify a possible fracture and again the staff "did not know what was going on." She reported she looked at the patient's leg and could tell there was something wrong with it, he still complained of pain and he could not straighten it. She spoke to LN 3 about an hour later. LN 3 then went into the room and assessed Patient 1 at that time.Following assessment and notification of Patient 1's physician on 6/27/10, Patient 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation and treatment. Per the GACH Emergency Department Report, Patient 1 was admitted with a left hip fracture and underwent a left hip hemiarthroplasty (artificial replacement of the highest part of the thigh bone) surgery on 6/29/10. GACH records revealed Patient 1 was discharged on 7/1/10 to a different skilled nursing facility for continued physical therapy. In an interview with LN 2 on 7/12/10 at 5:55 p.m., he reported the RP for Patient 1 approached him on Friday, June 25th to ask him if anything was being done about the fall the patient had experienced the night before. LN 2 reported he spoke to CNA 1 who had cared for Patient 1 on the night of the fall and she confirmed he had fallen and she had told the nurse on duty that night. He reported he had intended to investigate the incident further but he became distracted and forgot to look into it. He recalled the RP had asked him to assess the patient at that time and he observed the Patient 1 was resting well, but when he assisted the staff with changing his shorts the resident complained of pain on movement.In an interview with CNA 2 on 7/12/10 at 7:45 p.m. she reported she was working on the early morning of 6/25/10 when Patient 1 fell. She reported she saw CNA 1 call for LN 1 to come to the room. LN 1 went to the room as well and saw the patient on the floor. CNA 2 reported she saw blood on the resident and pointed it out to LN 1. In an interview with the Assistant Director of Nursing on 7/16/10 at 4:15 p.m. she reported it was her expectation the charge nurse on duty should have assessed Patient 1 for his range of motion and level of consciousness and she did not do this. She verified the staff on duty did not assess or report the fall as per the facility "Falls Management Program" policy. The facility's failure to promptly assess Patient 1 following an unwitnessed fall, and failure to promptly notify Patient 1's physician of the unwitnessed fall, delayed identification and implementation of treatment for a fractured hip for more than two days. Patient 1, who was to be discharged home from the nursing facility on 6/30/10, required transfer to a hospital and surgery to correct the fracture, requiring an extended stay in a nursing facility for continued therapy. These violations had a direct relationship to the health, safety, or security of the patients. |
| 100000057 |
Eskaton Care Center Greenhaven |
030009009 |
B |
16-Feb-12 |
807J11 |
7490 |
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. Nursing Service - Patient Care - 72315 (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Patient Care Policies and Procedures - 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. An unannounced visit was made to the facility on 6/9/09 to investigate a Facility Reported Incident CA00189854. The Department determined the facility failed to: 1) Ensure facility staff reported a suspected abuse of Patient A within 24 hours as required by law. 2) Ensure facility policy related to abuse reporting was implemented.3) Ensure each patient was treated with dignity and respect.Patient A's clinical record was reviewed on 6/9/09. She was an 85 year old female originally admitted to the facility on 1/6/09. Patient A's Quarterly Minimum Data Set (MDS, a standardized assessment tool), dated 4/22/09, documented Patient A as having no short or long-term memory problems, as having moderately impaired cognitive skills for daily decision making, able to make herself understood, able to understand others and as having no behavioral symptoms. The MDS also documented Patient A as needing supervision with bed mobility and locomotion off the unit and as needing limited assistance with transfers, dressing, toilet use and personal hygiene. A care plan dated 4/no date/09, identified Patient A with a language barrier since she spoke only Cantonese. Review of the facility's investigative report revealed Patient A was interviewed by Administrative Staff (AS) 1 and AS 2 on 5/26/09 using an AT &T interpreter. Patient A was asked if she could recall any incident where she was awakened by a staff member splashing water on her. Patient A stated "Yes, I remember, I was asleep. They got my head all wet." Patient A was asked if her sheets or nights clothes needed to be changed. Patient A stated that it was just her head that got wet and that she wiped her own face. Patient A was unable to recall the specific date or how long ago the incident occurred. Patient A further stated there were approximately 5-6 people in the room when the incident occurred and also explained that it was very noisy. Patient A was asked if she could describe the individual who sprinkled water on her but she stated she could not. Patient A stated, "It was a minor thing. I didn't want to start anything." The interview further documented that Patient A "did express some fear of the staff when she stated, "Well, in my heart, I'm a bit nervous. I don't dare say anything." It was also documented in the interview that overall Patient A felt "staff haven't bothered her." Patient A was interviewed, using an AT &T interpreter, on 6/9/09 at 9:30 a.m. She stated a female person flicked water on her face and that she was able to wipe it off. Patient A further stated, "It was no big deal." Patient A was unable to describe the individual. When Patient A was asked if she felt safe at the facility she stated, "I don't' know. I have no choice." When asked again Patient A stated she didn't feel safe at the facility. When asked why she replied "I don't know what is alright to say." Patient A was asked what would make her feel safe she stated, "I don't know." The facility's investigation report, dated 5/26/09, documented that Certified Nursing Assistant (CNA) 1 reported to the Administrative Staff 1 at approximately 5:30 a.m. on 5/26/09 that she had knowledge of an incident that occurred during the night shift approximately 3 weeks ago. CNA 1 stated she heard some yelling in the hallway and when to see what was happening when she walked in on CNA 2 standing over Patient A. CNA 1 stated she noticed Patient A was lying in bed and was wiping her face with her hands. When CNA 1 asked CNA 2 what happened CNA 2 stated, "I'm just splashing water on her face." When CNA 1 told CNA 2 not to do that CNA 2 just laughed about it.CNA 1 further stated she didn't see the event take place nor did she notice any water on Patient A's face. CNA 1 also stated the lights, in the room, were on and she could clearly see and also did not see any water containers knocked over. CNA 1 was asked if she had reasonable suspicion that abuse of Patient A had occurred and she stated, "Yes." CNA 1 acknowledged that she failed to report the abuse of a patient and stated, "I just didn't do it. I don't know why." CNA 1 understood that she is a mandated reporter. CNA 1 also confirmed she had not told any other CNA or licensed nurse about the incident. CNA 1 was unable to recall the specific day the incident occurred but confirmed it took place about 3 weeks ago. CNA 1's personnel file was reviewed on 6/9/09 and contained a form tilted, "Rules of Conduct," dated 5/26/09. The form documented on 5/26/09 CNA 1 reported a suspected patient abuse which she alleged occurred approximately 3 weeks ago. CNA 1 stated that she felt the incident could be considered abuse but she failed to report the incident to anyone until today (5/26/09). The form further documented that CNA 1 is a mandated reporter and must report suspected abuse immediately to her charge nurse.Review of the facility's "Elder and Dependent Adult Suspected Abuse & Reporting," policy, last revised 11/15/06, documented "any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or no that person received compensation, including administrator, supervisors and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, or employee of a county adult protective services agency or local law enforcement agency is a mandated reporter." According to the facility's policy "all suspected/alleged or witnessed abuse as listed above shall be immediately reported verbally and/or in writing to the mandated reporter's immediate supervisor and the Administrator or his/her designee, and the Director of Nursing. The mandated reporter is responsible for assuring that the Ombudsman or local law enforcement is notified immediately, or within 24 hours and the SOC 341 is completed." Review of the facility's "Investigative Summary," CNA 2 turned in her resignation during her suspension while the facility conducted its investigation. During an interview with AS 1 on 6/9/09 at 9:10 a.m. she confirmed the allegation of abuse towards Patient A was substantiated and CNA 2 would have been terminated if she had not turned in her resignation. The Department determined the facility failed to: 1) Ensure facility staff reported a suspected abuse of Patient A within 24 houras required by law. 2) Ensure facility policy related to abuse reporting was implemented.3) Ensure each patient was treated with dignity and respect.Failure to comply with the requirements of this section of the Health & Safety Code shall be a Class B Citation. The facility failure to ensure the patient was treated with dignity and respect had a direct relationship to patient health, safety and security. |
| 100000057 |
Eskaton Care Center Greenhaven |
030009010 |
B |
16-Feb-12 |
BC4C11 |
7788 |
Health & safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Patient Care Policies and Procedures - 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. An unannounced visit was made to the facility on 6/9/09 to investigate an Entity Reported Incident CA00188964. The Department determined the facility failed to: 1) Ensure facility staff reported an alleged or suspected abuse of Patient A within 24 hours as required by law. 2) Ensure facility policy related to abuse and abuse reporting was implemented.Patient A's clinical record was reviewed on 6/9/09. She was an 85 year old female originally admitted to the facility on 1/6/09. Patient A's Quarterly Minimum Data Set (MDS, a standardized assessment tool), dated 4/22/09 documented Patient A as having no short or long-term memory problems, as having moderately impaired cognitive skills for daily decision making, able to make herself understood, able to understand others and as having no behavioral symptoms. The MDS also documented Patient A as needing supervision with bed mobility and locomotion off the unit and as needing limited assistance with transfers, dressing, toilet use and personal hygiene. A care plan dated 4/no date/09, identified Patient A with a language barrier since she spoke only Cantonese. The facility's investigation report documented Patient A was interviewed on 5/18/09, using a family member of Patient A's as an interpreter. Patient A stated around 3:00 a.m. 6-7 people came into her room and one of them began pinching her cheek repeatedly and pulling her hair. Patient A was unable to recall what day the incident occurred and on 5/18/09 was observed to have a bruise on her right cheek. Patient A was interviewed, using an AT &T interpreter on 6/9/09 at 9:30 a.m. She stated between 12:00 a.m. and 3:00 a.m., more than one person came into her room and started beating up the other old lady. Patient A stated she tried to stop it when a female came over and pinched the right side of her face and pulled her hair. Patient A was unable to describe the female.The facility's investigation report contained an interview with Licensed Nurse (LN) 1 dated 5/19/09 and conducted by Administrative Staff (AS) 1. LN 1 stated at the change of shift while getting report from LN2, Patient A was in the day room area. Patient A appeared agitated and was pointing to her cheek. LN 1 asked LN 2 what was wrong with Patient A and LN 2 replied that Patient A had been agitated and the CNAs (Certified Nursing Assistant) were trying to figure out what was bothering her.After the evening shift left, CNA 1 told LN 1 that Patient A stated someone pinched her. LN 1 stated she was not sure what to do and around midnight she called the Unit Manager. LN 1 told the Unit Manager that Patient A was agitated and pointing to her cheek. The Unit Manager told her to assess Patient A for pain. LN 1 stated upon assessment Patient A appeared to have a "small red pinch mark on her cheek" AS 1 asked LN 1 what the pinch mark looked like and demonstrated pinching AS 1's forearm. AS 1 asked LN 1 if she thought a pinch mark would last 2 hours that lapsed between change of shift and midnight. LN 1 then stated that the red area looked more like a bug bite. AS 1 reminded LN 1 that in her statement given to the Unit Manager on 5/19/09, she did not mention a bug bite and repeatedly referred to the red area as a pinch.LN 1 was asked why, as a mandated reporter, she had not completed a SOC 341 (a standardized reporting form). LN 1 stated that she didn't want to be responsible for blaming or accusing anyone. LN 1 was asked what she did to ensure Patient A was free form potential abuse. LN 1 did not answer the question and said she felt LN 2 had left her in a difficult situation. LN 1 stated she thought LN 2 had documented in Patient A's record. AS 1 informed LN 1 that if there was a potential of a "pinch" from a staff member, a SOC 341 should had been completed. LN 1 "eventually acknowledged that she should have documented the event in Patient A's record.The facility's investigation report documented LN 2 was interviewed on 5/19/09. LN 2 stated on 5/13/09 while giving report to LN 1 at the nurse's station, Patient A came to the station to LN 1 pointing at her cheek. LN 1 then told LN 2 "that she thinks someone may have pinched her." As LN 2 was leaving (her shift was over) she asked a Certified Nursing Assistant (CNA) what had happened. The CNA stated that Patient A had pinched her buttocks and the CNA told Patient A not to do that because it hurt. LN 2 then told LN 1 what CNA told her and left for the evening. LN 1's personnel record was reviewed on 6/9/09 and contained a form titled, "Rules of Conduct," dated 5/19/09, that documented Patient A had made an allegation that a staff member had "pinched" her. LN 1 "failed to document assessment of incident" and "as a mandated reporter employee (LN 1) also failed to report knowledge of suspected physical abuse against patient (Patient A)." At the bottom of the form where the employee was to sign her name was documented "refused to sign." Another "Rules of Conduct," form, dated 5/22/09, documented, "Employee (LN 1) is being terminated for failing to document an assessment of a pt. (Patient A) who may have been pinched or had a bug bite. No progress note in chart. No documentation on Supervisor's Report or 24 Hour Report or Event Report. As a mandated reporter employee (LN 1) should have also completed a SOC 341 Report of Suspected Abuse. Employee exhibited gross negligence by failing to assure safety of potentially abuse patient." At the bottom of the form where the employee was to sign her name was documented "Refused to sign/Hostile." Review of the facility's "Elder and Dependent Adult Suspected Abuse & Reporting," policy, last revised 11/15/06, documented "physical abuse includes hitting, slapping, pinching, kicking, etc..." The policy also documented that "any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that person received compensation, including administrator, supervisors and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, or employee of a county adult protective services agency or local law enforcement agency is a mandated reporter."According to the facility's policy "all suspected/alleged or witnessed abuse as listed above shall be immediately reported verbally and/or in writing to the mandated reporter's immediate supervisor and the Administrator or his/her designee, and the Director of Nursing. The mandated reporter is responsible for assuring that the Ombudsman or local law enforcement is notified immediately, or within 24 hours, and the SOC 341 is completed." During an interview with Administrative Staff (AS) 1, on 6/9/09 at 10:10 a.m., she stated they were unable to substantiate the allegation of abuse but did terminate LN 1 since she failed to report and document the suspected abuse. The Department determined the facility failed to: 1) Ensure facility staff reported a suspected abuse of Patient A within 24 hours as required by law. 2) Ensure facility policy related to abuse and abuse reporting was followed.Failure to comply with the requirements of section 1418.91 of the Health & Safety Code shall be a Class B Citation. |
| 030000053 |
Eskaton Care Center Manzanita |
030009697 |
B |
11-Jan-13 |
4JWJ11 |
4473 |
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. 72527 - Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On 11/03/09, an unannounced visit was made to the facility to initiate an investigation of Entity Reported Incident(s) #: CA00186774 and CA00197417. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure the patient was free from abuse. 2. Ensure all incidents of alleged or suspected abuse are reported to the Department immediately or within 24 hours as stipulated in statute.Record review was conducted on 11/03/09. Patient A was a 73 year old female admitted on 3/19/09. Pertinent diagnoses included heel ulcer, anxiety and high blood pressure. The admission MDS (Minimum Data Set - an assessment tool) dated 4/01/09 revealed Patient A was alert and oriented, with no cognitive impairment. She relied upon staff for extensive to total assistance for activities of daily living, such as bathing, toileting and repositioning. She was documented to be at ease interacting with others. Progress notes for Patient A dated 04/29/09 stated, "Complains that staff is not nice to her. Related PM (Evening shift) CNA (Certified Nursing Assistant) is a Little Witch and relates incident wherein that CNA chastised her for using the call light." The facility complaint investigation dated 04/29/09 stated. "(Staff 1) is a little witch.(Staff 1) told Patient A that she uses the call light too much and told her she should only use it twice per shift. One time (Staff 1) tossed the call button at her.Another time, Staff 1 threw it at Patient A." Patient A told the investigator that the events occurred three days ago but Patient A was "afraid to say anything for fear of retaliation". Patient B was an 83 year old woman admitted to the facility on 11/3/09 with diagnoses that included recent rib fractures needing rehabilitation. The MDS documented the patient was alert and oriented, was her own decision maker and had no mood or cognitive deficit.Patient B's clinical record contained Progress Notes dated 8/4/09 at 5:37 p.m., indicating Patient B had an "unpleasant experience with staff member" and stated, "Staff 1 threw a roll of toilet paper and coin purse at her and glared at her."A review of the facility policy statement for Elder and Dependent Adult Suspected Abuse and Reporting stated (in part), "Mistreatment, neglect, isolation, verbal or physical abuse or misappropriation of resident's property is prohibited.The personnel file for Staff 1 revealed the following: On 3/3/09, Staff 1 received a written warning for "scolding a resident who experienced an episode of incontinence." On 4/30/09, Staff 1 was accused of patient abuse when she 'threw the call cord at a resident." On 6/17/09, Staff 1 was accused of raising her voice in a rude manner and that the patient perceived the staff as "rough." On 8/04/09, Staff 1 threw a roll of toilet paper and a small carrying case at a patient.On 8/7/09, Staff 1 was terminated from the facility. The letter of termination dated 8/6/09 included the statement, "On 3/3/09 you (Staff 1) received a written warning regarding your conduct while providing resident care. In that case you were noted to have scolded a resident who had experienced an episode of incontinence." The facility had no documented evidence that the incident of abuse was reported to the California Department of Public Health, as required by statute.Therefore, the facility failed to: 1. Ensure the patient was free from abuse. 2. Ensure all incidents of alleged or suspected abuse are reported to the Department immediately or within 24 hours as stipulated in statute.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000020 |
Eagle Crest |
030009775 |
B |
08-Mar-13 |
GE7U11 |
4988 |
1418.91 Health and Safety Code (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of an unannounced visit to the facility on 8/5/11 at 8:20 a.m. to investigate Entity Reported Incident CA00278586 and complaint CA00278143. As a result of the investigation, the Department determined the facility failed to report alleged or suspected abuse to the Department within 24 hours as required. Patient A was a 79 year old female originally admitted to the facility on 7/13/11 with diagnoses including asthma, obstructive bronchitis and heart failure. Review of a "Nursing Assessment", dated 7/26/11, indicated Patient A had been re-admitted to the facility. The assessment indicated for Patient A: "Memory ok" and also indicated Patient A was oriented to person, place, time, and situation. A review of the Nursing Notes, dated 7/30/11 at 8 p.m., revealed Patient A's daughter reported her concern about a small round bruise on Patient A's cheek to the Charge Nurse. In addition, the note reflected the daughter also reported staff had "man-handled her mother last night."Review of the "Witness Statement" dated 7/31/11 at 4:40 p.m., confirmed a conversation between Patient A's daughter with the Administrator regarding her concerns of her mother's alleged abuse. In an interview with Patient A's daughter on 8/5/11 at 7:43 a.m., she indicated that on 7/30/11 sometime just after midnight, the Licensed Nurse (LN) found her mother on the floor and unresponsive. Patient A's daughter indicated that according to her mother, two aides, one male and one female, had rough handled her, and that one of the aides held or sat on her legs while the other one pushed her down on the bed. Patient A's daughter said her mother had a bruise on her cheek that was not there the night before. Patient A's daughter said she reported this incident to the administrator (on 7/31/11 via a telephone call), the nursing director and the social worker. During an observation and interview with Patient A on 8/5/11 at 9:58 a.m., she indicated that on the night of the alleged abuse she was having trouble breathing and was trying to get up. Two aides came in and "threw me back on the bed. They acted rough." The patient had a fading, deep reddish bruise, approximately the size of a quarter on the right side of her cheek.In an interview with the Director of Nurses (DON) on 8/5/11 at 10:15 a.m., she revealed she was not familiar with the abuse allegations and that she would have to get the investigative paperwork to look at. In an interview with the Social Services Assistant (SSA) on 8/12/11 at 10:27 a.m., she indicated that the Administrator completes the abuse investigations. "I was only asked to get a statement from the witness. [Patient A] recalled the alleged event to occur a couple weeks ago. I have not had any contact with the family. I've only talked with the resident." In an interview with the Administrator on 8/12/11 at 11 a.m., he shared the "Witness Statement" that he had via a telephone conversation with Patient A's daughter on 7/31/11. The Administrator indicated that he had not followed the facility's policy and procedure's for reporting or investigating the alleged abuse incident.In a follow up interview with the Administrator on 10/5/11 at 11:20 a.m., he indicated he started the investigation on 8/5/11. He reported that he did not suspend any staff during the investigation, nor did he move them to another unit during the investigation. "I did not send in an SOC 341 until [the department] informed me I needed to. I sent it in on 8/5/11."A review of the facility's "Abuse and Neglect Prohibition Program" dated January 2008 and revised 11/10, indicated, "7. Reporting/Response: Any and all allegations are reported immediately to the Administrator and/or DNS. The center ensures 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 center and to other officials, in accordance with state law through established procedures (including to the state survey and certification agency). An initial report will be completed and submitted to the Department of Health immediately upon notification of the allegation." According to Patient A, she was allegedly abused by two facility staff on or around 12 a.m. on 7/30/11. The department received the SOC 341 on 8/5/11, six days after the alleged event occurred. Therefore, the facility failed to report an allegation of abuse to the Department immediately, or within 24 hours as required. This violation had a direct or immediate relationship to the health, safety, or security of long term care facility patients. |
| 100000057 |
Eskaton Care Center Greenhaven |
030009780 |
B |
12-Mar-13 |
HN1B11 |
20303 |
72311 Nursing Service - General[WU1] (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessment shall commence at the time of admission of the patient and be completed within seven days after admission.72315 Nursing Service - Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. 72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Unannounced visits were made to the facility on 1/12/11, 1/18/11 and 2/15/11 to investigate complaint #CA00254907 & #CA00260468. As a result of the investigation, the Department determined the facility failed to: 1) Continually assess and provide the necessary fluids to ensure Patient A's hydration needs were met.2) Follow its current policy titled, "Intake and Output Criteria Documentation," by not ensuring Patient A's I & Os were assessed.3) Provide Patient A with good nutrition and necessary fluids for hydration. These failures resulted in Patient A being admitted to the hospital and treated for sepsis and dehydration. Patient A, an 83 year old male, was admitted to the facility on 3/12/10, from a general acute care hospital (GACH) with the following diagnoses: right hemiparesis (paralysis on one side) and expressive aphasia (unable to verbally communicate), dysphasia (difficulty swallowing), urinary retention, history of enlarged prostate with urinary retention and a history of bladder cancer. Patient A's Initial Minimum Data Set (MDS - an assessment tool), dated 3/26/10, indicated he had short and long term memory loss, severely impaired cognitive skills for daily decision making, as being easily distracted, as having periods of altered perception or awareness of surroundings and rarely/never able to make himself understood. The MDS also indicated Patient A was resistive to care (resistive taking medications/injections, Activities of Daily Living (ADL) assistance, or eating). The MDS further indicated Patient A as needing extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Patient A had swallowing problems and left 25% or more of food uneaten at most meals but had no weight loss or gain (5% or more in the last 30 days or 10% or more in the last 180 days). Under the Section P. Special Treatments and Procedures of the MDS, intake/output (I&O) and monitoring acute medical condition were both marked. The Resident Assessment Protocol Summary (RAP - a method of focusing on identified concerns found during the assessment to develop a plan of care) of the MDS indicated "Dehydration/Fluid Maintenance" problem area had triggered indicating this area needed further assessment. According to RAP #14 - Dehydration/Fluid Maintenance RAP Summary, Patient A had history of taking less than recommended fluid. A care plan was to be developed to monitor for S/S (signs & symptoms) of dehydration, encourage PO (by mouth) fluids, labs as ordered, monitor I & Os, assist with taking/providing fluids related to decreased functional mobility and or cognitive impairment, and notify MD if resident takes less than recommended fluid. The summary further documented that there were multiple factors present that increased the risk of dehydration for Patient A. The initial RAP also indicated, "Nutritional Status" as a problem area needing further assessment. Patient A required a mechanically altered diet related to swallowing difficulty and left 25% or more of foods uneaten at most meals. His nutritional status was compromised and he was identified to be at risk for weight loss. Patient A's "Preferred Intensity of Care" form, signed by Patient A's significant other on 3/12/10 and by Patient A's physician on 3/13/10, documented that Patient A did not want CPR (Cardiopulmonary Resuscitation) or artificial nutrition/hydration from a Nasogastric or Gatrostomoy tube. Patient A did want IV (intravenous) fluids other than antibiotics, oxygen, and to be transferred to acute hospital. Patient A was admitted to the facility with a urinary drainage catheter due to his urinary retention. During Patient A's stay at the facility he developed a urinary tract infection (UTI) on 4/9/10 and on 5/4/10 which he received treatment for.Patient A was admitted to the facility 3/12/10. His initial weight was not obtained until 10 days after being admitted to the facility. The Restorative Nursing Note, dated 3/18/10, documented staff was unable to obtain admission weight since Patient A was unable to stay still and was confused. The RNA (Restorative Nurses Aide) documented she had attempted several times to obtain the patient's weight with assistance from therapy staff but that Patient A was unsafe.Review of Patient A's Vitals Report revealed his weights were the following: 3/22/10 - 147 lbs, 3/25/10 - 145 lbs, 4/1/10 - 145 lbs, 4/8/10 - 142 lbs, 4/17/10 - 140 lbs, 4/22/10 - 135 lbs, 4/23/10 - 137 lbs, 4/29/10 - 131 lbs, 5/5/10 - 130 lbs.Review of Patient A's clinical record revealed a form titled, "Significant Weight Change Notification," dated 4/23/10. The LN (Licensed Nurse) documented that Patient A's current weight was 135 lbs and his admission weight was 147 lbs. Patient A had a 5 lb weight loss in one week and a 12 lb weight loss in one month. The LN documented that Patient A's meal percentage for the past 7 days ranged from "27% to 93%" with an average of "59%". Patient A was receiving Magic Cup (a supplement) twice a day, as well as a multivitamin every day in addition to his diet. The LN further documented that Patient A's advance directives indicated he wanted IV fluids. The physician signed his name on 4/23/10 in the section, "Physician Responses." There were no further instructions or new orders documented.On a second "Significant Weight Change Notification," dated 4/30/10, the LN documented that Patient A's current weight was 131 lbs. and his admission weight was 147 lbs. Patient A had a 6 lbs weight loss in one week. The LN documented that Patient A's meal percentage for the past 7 days ranged from "37% to 63%" with an average of "69%". The LN also documented that Patient A's advance directives indicated he wanted IV fluids. The section "Physician Responses:" was blank with no documented evidence that the physician received or reviewed the notification.Review of Patient A's Dietary Flowsheet from 4/23/10-5/12/10 indicated the majority of the meals recorded as consumed by Patient A were 50% or less, or had been refused. There was no documentation the physician was aware of how much food Patient A was consuming after 4/23/10.A care plan titled, "At risk for dehydration," dated 3/12/10, indicated that Patient A required assist with all ADL's, had a history of taking less than recommended fluids and has a history of UTIs (urinary tract infections). Under the section, "Approach" were the following listed interventions: encourage fluids, labs as ordered, monitor I & O per order, assist with meals and fluid intake as needed, monitor for signs and symptoms of dehydration ie: elevated temp, elevated heart rate, poor skin turgor, sternal tenting, elevated BUN (blood urea nitrogen) or Creat (creatinine), altered cognitive status, monitor meal intake and notify MD if take less than recommended fluid. A care plan titled, "At risk for altered nutritional status," dated 3/16/10 indicated Patient A had poor intake of meals, required assistance with meals and was at risk for weight loss, swallowing problems and had reduced ability to feed self. Under the section "Approach" was the following listed interventions: monitor and document meal intake, monitor weights per policy, notify MD of significant weight changes, assist with meals as needed, RD consult as needed, offer substitutes as needed, mineral/vitamins as ordered, monitor weight per facility policy and notify MD of weight changes of: 2.5% in one week, 5% or 5 lbs in one month, 7.5% in three months, and 10% in six months. Review of the facility's policy titled, "Weight Variance Protocol" last revised 10/26/09, indicated in part under section "6. Weight Variances... b. The [Assistant Director of Nurses]/Unit Manager and /or Charge Nurse will assess residents who have had a significant weight change for dietary intake; hydration status; and fluid overload/edema. The assessment will be documented in the progress note section of the [Electronic Health Record]." The policy further indicated under section "8. [Interdisciplinary Team] Evaluation of Weight Changes...b. The Unit Manager or Charge Nurse, and the Dietary Manager will review all residents on weekly weights with significant weight changes...and make appropriate recommendations..." Facility staff documented on the form, "Intake/Output" the amount of fluids (cubic centimeters - cc; one fluid ounce is 30 cc) consumed by Patient A each shift (7-3, 3-11, 11-7). The 24 hour totals, from 3/13/10-5/12/10, indicated the following average amounts of fluids consumed per week:3/13/10-3/18/10 - 713.3 cc 3/19/10-3/25/10 - 784.3 cc 3/26/10-4/1/10 - 898.6 cc 4/2/10-4/8/10 - 811.4 cc 4/9/10-4/15/10 - 787.1 cc 4/16/10-4/22/10 - 1000 cc 4/23/10-4/29/10 - 897.1 cc 4/30/10-5/6/10 - 428.5 cc 5/7/10-5/12/10 - 383.3 cc At the top of the Intake/Output forms was a place to record the "Fluid Recommendation ___cc/24 hrs." The first week at the facility, 3/12/10 - 3/18/10, this section was left blank. The second week thru the fifth week at the facility, 3/19/10 - 4/15/10, Patient A's fluid recommendation was calculated to be 1977 cc/24 hrs, the sixth and seventh week, 4/16/10 - 4/29/10 his fluid recommendation was calculated to be 1831 cc/24 hrs and the eight and ninth week the calculated fluid recommendation was left blank. The above data reflected that Patient A consumed less than the calculated 24 hour intake goal of either 1977 or 1831 cc during his entire stay at the facility.The Intake/Output forms contained the section "Weekly Intake/Output Assessment." The first week at the facility, 3/12/10 - 3/18/10, the nurse documented Patient A's average daily intake for week was 713 cc. Under the area "Document reason to continue/or discontinue/I&O monitoring below." This section was left blank. The second week at the facility (3/19/10 - 3/25/10) the LN documented Patient A's fluid recommendation was 1977 cc/24hrs. According to documentation Patient A's average daily intake was 767 cc and described Patient A's urine as amber and clear. The LN also documented to continue with I & O. The third week at the facility (3/26/10 - 4/1/10) the LN documented Patient A's fluid recommendation was 1977 cc/24hrs. Patient A's average intake for the week was 899 cc. During the sixth week at the facility (4/16/10 - 4/22/10) the LN documented Patient A's fluid recommendation as 1831 cc/24hrs. According to documentation Patient A's average daily intake was 1017 cc. Patient A's urine was described as dark yellow and the LN documented "on below fluid intake."During the fourth (4/2/10 - 4/8/10), fifth (4/9/10 - 4/15/10), seventh (4/23/10 - 4/29/10), eighth (4/30/10 - 5/6/10) and ninth (5/7-5/12/10) weeks at the facility, the Weekly Intake/Output Assessment section was left blank. There was no documentation that the LN assessed Patient A's fluid intake or determined if patient should continue on I & O monitoring and why. Review of the facility's policy titled, "Intake and Output Criteria Documentation," last revised 10/25/07, stated (in part) "a) I & O's will be recorded on worksheets by the CNAs (Certified Nursing Assistants). b) The licensed nurse will review and record the I & O shift total on the individual resident's I & O record. c) A licensed nurse will be responsible for totaling the I & O for the previous 24 hour period." The policy also indicated that "8) The Intake/Output Weekly Assessment section of the I & O record will be completed by the licensed nurse. 9) Following an assessment, the licensed nurse will determine whether the resident should continue on I & O monitoring or if it may be discontinued."The facility failed to follow their policy by not ensuring I & O's were recorded for 5/9/10, by not ensuring a LN totaled the I & O for the previous 24 hour period on 4/8, 4/13, 4/15, 4/29, 4/30, 5/1, 5/2, 5/6 and 5/10/10 and failed to ensure a LN completed the Intake/Output Weekly Assessment section for the fourth, fifth, seventh, eighth and ninth week at the facility.During an interview with the Director of Nurses (DON) on 1/18/11, at 10:08 a.m., she had no explanation as to why facility staff had not completed the intake and output assessment forms as required. During another interview with the DON on 3/30/11, at 9:49 a.m., she confirmed she was unable to locate documentation that Patient A was assessed for dietary intake and hydration status per facility policy. She also confirmed she was unable to locate documentation that the facility's Interdisciplinary Team evaluated Patient A's weight variance per the facility's policy. On 3/1/10 a form titled, "Fluid Intake Less Than Recommended Notification To Physician." The LN left the section, "Recommended Fluid Intake" blank and hand wrote next to it "no body weight." The LN marked the boxes that Patient A had "increased confusion, dry skin and dry lips." The LN also documented that Patient A's past 24 hours intake was 820 cc and Patient A's past 7 day intake ranged from 520 cc to 820 cc with an average of 713 cc. Under the section "Physician Responses" the physician signed his named which was dated 3/19/10 at 8 a.m. There were no further instructions or new orders from the physician at that time. On 4/2/10 another notice of "Fluid Intake Less Than Recommended Notification To Physician" was sent to the physician. Under the section, "Recommended Fluid Intake" was 1977 cc. The LN documented Patient A's past 24 hrs intake was 890 cc and his past 7 day intake ranged from 640-1080 cc with an average intake of 899 cc. Under the section "Physician Responses" was the physician signature with a date of 4/2/10 at 8 a.m. There were no further instructions or new orders from the physician at that time. On 4/23/10 a third notice for "Fluid Intake Less Than Recommended Notification To Physician" was sent to the physician. The Recommended Fluid intake was documented as 1831 cc. The LN documented Patient A's past 24 hrs intake was 1100 cc and the past 7 day intake ranged from 610-1260 cc with an average of 1017 cc. Under the section Physician Response again the physician signed the form on 4/23/10 with no further instructions or new orders. Review of Patient A's clinical record revealed no other notice of "Fluid Intake Less Than Recommended Notification To Physician" was sent to Patient A's physician after 4/23/10 even though he continued to consume less that the required recommended fluid intake. Patient A's spouse was interviewed via telephone on 2/7/11 at 9:20 a.m. She stated she was at the facility around 10 hours a day. She stated she would feed Patient A lunch, dinner and sometimes breakfast if the tray was still in the room when she got there. The spouse stated Patient A ate "very little" the last two weeks at the facility and sometimes refused to eat. The spouse further stated her daughter requested an IV but was told by staff "don't need a MD order not stressed enough" for an IV. The family even placed several calls to the physician but the MD never returned their calls or came in. The spouse stated while on B Wing he had mittens on his hands to keep him from pulling out his Foley catheter. The spouse stated up to the last two weeks in the facility Patient A was "doing alright." The spouse confirmed when Patient A was offered fluids in the end he wasn't taking fluids very well. The spouse also confirmed that staff never suggested getting an IV. The spouse was asked if she thought Patient A would pull out an IV she replied, "I don't think so."Review of Patient A's clinical record revealed he had lab tests on 4/9/10 while at the facility. His BUN was 17 (reference value 6-25 mg/dl), Creatinine was 1.0 (reference range 0.8-1.3 mg/dl), Chloride was 104 (reference range 98-107), Sodium was 137 (reference range 136-145 mEq/L) and Patient A's White Blood Count (WBC) was 5.1 (reference range 3.5-9.9) on 04/10/10.According to a Resident Progress Note, dated 5/13/10, at around 10:30 a.m. Patient A was showing decreased LOC (level of consciousness) with minimum response to sternal rub and skin cool to touch. Patient A's vitals were the following: B/P- 80/60, P-42, R-26, T-98.4 and O2 saturation 84% on room air. According to the progress note Patient A was transferred to the hospital.Review of Patient A's Emergency Department (ED) Report, dated 5/13/10, indicated Patient A was brought into the ED due to having a cough the last few days, decreased p.o. (by mouth) intake and decreased responsiveness. According to the ED report Patient A was found by paramedics to be hypotensive (low blood pressure) and was given fluid bolus. The ED also continued with fluid bolus as well, "to resuscitate him a little bit more effectively." The ED report further indicated that Patient A's hypernatremia (high blood sodium level) would be followed and was "likely related to decreased fluid state" and they would continue to hydrate him. Under the section "Clinical Impression:" was listed the following diagnoses: altered level of consciousness, multidrug resistant urinary tract infection, dehydration, hypernatremia, renal (kidney) failure. Patient A's lab results in the ED, on 5/13/10 at 1:35 p.m. were the following: Sodium was 164 (reference range 136-146 mmol/L), Chloride was 131 (reference range 95-110 mmol/L), BUN was 123 (reference range 8-25 mg/dl), Creatinine was 3.76 (reference range 0.50-1.50 mg/dl). According to Patient A's History and Physical (H & P), dated 5/13/10, over the previous 2 or 3 days Patient A "had poor oral intake, has had increasing cough but was unable to expectorate [cough up and spit out mucous]....has progressively got more lethargic to the point that he was extremely short of breath today, tachypneic [rapid respiratory rate] and was found to be hypoxic [low blood oxygen level]." Review of Patient A's General Acute Care Hospital (GACH) Discharge Summary, dated 5/15/10, indicated Patient A's final diagnoses included: cardiopulmonary arrest, severe septic shock secondary to methicillin-resistant Staphylococcus aureus urinary tract infection/Klebsiella pneumonia urinary tract infection, possible health care associated/aspiration pneumonia, acute renal failure, hypernatremia. According to the Discharge Summary Patient A, upon admission to the hospital, was found to be in severe septic shock with a blood pressure in the 70s to 80s systolic, severe lactic acidosis with a lactic acid level of 6.0 [reference range: 1.0 - 2.0 mmol/L] and respiratory distress. According to the discharge summary, Patient A was "aggressively hydrated" and was found to be in acute renal failure as well as hypernatremic. After detailed discussion with Patient A's family regarding his poor prognosis Patient A was subsequently placed on comfort care and expired on 5/15/10.Review of Patient A's death certificate listed cause of death as: cardiopulmonary arrest, septic shock, MRSA urinary tract infection. Therefore, the Department determined the facility failed to: 1) Continually assess and provide the necessary fluids to ensure Patient A's hydration needs were met.2) Follow its current policy titled, "Intake and Output Criteria Documentation," by not ensuring Patient A's I & Os were assessed.3) Provide Patient A with good nutrition and necessary fluids for hydration. These failures resulted in Patient A being admitted to the hospital and treated for sepsis and dehydration. These violations had a direct or immediate relationship to the health, safety, or security of long term care facility patients or residents. |
| 030000020 |
Eagle Crest |
030009885 |
A |
16-May-13 |
ADZG11 |
8062 |
72301 - Required Service (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 72523 - Patient Care Policies And Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. This citation is the result of an unannounced visit made on 6/10/11 to initiate an investigation of an Entity Reported Incident # CA00265051 concerning an unexpected death. The reports identified allegations of the failure of nurses to perform CPR for a patient who requested CPR.As a result of the investigation the Department determined that the facility failed to: 1. Perform CPR (Cardiopulmonary Resuscitation) for a patient with orders for full resuscitation measures. 2. Have the licensed nurse provide proof of current CPR training prior to being hired as indicated in their policy.3. Verify a Registered Nurse's job references or confirm she had completed training in CPR, as required by facility policy. This same nurse was then placed in a position of authority as the nursing supervisor, and she failed to perform CPR or contact emergency responders when Patient A was found unresponsive. Patient A was a 55 year old, admitted to the facility on 1/19/11, with diagnoses which included pneumonia, alcohol and drug abuse, and a recent history of a blood clot in her leg and lungs. An admission MDS (Minimum Data Set, an assessment tool) dated 1/25/11, described the patient as having full cognitive capacity and being totally dependent upon staff for all of her activities of daily living, except eating. The patient was not able to walk. Patient A's weight was 219 pounds on admission. In an interview with CNA (Certified Nursing Assistant) 1 on 6/10/11 at 5:35 a.m., CNA 1 stated that during her 4 a.m. rounds, on 3/13/11 Patient A was found not breathing and the patient did not respond to her name being called. CNA 1 stated, "I came down the hall to the desk where the supervisor (Licensed Nurse)[LN 1], who was a Registered Nurse assigned to oversee all staff and patients during her shift), was and told her the patient may have passed." CNA 1 further stated the supervisor went with her to the patient's room but neither had a stethoscope and they "Did not listen to her heart or check the patient's blood pressure." CNA 1 stated the patient's coloring "looked the same to me as usual. She did not look like she'd been gone long." Review of the clinical record for Patient A revealed a physician's order dated 1/19/11 for "CPR." There were also Physician Orders for Life-Sustaining Treatment (POLST) signed by the physician on 1/19/11 which ordered "Attempt resuscitation/CPR." The POLST indicated Patient A wanted all possible treatment including transfer to the acute care hospital.A nurse's note dated 3/13/11 at 4:40 a.m. by Licensed Nurse 2 (LN 2), a Registered Nurse caring for the patient on the night shift of 3/13/11 stated, "CNA summoned, resident stopped breathing VS [vital signs] taken, not appreciated. Blood pressure 0, pulse 0 respirations 0 with cold clammy skin." A nurse's note by LN 2 dated 3/28/11 at 10:50 a.m., documented, "Late entry dated 3/13/11 NOC (night) shift: CNA came and informed me at around 4:30 a.m. that the resident (Patient A) was dead. I went to her room and felt the pulse, listened to her breath, it's not appreciated. The skin was cold and already with purple discoloration. Face is swollen. I went to my supervisor and informed her that the resident is already dead. The supervisor called and notify the MD." A nurse's note by LN 1 dated 3/28/11 at 11 a.m. documented, "Late entry dated 3/13/11 Notified MD resident levity [sic] set in and no CPR done. MD stated OK." Review of a note written by MD 1 on 4/4/11 revealed "This was an unexpected death." Review of the facility policy titled "Death of Resident" dated June 2002 included (in part), "Residents with Full Code Status: The staff member assesses the resident for vital signs and initiates CPR if vital signs are absent. 911 and physician are notified and CPR continued until arrival of emergency services. If resuscitation is unsuccessful, pronouncement of death is rendered by the emergency personnel, as allowed by State regulation." Facility policy did not empower nurses to pronounce the death of a resident, therefore CPR should have been initiated and 911 should have been called. Review of a "Record of Counseling" for LN 2, dated 4/12/11 included, "The results of the investigation is as follows: Gross misconduct for failure to perform within the nursing standards of practice. This is in regards to not initiating CPR on a full code resident." In the section for action taken, "discharge" was checked. In an interview with the Nurse Consultant (NC) 1 on 6/30/11 at 10 a.m., NC 1 stated LN 1 and LN 2 were terminated for not doing CPR on a full code patient. Review of the personnel file for LN 1 revealed she was hired at the facility on 2/1/11. The file contained two forms titled "Reference Check Form." Each form contained the name of LN 1's prior employer; each listed a different "Reference Name." Both forms were incomplete, neither form included documentation that the references had been checked. The areas where the person checking references would document the candidate's previous work performance were blank and there were no signatures or dates on either form. A "Nurse Experience Record" documented LN 1 had worked for 1 year at a non-medical senior residential facility and had worked for 11 months at an outpatient plasma center. The file did not include a copy of a CPR card. A "New Hire Checklist" dated 2/1/11 listed requirements for new hires, the field for "CPR Card Copy" had been dated 1/14/11, but was crossed out, with the initials of the Director of Staff Development beside the strike-through mark. This form was not signed or dated as reviewed. California's Board of Registered Nursing website listed the date LN 1's license was issued as 8/20/08. Review of policy titled "CPR Certification" with a revision date of 5/07 included (in part), "All licensed nurses must obtain CPR certification within 30 days of hire and maintain their certification throughout employment....Copies of certification shall be maintained in the employee personnel file in accordance with [corporation name] policy..." The death of Patient A occurred more than 30 days after LN 1's initial date of hire. Review of an undated form titled "CPR Cards-Verification" included the name of LN 1. In the column titled "Card on file" an arrow was drawn through the box next to LN 1's name pointing to "suspended-not in file." In an interview with the Director of Staff Development (DSD) on 6/14/11 at 4:10 p.m. she verified LN 1 did not have a CPR card. DSD stated LN 1 "didn't have a CPR card with her" during orientation. DSD stated "I crossed it off the form because she couldn't produce it." The DSD also stated that LN 1's references were not checked prior to being hired, she stated, "We played phone tag." As a result of the investigation the Department determined that the facility failed to: 1. Perform CPR (Cardiopulmonary Resuscitation) for a patient with orders for full resuscitation measures. 2. Have the licensed nurse provide proof of current CPR training prior to being hired as indicated in their policy.3. Verify a Registered Nurse's job references or confirm she had completed training in CPR, as required by facility policy. This same nurse was then placed in a position of authority as the nursing supervisor, and she failed to perform CPR or contact emergency responders when Patient A was found unresponsive. 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. |
| 030000020 |
Eagle Crest |
030009887 |
B |
16-May-13 |
EC9Y11 |
10700 |
F 323 Free of Accident Hazards/Supervision/Devices 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an investigation of a facility reported incident regarding a resident elopement (CA00250717). An unannounced visit was made on 4/22/11 to investigate the incident.As a result of the investigation, the Department determined the facility failed to: 1. Provide adequate supervision to prevent an avoidable elopement when Resident 1 exited the facility on the night of 11/28/10, without detection, and was found sitting outside shivering with a body temperature of 96.5 degrees Fahrenheit.2. Ensure the effectiveness of the elopement prevention devices. Resident 1 was admitted to the facility on 10/11/10 with diagnoses which included Alzheimer's disease and anxiety. An Admission Nursing Assessment, dated 10/11/10, described the resident as being confused, only oriented to her own name, not the date or location. The assessment described the resident as "Exit seeking/wandering." Review of the clinical record for Resident 1 included: -A History & Physical report, dated 10/8/10, which described Resident 1 as "Wandering and unable to be contained at home." -An Elopement/Wander Risk Evaluation Form with an Admission assessment dated 10/11/10 which had the box for "Yes" checked next to Elopement Potential. Written beside it was, "She walks aimlessly along the hallway." Review of a physician's order, dated 10/12/10, indicated "Attach a [exit alarm, a device used to alert staff of unassisted exits out of the facility] to patient's body to alert staff for any unassisted leaving." Review of a care plan, dated 10/12/10, for progressive decline in memory, indicated "Potential for elopement" and included the following interventions: "Electronic safety device if actively exit seeking; Attach [exit alarm] to patient's body to alert staff for any unassisted leaving the facility," and "Monitor placement and functionality of the [exit alarm] device (every) shift." An Interdisciplinary Team note (IDT) dated 10/14/10 included, "Patient was identified as wanderer..." Review of a care plan, dated 10/21/10, for "At risk for elopement 2/2 (sic) multiple attempts to exit the facility, without staff assistance, decreased safety awareness." The care plan goal was "Will not leave the facility unassisted." Interventions included: "Resident to have an order to [sic] [exit alarm] to alert staff of unassisted leaving of the facility; Redirect patient when exit seeking; keep resident actively involved with group activities." Review of the facility Event Management System report, dated 11/28/10, included: -"Resident was not seen... for dinner...found resident sitting at the edge of the road across the back of the facility." -"Resident pulled the [exit alarm] system wiring off the wall before the incident occurred, the reason why nobody heard the alarm go off." -"Yes" was marked next to the question "was resident identified as exit seeking/wandering?" -The resident's body temperature was recorded at 6:15 p.m. as 96.5 degrees Fahrenheit (F). -The section titled "Describe summary of investigation of incident and status of the Resident" contained the following: "Resident has been trying to leave the facility thru back exit (hall 5) and they were able to stop her from going out and she gets combative with the staff. During meal time, CNA [Certified Nursing Assistant] got busy preparing other residents and when the CNA in charge of Resident noticed that she is not in her room or hallway, she notified charge nurse and searched was initiated inside the facility, then outside search was done and they found resident across the street on the backside of the facility sitting at the edge of the road. Resident was alert with confusion per her baseline and was able to answer questions appropriately. Physical assessment did not show any injury, resident stated she has knee pain because "I took a short walk and I'm tired so I sat down." -The section titled "Describe corrective or proactive actions being taken" contained the following: "[Exit] alarm system will be fixed by maintenance department on 11/30/10...solicited family assistance to stay with resident during the afternoon to give time for the staff to attend to other residents." During an observation on 4/22/11 at 1:10 p.m. outside the room previously occupied by Resident 1 was approximately 7 feet from an exit door which led to a ramp along the west side of the building, down to ground level behind the facility. During an interview with Administrative staff member 1 (AS 1) on 4/22/11 at 1:10 p.m. near the exit door for the 500 hall (the corridor with room numbers starting with a 5), AS 1 stated, Resident 1 had "pulled out the alarm wires at the right of the door about 1 month before she was found outside." AS 1 stated Resident 1 "was always fooling with the door." AS 1 stated the individual exit alarm system had not been alarming and maintenance and the charge nurse had been notified of the problem before Resident 1's elopement. During an interview with CNA 3 on 4/29/11 at 2:10 p.m. he stated on 11/28/10 an announcement was made over the paging system to check room-to-room for Resident 1. CNA 3 stated, "It was the middle of dinner. I helped with the search inside and about 30 minutes after the first page I checked outside." CNA 3 stated he went to the back parking lot and it was cold and dark and he looked for her approximately 15-30 minutes before finding her. CNA 3 stated he saw some white through the trees and brush and walked through the area and saw Resident 1 "She was hanging on the fence sitting on the road." CNA 3 stated Resident 1 had mud on her feet and legs. CNA 3 stated it took three of us to get her back; the wheelchair didn't have leg rests so 2 people held her legs while the third pushed the chair. It was almost 7 o'clock when I got back inside." In a concurrent observation with CNA 3 on 4/29/11 at 2:10 p.m. the area where Resident 1 was found the night of 11/28/10 was observed. CNA 3 demonstrated the location to be unpaved ground surrounded by trees and covered with weeds, approximately 100 feet from the back parking lot. The resident had been found after CNA 3 walked through approximately 100 feet of weeds and mud to a ditch, adjacent to wood guard rail on which the resident was leaning. The guard rail was on the edge of a private, unnamed road, outside the facility's property line, which led to a single house. CNA 3 also demonstrated the route taken to bring Resident 1 back to the facility via wheelchair which he estimated to be 0.25 miles.In an interview with CNA 1 on 4/29/11 at 2:45 p.m. she stated she was passing dinner trays out and Resident 1 was by the exit door near her room. CNA 1 stated "she was always trying to get out this door or other doors. We had to watch her so she doesn't get out." CNA 1 stated 11-12 residents were assigned to each CNA on the evening shift. CNA 1 stated the door alarms were not set off the night Resident 1 eloped. During an interview and observation with Maintenance Supervisor 1 (MS 1) on 4/29/11 at 3:45 p.m. MS 1 stated the ramp outside the exit door of hall 500 was "40 yards long" and he estimated it to be a 25-30 degree slope down to the ground level behind the facility. MS 1 stated he was on a leave of absence "between October 19 and the beginning of December 2010." MS 1 stated the Housekeeping Supervisor (HS 1) "covered my job and his during my leave." MS 1 stated he did not keep repair logs so he did not know if the individual exit alarm system had been reported to be out of order prior to 11/28/10. MS 1 was able to locate his logs of the alarm system starting 1/1/11, a month after Resident 1 eloped. He stated he had checked the alarm system "daily since March first 2011." MS 1 stated "the logs are gone prior to that...they might have been tossed." During an interview with CNA 2 on 5/6/11 at 7:35 a.m. CNA 2 stated the two exit door alarms on the 500 Hall door both required being reset manually, "They don't stop alarming otherwise." CNA 2 stated both the [exit alarm] and the emergency exit alarm "could be turned off, it's been known to happen, if the elevator is broken then laundry is brought up through the door." In a concurrent observation with CNA 2 there was no visual indicator to verify the emergency alarm was active. CNA 2 stated "We don't know if it's activated unless we tried the door." Review of the facility Meal Service Times sheet, undated, revealed the first meal dinner cart went to Courtyard dining room and the second cart went to Hall 5, the hall for Resident 1's room. In an interview with Dietary Manager (DM) on 5/6/11 at 8:05 a.m. DM stated the 500 Hall dinner cart usually arrived to be passed out to residents before 5:15 p.m. In an interview with Registered Nurse 1 (RN 1) on 5/6/11 at 8:30 a.m. RN 1 stated, "The alarm didn't sound when I went out the 500 hall exit door [to help with Resident 1]. It was really dark, everything was dark...We got blankets and a wheelchair to bring her back in...She had dirt on her feet and legs." RN 1 stated "A few days later when it was light out I saw what the area looked like and I couldn't imagine how she made it through there." Review of facility policy titled Elopement Management Program, dated January 2008, included: -"Objectives....Elopement, the unplanned absence of a resident from the center poses many potential hazards such as: over exposure to heat or cold, dehydration and/or other medical complications, drowning, being struck by a motor vehicle....Utilize individualized interventions to maintain a resident's safety within the center." -Under "Planning, Implementation, and Evaluation..." was "Securing exit doors with alarms or electronic locks with keypads that are tested daily with results documented." - Under "Reviewing the Plan..." noted, "...by communicating new behaviors and or changes in existing behaviors to the charge nurse immediately, so that appropriate interventions can begin as soon as possible." Therefore, the facility failed to: 1. Provide adequate supervision to prevent an avoidable elopement when Resident 1 exited the facility on the night of 11/28/10, without detection, and was found sitting outside shivering with a body temperature of 96.5 degrees Fahrenheit.2. Ensure the effectiveness of the elopement prevention devices. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000020 |
Eagle Crest |
030010237 |
A |
30-Oct-13 |
IIZJ11 |
9105 |
F282 - Service By Qualified Persons/per Care Plan 483.20 (k)(3)(ii) The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care. F323 - Free Of Accident Hazards/supervision/device 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 12/14/11 an unannounced visit was made to initiate an investigation of an Entity Reported Incident CA00255627. On 1/12/11, Resident 1 fell and injured his upper arm. The plan of care for Resident 1 indicated the need for a personal motion alarm which had not been implemented. As a result of the investigation, the Department determined that the facility failed to: 1. Implement Resident 1's written plan of care. 2. Ensure Resident 1 received adequate supervision and assistance devices to prevent an accident.The failures violated regulatory requirements and placed Resident 1 at risk for significant fractures or other injuries, the need for acute care hospitalization admission and treatment, the need for surgical intervention, loss of blood, infection, prolonged bedrest and loss of mobility, pneumonia, pain, suffering and death.Resident 1 was admitted to the facility on 12/28/10 with diagnoses that included pneumonia, orthostatic hypotension (a drop in blood pressure when a person stands up, causing dizziness), and a personal history of falls.The clinical record review for Resident 1 was initiated on 12/14/11. An Interdisciplinary Team Note (IDT) dated 12/29/10 noted "Resident is high risk for [with] multiple falls prior to admit...care plan initiated and will update as needed." An IDT note dated 1/5/11 indicated the resident was oriented to person and place, with "confusion toward situation, able to make needs known". The note indicated the resident had not experienced any respiratory distress or adverse reactions from the use of antibiotics. The note further indicated the resident was using the call bell to ask for assistance at that time.A 12/29/10 "Rehab Care Plan" had been updated on 1/10/11 and identified the resident was refusing to use the call light for assistance. The new approach to managing this problem was "Keep reminding patient to use the call light when using the bathroom or when needing assistance." A Change of Condition Documentation form dated 1/11/11 indicated the patient had been found sitting on his bathroom floor at 10 p.m. The resident had communicated to the staff he had slipped off the toilet. The note indicated the staff had ordered a personal alarm and initiated neurological checks for the next 72 hours. A physician order dated 1/11/11 documented a need for a personal alarm to be attached to bed and wheel chair to alert staff of any unassisted transfers. An untitled care plan dated 1/11/11 indicated Resident 1 had been found on the floor. The care plan indicated a personal alarm had been ordered for his bed and wheelchair.A 1/12/11 Change of Condition Documentation indicated Resident 1 had been found on the floor in his room that morning (around 11 am). The document indicated Resident 1 was experiencing pain and an inability to move his right arm. The resident had reported to staff at the time that he had tried to transfer himself and he slid. 1/12/11 nursing note indicated Resident 1 had been sent to acute care hospital emergency department at 11:29 that morning. 1/12/11 nursing note indicated the acute hospital had reported the resident had experienced a fracture of the upper arm. The facility provided an investigation file which included the following information: A Change of Condition Report for 1/11/11 indicated Resident 1 had fallen at 10 p.m. and his care plan had been updated. A Fall Investigation dated 1/11/11 indicated the resident had fallen while in the bathroom. The report indicated a personal alarm was not in use at the time of this fall, but the staff had identified a need for a personal alarm and ordered the alarm. A Fall Investigation Report dated 1/12/11 indicated Resident 1 had fallen while trying to self-transfer to a bed on 1/12/11 at 11:30 that morning. This was the second fall in less than 24 hours. The investigation documented a personal alarm was not in use at the time of the fall. The investigation once again indicated the care plan would be updated to add the personal alarm.A "Record of Counseling" for LN (Licensed Nurse) 1, dated 1/13/11 indicated the nurse had been counseled for "Failure to carry out the intervention, specifically, the placement of personal alarm to patient when in bed and wheelchair to patient in room 28-A and failure to provide the report to incoming AM shift charge nurse about the fall incident." The acute care facility clinical records for Resident 1 included the following information. A History and Physical dated 1/12/11 indicated the resident had been admitted for pain to his right shoulder following a fall. An x-ray performed at the time indicated Resident 1 had sustained a fracture of the right upper arm. The resident was recovering from pneumonia, but was not experiencing any shortness of breath at the time the physical was performed.A 1/13/11 physician note indicated Resident 1 was not experiencing any shortness of breath and his lungs were clear. A 1/14/11 physician note indicated Resident 1 had suddenly developed respiratory arrest, and CPR had been successful. "According to family at bedside, P[atient] was talking with them earlier and slept after Ativen (sic) given, but arousable. Family found his breathing became [shallow then stopped].The document indicated the physician suspected Resident 1 had developed a clot in his lung, of either blood or fat.The discharge summary dated 1/15/11 indicated Resident 1 had been admitted to the acute hospital for treatment of a fracture of the right upper arm. The hospital had immobilized the arm but had not performed any surgical interventions. The summary indicated the resident's condition was stable and he was scheduled for transfer back to the facility when he developed a sudden onset of respiratory distress and he developed respiratory and cardiac arrest and died 1/14/11. The summary further indicated it was considered "most likely the resident had pulmonary emboli" (a blockage of blood to the lung caused by a blood clot or by a plug of fat). On 12/15/11 at 1:55 p.m. the person who was the Assistant Director of Nurses at the time of the fall on 1/12/11 was interviewed. She reported she had been responsible for investigating the cause of the fall on 1/12/11. She stated she had observed the conditions under which Resident 1 fell and determined the personal alarm had not been attached to his wheelchair. She had investigated further at the time and determined that although the evening shift from the prior day had reported the fall to the night shift, the night shift had not reported the ongoing circumstances to the following day shift. She reported the nurse on the night shift was supposed to have notified the day shift of the fall and of the changes to the care plan for Resident 1.In an interview with Certified Nursing Assistant 1 on 12/15/11 at 2:10 p.m. he reported he had been assigned to care for Resident 1 on 1/12/11. He reported he had been on break when the fall occurred and was unaware of how the fall occurred. He reported he had been unaware of both the fall that occurred on the prior shift and the updated plan of care for the staff to attach a personal alarm to the resident when he was in a wheelchair.In an interview with the physician who had treated Resident 1 in the acute care facility after the fall on 1/12/11 he reviewed the acute hospital clinical records for Resident 1 and stated "An emboli can be caused by a variety of things...if it was a blood emboli it could be from a fracture, or from being bed bound. But if it were fat emboli it would come from the fracture. Fracture of long bones can cause emboli...Without an autopsy we can't be sure what happened, but [the emergency room doctor] completed the discharge summary and it was very reasonable to assume the fracture caused the emboli."The Coroner Final Report of Investigation dated 3/1/2011 documented the cause of Resident 1's death as, "Acute Respiratory Failure due to Pulmonary Emboli and other significant conditions - Clostridium Difficile Colitis (bacterial inflammatory process) and Right Humeral Fracture." No autopsy was performed.The Department determined that the facility failed to implement Resident 1's plan of care for a personal motion sensor alarm and failed to ensure adequate supervision and assistive devices were provided to prevent an accident.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. |
| 030000053 |
Eskaton Care Center Manzanita |
030010243 |
B |
14-Nov-13 |
Z3OJ11 |
7710 |
F333 - Residents Free Of Significant Med Errors 483.25(m)(2) The facility must ensure that Residents are free of any significant medication errors. The following citation was written as a result of an unannounced visit on 5/19/11 for the investigation of complaint number CA00268972. The Department determined the facility failed to prevent a significant medication error when Resident 1 received a medication that she was known to be allergic to. This failure resulted in adverse reactions and Resident 1 having to be hospitalized and had the potential to affect all residents in the facility that had medication allergies. Resident 1 was admitted to the facility on 3/15/11. She had diagnoses including cellulitis (a skin infection) and a status (non-pressure) wound on her leg. Resident 1 also had multiple allergies to antibiotics, including Co-Trimoxazole (a sulfa based antibiotic - sulfonamide, also known as Bactrim DS). An admission Minimum Data Set (an assessment tool), dated 3/21/11, indicated Resident 1 had no cognitive deficits or behavioral problems. Resident 1 had a Physician's Order, dated 4/4/11, for Bactrim DS 1 tablet orally twice a day for 10 days. The medication was started on 4/4/11 at 5 p.m. A Medication Administration Record (MAR) for April 2011 was reviewed. The MAR indicated Bactrim DS was given once on 4/4/11, twice a day from 4/5/11 through 4/12/11, and once on 4/13/11 at 9 a.m. Resident 1 received 18 of the 20 doses ordered by the physician of a medication she was allergic to. The most common adverse reactions of Bactrim DS include gastrointestinal upset (nausea), dermatologic reactions (rash), and pruritus (itching). Fever, which may develop 7 - 10 days after the initial sulfonamide dose, is a common adverse effect of sulfonamide therapy. Other adverse effects include weakness, fatigue, and drowsiness. (Ref. Lexicomp on-line, 12/11)Resident Progress Notes, dated 4/6/11 at 1:52 a.m., indicated Resident 1 "[complained] of being very sleepy. Told her it was not a side effect of her new [oral] antibiotic..." Resident Progress Notes, dated 4/10/11 at 2:10 a.m., indicated Resident 1 "[complained of] nausea." Resident Progress Notes, dated 4/11/11 at 10:22 p.m., indicated Resident 1 "[complained of] nausea." At 10:22 p.m. she "[complained of] generalized body pain..."Resident Progress Notes, dated 4/13/11 at 4:17 a.m., indicated "Residents temperature was slightly elevated (99.0 F)." A Physician Notification/Problem/Assessment form, dated 4/13/11 at 3 p.m., was faxed to the physician. The form indicated, "Resident with low grade fever that started 4/13/11 [night] shift = 99 [degrees], this AM 10:00 = 99 [degrees]. Resident verbalized she feels more sleepy. Resident on Bactrim DS..." The physician responded with an order to discontinue the Bactrim DS. Resident Progress Notes, dated 4/14/11 at 2:06 a.m., (notes actually for PM shift on 4/13/11) indicated "PM shift. Resident had elevated temp since last night, [night], 99.0, AM 99.0, [evening] 100.1, Rechecked at 1600 (4 p.m.) 101.4, [physician] in facility informed of resident condition, also resident [complained of] not feeling well, but unable to explain [signs/symptoms], [physician] order to transfer resident to [Emergency Room] for [evaluation] and [treatment]." Resident 1 was sent to the Emergency Department on 4/13/11 after the physician discovered she was allergic to the Bactrim DS and 18 of the 20 ordered doses had been administered. Resident Progress Notes, dated 4/15/11 at 6:34 p.m., indicated "[Resident] developed rash to both arms, redness, itching...Start Benadryl (for itching) [as needed]." Resident Progress Notes, dated 4/16/11 at 1:55 a.m., indicated "PM Shift 4/15...Benadryl given x 1 for rash." At 7:45 a.m., the note indicated Resident 1 had "Rash to [bilateral] forearms, Benadryl given per request at [midnight]."A telephone interview was conducted with Resident 1 on 5/19/11. She stated she was admitted to the facility for intravenous (IV) antibiotics and wound care. She had gone out of the facility to see her Infectious Disease doctor on 3/31/11 and he recommended continuing the IV antibiotics. She stated the facility did a wound culture on her leg wound and started her on oral antibiotics on 4/4/11. Resident 1 stated she asked the nurses at the onset of oral antibiotic administration, and intermittently throughout the course of the antibiotics, if this was a medication she was allergic to. Resident 1 stated on 4/13/11 she started to run a fever and had been more sleepy than usual. She stated at that time her nurse thought she might be allergic to the medication and discovered that she was, in fact, allergic to the oral antibiotic. An interview was conducted with Unit Manager 1 on 5/19/11 at 4:15 p.m. She stated the nurses were expected to check for allergies when an order was obtained from the doctor or when a resident questioned if they were allergic to the medication. A phone interview was conducted with Medical Doctor (MD) 1 on 8/10/11 at 10:55 a.m. He stated he was not in the facility when he gave the order for the antibiotic. He expected the nurses to inform him of medication allergies when reporting laboratory findings or symptoms. An interview was conducted with Unit Manager 1 on 7/13/11 at 4:40 p.m. She stated all residents received medications from Pharmacy A. The procedure was to fax the face sheet with the resident information and allergies along with Physician's Orders to the pharmacy after the resident was admitted to the facility. An interview was conducted with Pharmacy Manager 1 on 7/21/11 at 9:45 a.m. He stated the facilities fax a face sheet with allergies along with Physician's Orders to the pharmacy to fill the medication orders. He was shown Resident 1's face sheet with allergies listed. He compared this to the pharmacy's list of allergies for Resident 1. He confirmed the Co-Trimoxazole was not listed on the pharmacy record. Pharmacy Manager 1 looked up the drug in his reference materials. He confirmed it was the same medication as Bactrim DS, Resident 1 was allergic to it, and it was not on the pharmacy's list of allergies for this resident. The facility policy titled Medication Administration General Guidelines, dated 9/10, directed, "Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so." Under the section titled Medication Administration, number 7 directed, "Note any allergies or contraindications the resident may have prior to medication administration." Under the section titled Documentation, number 7 directed, "Observe resident for medication actions/reactions and record in the nurses notes as appropriate. Any noted adverse consequence should be reported to the prescriber and/or attending physician." The facility policy titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 9/10, under Guidelines and Definitions, number 3 directed, "Medication errors and adverse drug reactions are considered significant if they: a. Require discontinuing a medication or modifying the dose and b. Require hospitalization." Under the section titled Procedures, number 2. "When a resident receives a new medication, the medication order is evaluated for the following; c) The resident has no known allergies to the medication." The Department determined the facility failed to prevent a significant medication error when Resident 1 received a medication that she was known to be allergic to. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000053 |
Eskaton Care Center Manzanita |
030010396 |
B |
23-Jan-14 |
MGZG11 |
5305 |
72523 -- Patient Care Policies And Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made on 4/20/11 to investigate facility reported incident #CA00266172. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure residents were free from mental and physical abuse; and 2. Implement its Abuse policy when the investigation interviews did not include any residents who had received care from Certified Nursing Assistant (CNA) 1 and the facility failed to notify the CNA licensing board of the abuse allegations. Patient 1 was admitted to the facility on 10/19/09.During an interview with Patient 1 on 4/20/11 at 2:40 p.m. she stated when CNA 1 gave her a shower CNA 1 was screaming at her and used very hot water, then changed the water temperature, making it too cold. Patient 1 stated "Then I was wet and she put a diaper on me and I said 'you need to dry me.' I'm just getting over it now." In an interview with Responsible Party 1 (RP 1), a family member of Patient 1, on 4/21/11 at 12 p.m. she stated on Tuesday 4/12/11 a male CNA was assigned to care for Patient 1 in the evening. Patient 1 requested only females shower her, so a female CNA who was not assigned to Patient 1 gave the shower (CNA 1). "She told me she was put under cold water and the gal was shouting at her then the water turned very hot." RP 1 stated "She was very, very upset about the CAN's attitude and the hot and cold water."In an interview with the Unit Manager (UM) on 4/21/11 at 12:55 p.m. she stated after the incident, Patient 1 was very upset. UM 1 stated she requested a doctor's order for Ativan (medication for anxiety) because the patient was not able to relax. Review of the clinical record for Patient 1 included: -A fax report to the physician dated 4/14/11 at 4:55 p.m. with notification the "Resident had an unpleasant experience with caregiver." The second item on the report was a request for Ativan for anxiety, manifested by the inability to relax. -A Social Services note dated 4/14/11 at 4:48 p.m. which described the patient's condition after the incident of 4/12/11. The patient "has difficulty getting bad pictures out of my head....states she feels shaky since the incident." -A care plan listing the problem as "Unpleasant experience with care giver" and dated 4/14/11. -A care plan dated 4/14/11 for "inability to relax." During an interview with Patient 2 on 4/20/11 at 4:30 p.m. she was asked if she had experienced rough care, and if so could she identify the staff member. Patient 2 responded using CNA 1's name: "[CNA 1] is the CNA you are asking about." During an interview with Patient 3 on 4/20/11 at 4:40 p.m., she was asked if she had experienced rough care by a CNA. Patient 3 stated CNA 1 had been rough with her.Review of facility policy titled Elder and Dependent Adult Suspected Abuse & Reporting, dated 8/4/06 included: "The Administrator/designee shall be responsible for conducting a thorough investigation of the suspected/alleged abuse....This internal investigation shall...consist of the following...interviews with any involved parties including but not limited to...Resident's roommate....other residents to which the accused individual provides care or has contact with the resident...The Administrator/designee shall notify the appropriate licensing or certification agency if the suspected/alleged abuser is a staff member." Review of the facility investigation file revealed: The Abuse Report form, dated 4/14/11, described the incident on 4/12/11. In the section titled "Abuse Resulted in", facility staff had checked "mental suffering." The interviews documented in the file did not include any resident interviews. The conclusion of the investigation included "It is evident that this resident had a poor experience with [CNA 1], which is significant to resident's care and well-being." The facility's investigation concluded there was no abuse due to a lack of "witnesses or physical evidence." In an interview with the Administrator on 4/20/11 at 2:50 p.m. the Administrator stated CNA 1 had not been reported to the CNA board by the facility, as required by facility policy. Therefore the Department determined the facility failed to: 1. Ensure residents were free from mental and physical abuse; and 2. Implement its Abuse policy when the investigation interviews did not include any residents who had received care from Certified Nursing Assistant (CNA) 1 and the facility failed to notify the CNA licensing board of the abuse allegations. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000020 |
Eagle Crest |
030010397 |
B |
23-Jan-14 |
JUJ711 |
4008 |
72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made on 4/22/11 to investigate entity reported incidents # CA00257105 and CA00257217.As a result of the investigation the Department determined that the facility failed to:1. Protect Patient 1 from financial abuse; and 2. Thoroughly screen a Housekeeping Supervisor (HS) with a criminal conviction of a financial crime. Patient A was admitted to the facility on 6/8/07. A quarterly Nursing Assessment form, dated 2/28/11, described Patient 1 as being independent in decision making, oriented to person, place and time.In an interview with the Activities Director (ACT) on 4/22/11 at 10 a.m. she stated Patient A was unable to locate his prepaid credit card on 1/26/11. ACT stated she contacted the credit card company and they provided a list of unauthorized cash withdrawal transactions between 1/7/11 and 1/19/11, which totaled $1,705. ACT stated Patient A had given Housekeeping Supervisor (HS) his personal identification number (PIN) in order to periodically deposit cash he withdrew from his facility Trust Account, into the credit card account, for purchases on the internet. ACT stated the police had "confirmed [HS] was the one who pulled the cash out." ACT stated the police had shown her a photo from the cash machine's surveillance cameras and it was HS. Review of the personnel file for HS revealed he was hired by the facility on 6/22/06, and included the following documents: -An employment application, undated, included the question "Have you ever been convicted of a crime (felony or misdemeanor)* other than a minor traffic violation?" The box next to "Yes" was checked. Written into the line titled "Offense" was "possetion [sic] of check with intent to cash." HS had written the conviction date in as 11/9/05. -A criminal background report for HS dated 6/14/06 did not list any criminal offenses. The report included "Disposition: Meets Criteria-Mgmt [Management] Eligible." -The personnel file did not include any documentation of reference checks having been conducted. During an interview with Human Resource Personnel [HR] 2 on 4/22/11 at 12:30 p.m., she reviewed HS's personnel file and stated there were "no reference checks in the file." HR 2 stated no other records would contain the reference check documentation. During an interview with the Director of Staff Development (DSD) on 4/22/11 at 12:45 p.m., she stated it was the facility's policy to check references by telephone and write down the outcome. "We attempt to get 2 reference checks." Review of the corporate file of HS's criminal background revealed a report dated 6/14/06 which listed an alert next to the County Criminal Record Search and included "Charge: 1 POSSESS CHECK TO DEFRAUD. Type: FELONY REDUCED TO MISDEMEANOR." The "Arrest/Charge Date" indicated, "06/23/05." During an interview with HR 1 on 4/22/11 at 3:30 p.m., she located criminal background files for HS at the corporate office. HR 1 stated hiring HS "meets criteria, it was a human decision that takes into account the position and housekeeping wouldn't normally have access to patient funds." HR 1 agreed the company did not know the details of HS's previous criminal record. Therefore, the Department determined the facility failed to: 1. Protect Patient 1 from financial abuse; and 2. Thoroughly screen a Housekeeping Supervisor (HS) with a criminal conviction of a financial crime. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000020 |
Eagle Crest |
030011077 |
B |
17-Oct-14 |
5L7E11 |
6502 |
F 323 Free of Accident Hazards/Supervision/Devises 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an unannounced visit, made on 12/18/13, to initiate an investigation of Entity Reported Incident #CA00380729, concerning a patient who choked on a peanut butter sandwich that he obtained from an unsupervised nourishment delivery cart, and subsequently died.The Department determined the facility failed to adequately supervise Resident A to prevent access to an open nourishment delivery cart. Resident A took a peanut butter sandwich that was for another resident during the evening nourishment delivery. This failure resulted in Resident A obtaining food that was inconsistent with his ordered diet texture. The resident then consumed the sandwich rapidly, causing him to choke to death on the peanut butter sandwich. Resident A was a 73 year old admitted to the facility on 12/21/12, with diagnoses which included a history of dementia and difficulty swallowing due to stroke. Review of the Minimum Data Set (MDS-an assessment tool) dated 9/29/13, showed Resident A had long and short term memory problems and had moderate impairment of daily decision making ability. The MDS also indicated that Resident A was able to move around the facility independently when already in the wheelchair. The MDS indicated that the resident needed assistance with meal setup and one person assistance while eating. Review of the clinical record for Resident A showed a doctor's order for a diet texture of "Dysphagia Advance" dated 11/4/13, and an order for Remeron (an antidepressant medication that stimulates appetite) dated 12/21/12, every day at bedtime for depression "[manifested by] poor oral intake." Review of a facility Diet Manual, dated 2011, titled, "Dysphagia Advanced (Level 3) Diet", indicated this diet texture is used for people with mild dysphagia (difficulty swallowing). It indicated that foods that are difficult to chew would be chopped, ground, shredded, cooked or altered to make them easier to chew and swallow. The document indicated that any foods that are very hard, sticky or crunchy should be avoided. The document specifically indicated that peanut butter be avoided. Review of Resident A's care plans revealed a plan which focused on, "Exhibits sx [symptoms] of Depression m/b [manifested by] poor appetite", dated 12/26/12, with interventions including, "give Remeron as per physician orders. Monitor for side effect and notify MD of any abnormal findings...weight gain...Remeron as prescribed to stimulate appetite." Another care plan focused on, "Potential for weight fluctuations [related to] dysphagia, dementia..." dated 12/31/12. The plan had interventions which included, "Diet as ordered. Provide adequate time for self-feeding. Observe and report coughing, drooling. Observe and report [signs and symptoms] of aspiration." During an interview with the Dietary Supervisor on 12/18/13 at 12:05 p.m., she stated that Resident A received a half of a tuna sandwich every evening. She stated that tuna was allowed on the dysphagia diet because the meat is in small pieces and the sandwich is moist. During the interview with the Dietary Supervisor, she confirmed the nourishment delivery carts were open and the food was sitting on top, uncovered, easily in reach of someone in a wheelchair. During an interview with Certified Nursing Assistant 1 (CNA 1) on 1/3/14 at 5 p.m., she stated she had the nourishment cart, and was passing nourishments on 12/16/13 at 7:30 p.m. She stated that she left the cart outside a resident room while she delivered the snacks. When she came out of a resident room, she saw that Resident A had taken another resident's peanut butter sandwich from the cart and ate it very fast. She stated Resident A always ate fast, and that he looked for food. She stated she was in the resident room for approximately 1-2 minutes. She stated that she followed the resident trying to get the rest of the sandwich, and he started choking. Review of the facility investigation dated 12/16/13 indicated the facility interview with CNA 1. CNA 1 stated in her interview that she was "delivering the snacks around 7:30 p.m. to the residents when she came out of a resident's room and saw Resident A engulfing another resident's sandwich. She told him he was eating another resident's sandwich and he shoved the entire sandwich into his mouth. Then he immediately began propelling himself down the hall towards the dining room. She stated she followed him into the dining room....She turns to walk out and noticed that [Resident A] was gulping and appearing to choke. She immediately called for help..." Review of a physician communication and progress note for new symptoms, signs and other changes in condition, dated 12/16/13, indicated that the physician was made aware that Resident A had choked and 911 was called. Further review of the progress notes indicated at 7:52 pm, "EMS arrived to take over CPR (Cardio Pulmonary Resuscitation) and care. At [8:07 pm] EMS pronounced resident expired..." During an interview with the Deputy Coroner on 1/24/14 at 4:30 p.m., she stated, in the pathologist's opinion, Resident A's death was consistent with choking due to the large amount of peanut butter that was found in his upper airway.Review of a letter to the Department, dated 1/25/14, sent by a Deputy Coroner with the County of Sacramento indicated in part, "...preliminary findings were positive for a large amount of peanut butter being lodged in his [Resident A's] airway. The decedent also had evidence of natural disease. However, it was the opinion of our pathologist that his death was more consistent with a choking incident." Therefore, the Department determined the Facility failed to adequately supervise Resident A to prevent access to an open nourishment delivery cart. Resident A took a peanut butter sandwich that was for another resident during the evening nourishment delivery. This failure resulted in Resident A obtaining food that was inconsistent with his ordered diet texture. The patient then consumed the sandwich rapidly, causing him to choke to death on the peanut butter sandwich. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000020 |
Eagle Crest |
030012313 |
A |
08-Jun-16 |
WMMK11 |
7909 |
Nursing Service - Patient Care T22 DIV5 CH3 ART3-72315 (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. The following citation was written as a result of a complainant appeal unit review for complaint #CA00322035. The facility failed to perform a comprehensive assessment and provide necessary care and treatment to prevent the development of a pressure sore for Resident A. The facility's failure resulted in the development of an avoidable pressure sore and put Resident A at risk for pain, infection, and further skin breakdown. Resident A, an 85-year-old admitted to the facility in XXXXXXX 2012 with diagnoses including: paralysis from a stroke, inability to swallow, a feeding tube in place for nutrition, diabetes, dementia and high blood pressure. Resident A was transferred to the facility from Facility 1 (another skilled nursing facility) inXXXXXXX 2012. Review of a Facility 1 document titled, "Skin Condition Record, for non-pressure ulcer skin conditions" indicated: 1. A left lower lateral leg skin tear measuring 0.5 x 1.5 cm (centimeters), dated 7/19/2012. 2. A left posterior upper thigh abrasion measuring 0.8 x 1.5 cm, dated 7/19/2012. 3. Two left buttock abrasions measuring 1 x 0.5 cm and 0.8 x 0.5 cm respectively, dated 7/19/2012. A review of the facility's admission "Nursing Assessment" dated 7/20/2012, was incomplete because it did not contain vital signs, a comprehensive skin assessment, skin assessment evaluation tool, or a pain assessment. The clinical record did not contain a nursing care plan for actual or potential skin breakdown. Review of a clinical record document titled, "Interdisciplinary Progress Notes" dated 7/20/2012 at 9:15 p.m. contained no reference to Resident A's skin condition. An entry dated 7/21/2012 at 6 a.m. noted, "skin W/D (warm and dry) to touch . . ." An entry the same day at 2 p.m. indicated patient "refused skin assessment." A note dated 7/22/2012 at 6 p.m. indicated "kept clean and dry." An entry, dated 7/23/2012 at 1 a.m., indicated Resident A had a shower and two large bowel movements. There was no documentation of the resident's skin condition. Review of Interdisciplinary Team meeting notes, dated 7/23/2012, indicated the resident was at risk for skin breakdown related to bowel and bladder incontinence and impaired mobility. There was no indication of actual skin condition or assessment. There was no documented evidence of a nursing care plan for actual or potential skin breakdown. Review of the Physician Orders revealed wound care orders for excoriated areas on 7/26/2012, six days after the patient was admitted to the facility. Review of documents titled, "Non-Pressure Wound and Skin Condition Documentation Form" first dated 7/25/2012 indicated identification of "scattered excoriation (scratch like) "to left buttock and coccyx. The same document, dated 8/8/2012, noted the scattered scratch-like excoriations to left buttock were "merging [with] each other, and the scattered scratch-like excoriation on coccyx had "spreaded [sic] some towards right buttock". There was no documented evidence of a nursing care plan for skin breakdown. Resident A transferred to the General Acute Hospital on 8/9/2012. Review of the History and Physical, dated 8/9/2012, indicated Resident A was found in the facility unresponsive and "close to intubation". The document indicated there were open areas to the resident's lower back and buttocks. Review of an "Initial Pressure Ulcer Photographic Wound Documentation", dated 8/9/2012, indicated for "Pressure Ulcer Location", "L [left] and R [Right] buttocks." For "Stage" the assessment indicated, "unstageable" (a pressure ulcer that is covered by adhering tissue making it difficult to determine the depth of the wound). The General Acute Care Hospital "Discharge Summary" dated 8/11/2012, indicated the resident had a sacral decubitus ulcer that was unstageable. Further review of the "Wound Care Photo Record" dated 8/11/2012, indicated the wounds measured 11cm x 14.2cm x 0.1cm. In a telephone interview with Licensed Nurse 1 (LN 1) on 9/21/2012 at 3:25 p.m., he stated he took care of Resident A only one night on 7/21/2012. He stated that it was a "crazy" night and he did not have time to assess the patient's skin. He indicated that if there was a problem with someone's skin, the CNA would let him know so he could do an assessment. In an interview with LN 2 on 9/20/2012 at 1 p.m., he stated he did not see the skin on Resident A's buttocks because the patient refused to let anyone look at their skin. He stated the resident was dressed and in the wheelchair and did not want anyone to touch them. In an interview with Certified Nursing Assistant 1 (CNA 1) on 9/20/2012 at 3 p.m., she indicated Resident A's skin was clear and they had no skin breakdown on 7/21/2012. She stated she did not notice any open areas on Resident A's buttocks or sacrum. CNA 1 stated that between 7/23/2012 and 7/24/2012 when she noticed areas that looked bad, she alerted the nurse, and asked the nurse to come and look at the patient's skin as the skin condition was deteriorating quickly. CNA 1 stated she informed Resident A's nurses, who failed to go to the Resident and assess their skin. CNA 1 stated she finally alerted the charge nurse and the treatment nurse on 7/25/2012 and the treatment nurse went to assess the resident's skin. There was no documented evidence a nursing care plan for skin breakdown was developed or implemented. Review of a facility document titled, "Skin Care & Pressure Ulcer Management Program", dated January 2008, indicated for Section 1 "Assessment: Identifying Residents at Risk for Skin Breakdown" under time frame, it indicated ...during the admission process; daily, weekly, monthly, and quarterly. . . ; PRN (as needed). Under the heading, "When a Resident Arrives" the licensed nurse reviews the pre-admission screen and completes a head-to-toe assessment, documenting the findings on the Nursing Assessment. This process provides the team with an accurate description of the resident's actual skin condition. In Section 2, it indicated that based on the assessment an individualized care plan is developed. Review of a facility document titled, "Care Plan-Interdisciplinary" dated January 2008, indicated the Interdisciplinary Team was to develop care plans within 24 hours of admission addressing the resident's most acute problems. In an interview with LN 3 on 9/20/2012 at 11:30 a.m., she stated she first assessed Resident A's skin on 7/25/2012. She stated it looked like scratches on the patient's coccyx and left buttock. She indicated she reminded the CNAs to turn the patient every 2 hours. She stated, "I don't think they did what I told them to do. Some CNAs are good, but some don't do what they are supposed to do." In an interview with the DON, on 8/17/2012 at 2:05 p.m., she indicated the Registered Nurse (RN) did not complete a skin assessment on admission, therefore there were no treatment orders, nursing care plan or follow up; "We dropped the ball." The facility failed to ensure the patient received care to prevent formation and progression of a decubiti and failed to provide care to maintain clean, dry skin free from feces and urine by changing linens and other items in contact with the patient as necessary to maintain clean and dry skin free from feces and urine. The facility's failure prompted development of an avoidable pressure ulcer, which required skin treatment to prevent further skin breakdown. This deficient practice resulted in substantial probability of death or serious physical harm to the Resident. |
| 030000020 |
Eagle Crest |
030012428 |
B |
27-Jul-16 |
EPVA11 |
14891 |
F323 Free of Accident Hazards/Supervision/ Devices - 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation is written as a result of complaint #CA00493031. Unannounced visits were made to the facility on 6/24/16, 6/28/16 and 7/1/16 to investigate an injury involving burns from coffee to both thighs. The Department determined the facility failed to adequately supervise and prevent an accident when Resident A was left unsupervised with a hot cup of coffee contrary to her plan of care. This violation caused the resident to sustain second degree burns, which resulted in severe pain, decreased mobility, and an increased potential for infection. Resident A was admitted to the facility with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dysphagia (difficulty or discomfort in swallowing), and pneumonitis (inflammation of the walls in the lungs) due to inhalation of food and vomit. Review of a care plan initiated 1/10/16 for Resident A indicated, "[resident name] required maximum assistance for ADL (activities of daily living) care in bathing, grooming, dressing, eating...due to Cognitive loss/dementia with Parkinson's disease and related mobility loss. She is able to verbalize very simple answers to immediate situation at times and at times is not able to verbalize needs at all. She is highly reliant on others to anticipate and meet all her needs. Improvement in ability to participate in self-care a task is not anticipated with ongoing debility and decline expected as disease process advances." Review of Occupational Therapy's Initial Evaluation, dated 1/11/16 with the OTA on 7/1/16 at 11:50 a.m. indicated, Resident A required maximal assistance for feeding. The OTA stated Resident A was admitted requiring assistance to be fed and will continue to require assistance. Resident A was discharged from Occupational Therapy and was dependent upon others for feeding. Review of the Order Summary Report for Resident A indicated, an order, dated 1/22/16, for acetaminophen (pain medication) extra strength 500 mg (milligrams, a unit of measure) every eight hours as needed for pain. Resident A was not administered this medication for the month of June until 6/12/16 where she received one dose on 6/12/16, the day after Resident A sustained burns to her right and left thighs. Resident A's Minimum Data Set (MDS, a resident assessment tool) dated 4/15/16, indicated a BIMs (brief interview for mental status) score of 1 out of 15 indicating severe cognitive (reasoning) impairment. Section G of the MDS indicated Resident A's functional status for eating (including drinking) was total dependence with the assistance of one person. Review of Resident A's Nursing Assessment, completed upon admission, and indicated permanent muscle contraction to the left and right hands. Review of the Nursing Summary Progress Note, dated 6/6/16 at 6:08 p.m., indicated Resident A had swallowing precautions and required extensive assistance for eating with one person physical assistance. Review of Resident A's Progress Note dated 6/11/16 at 1:30 p.m. indicated a change of condition in which a CNA (Certified Nursing Assistant) reported that Resident A had redness to bilateral inner thighs. The CNA reported Resident A spilled coffee during activities. Resident A's physician was in the facility and was notified of the incident at 1:30 p.m. Resident A's physician assessed the resident and ordered silver sulfadiazine cream to be applied twice a day for two weeks. Physician orders revealed Resident A had increased pain following the burn on 6/11/16. Physician orders dated: 6/12/16 for acetaminophen extra strength 500 mg every six hours as need for pain was administered on 6/12/16 and 6/13/16 for leg and bilateral inner thigh pain. 6/13/16 a new order for acetaminophen extra strength 500 mg every four hours as needed for pain was administered on 6/14/16 and 6/15/16 for leg pain. 6/14/16 a new order for Tylenol #3 every 6 hours as needed for pain for one week was administered 6/16/16 thru 6/21/16 for bilateral inner thigh pain. A record review revealed a physician order, dated 6/12/16, for silver sulfadiazine cream to inner thigh bilaterally (both sides) two times a day for two weeks. On 6/29/16 there was an order to continue the silver sulfadiazine cream to the bilateral inner thighs over burn areas two times a day. Review of the nursing summary progress note for Resident A, dated 6/13/16 at 11:14 p.m., indicated Resident A had swallowing precautions, was a one person physical assist, and totally dependent for eating. Review of Resident A's Progress Note, dated 6/13/16 at 11:59 a.m., indicated the Interdisciplinary Team (IDT) met to review the accidental injury where Resident A sustained burns to the inner thighs from a coffee spill while at activities. The progress note indicated Resident A was at the morning coffee social activity when staff asked if she wanted coffee and Resident A nodded yes and nodded again when asked if she wanted sugar and cream. The coffee was placed on a table in front of Resident A. It was noted by activity staff to be empty at the end of the activity. The progress note indicated risk factors included significant cognitive loss, needs assistance with meals, and tissue paper thin skin integrity. Review of physician's encounter notes, dated 6/14/16 for Resident A, indicated "Resident with history of Parkinson with dementia, who sustained a coffee burn to medial thighs bilaterally, which has sloughed off, blistering resolved, but patinet [sic] with severe pain" and "burn injury medial thighs: tylenol #3 [narcotic pain medication with codeine and acetaminophen], encourage fluids, wound md [medical doctor] evaluation..." Review of Resident A's Skin Integrity Report dated 6/15/16 for the left anterior medial thigh burn wound indicated the appearance was necrotic (death of cells and tissue) with granulation and the right anterior thigh burn wound indicated the appearance was necrotic, with slough (shed skin) and granulation. Both thighs had serous (clear to yellow fluid) and purulent (thick milky liquid) drainage. Resident A's MDS dated 6/15/16 indicated a BIMs score was 2 out of 15 indicating severe cognitive impairment. Section G of the MDS indicated Resident A's functional status for eating (including drinking) was total dependence with the assistance of one person. The MDS indicated Resident A had a skin condition identified as, "F. Burn(s) (second [affect both the outer and underlying layer of skin] or third degree)." In an interview on 6/24/16 at 9:45 a.m. with CNA 1, CNA 1 stated Resident A is assisted by a CNA because she is shaky and does not feed herself. In an interview on 6/24/16 at 11 a.m. with Activities Assistant (AA) 1, AA 1 stated she had worked with Resident A primarily when Resident A attended activities and received one half cup of coffee with a lid and straw as she was unable to grasp the cup. AA 1 stated she stays by Resident A to assist her drinking the coffee. In an interview on 6/24/16 at 11:40 a.m. with AA 2, AA 2 stated she worked on 6/11/16 and was in the Courtyard Dining room to do the 10 a.m. coffee social when a staff member brought Resident A to the dining room. AA 2 stated this was the first time she had Resident A in an activity with her. AA 2 stated she asked Resident A if she would like some coffee and Resident A nodded her head. AA 2 stated she took Resident A nodding her head as a yes. AA 2 stated she never saw Resident A drink the coffee and when AA 2 picked up the cup it was empty. AA 2 stated she was not aware of Resident A's need for assistance. In a concurrent interview and observation on 6/24/16 at 1:45 p.m. with Dietary Aide (DA) and Administrator (ADM) in the facility's kitchen, the DA obtained a cup of coffee from a coffee machine. The DA and ADM verified the temperature of the coffee was 158 degrees Fahrenheit (unit of measure). The DA stated the coffee was placed in a metal pot for activities and the temperature can be maintained in the metal pot for approximately one hour. Review of the American Burn Association's Scald Injury Prevention Educator's Guide retrieved from Internet site http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf on 7/1/16 at 2:15 p.m. revealed, older adults are a high risk group for scald burns. "Older adults have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation [circulation of the blood in the smallest blood vessels], heat is removed from burned tissue rather slowly." The guide indicated water temperature at 155 degrees Fahrenheit takes one second for a third degree burn [affect the deep layers of skin] to occur. In an interview on 6/28/16 at 10:07 a.m. with Licensed Nurse (LN) 2, LN 2 stated on 6/11/16 around 1 p.m. CNA 2 notified her of redness to the inner thighs of Resident A. LN 2 stated Resident A's physician was at the facility and assessed the resident and ordered silver sulfadiazine cream (topical antimicrobial drug for the prevention and treatment of wounds in residents with second-and third-degree burns) to be applied. LN 2 stated the next day Resident A had "big" blisters on each thigh near the groin and was making noises indicating she was in pain. LN 2 stated Resident A was "moaning" when the cream was applied. In an interview on 6/28/16 at 10:51 a.m. with CNA 2, CNA 2 stated on 6/11/16 she got Resident A up from bed at around 10 a.m. and took her down to the Courtyard Dining room for activities. CNA 2 stated she returned to get Resident A around 12 p.m. to take her to her room for lunch. CNA 2 stated she fed Resident A lunch and waited 45 minutes prior to putting her back to bed. CNA 2 stated Resident A did not have any coffee for lunch. CNA 2 stated when she put Resident A to bed she noticed Resident A's pants were wet and smelled of coffee but her incontinent briefs were dry. CNA 2 stated Resident A's thighs were both red near the groin area. In a concurrent interview and record review on 6/28/16 at 2:15 p.m. with LN 1, LN 1 stated and verified Resident A received an order for Tylenol #3 due to pain from the burn. LN 1 reviewed and verified Resident A's Medication Administration Record (MAR) for June 2016 indicated Resident A had received Tylenol #3 eleven times over six days for leg/bilateral thigh pain. LN 1 confirmed Resident A was receiving treatments of silver sulfadiazine cream twice a day to bilateral thighs. In a subsequent interview and clinical record review with LN 1, LN 1 stated Resident A had been seen by the wound care physician on 6/15/16 and 6/22/16. LN 1 reviewed and verified the wound care specialist initial evaluation of 6/15/16 indicated Resident A had a burn wound on the left anterior (front) medial (middle) thigh measuring 6 cm (centimeters, a unit of measure) by 11 cm; right anterior, medial thigh measuring 13 cm by 13 cm; and right posterior (back) upper thigh measuring 6 cm by 4 cm. All three wounds had 100% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process). LN 1 confirmed the wound care physician notes dated 6/22/16 indicated there was no change in the wound progress for the three burn areas. In an interview on 6/28/16 at 2:50 p.m. with Resident A's physician (MD), the MD stated he was in the facility the day Resident A was noted to have redness on her bilateral thighs. MD stated the burns were caused by coffee and were approximately 4 inches by 10 inches. MD stated the redness spread and blistered which were 2nd degree burns. MD stated Resident A was affected more by the burn than "us" because she was fragile and was in "severe pain." In an interview and facility document review on 6/28/16 at 3:10 p.m. with the Activity Director (AD), the AD stated her expectation of the activity staff is to double check and communicates with LN or CNA what residents can or cannot have. AD stated AA 2 was to request another staff member to assist as she is unable to help residents drink. AD verified the facility recreation policy and procedure titled Supporting Dietary Compliance revised 7/1/14 stipulated "...Recreation staff is aware of resident/resident diets" and "4.4 Proper methods of assisting or feeding residents/residents per state regulation." During a concurrent interview and observation on 7/1/16 starting at 11:30 a.m., Resident 1's right and left thigh burn wounds were photographed with LN 1 who confirmed the measurements and description. LN 1 confirmed the burns were pink with white slough. LN 1 confirmed the right thigh burn had necrotic tissue between the upper and lower aspect. The upper right thigh burn measured 2 cm (centimeters, a unit of measure) by 9.5 cm and the right lower thigh burn measured 6 cm by 6 cm. The upper left thigh burn wound measured 2.5 cm by 0.5 cm, the lower left thigh burn measured 5 cm by 8 cm, and the medial left thigh burn measured 0.5 cm by 5 cm. In a concurrent interview and record review on 7/1/16 at 11:50 a.m. with the Occupational Therapy Assistant (OTA), the OTA stated Resident A had contractures (decreased movement and range of motion) to both hands since admission. The OTA stated Resident A had the drive to try and grasp a cup but due to her Parkinson's, dementia, and hands being contracted and not very functional it was extremely difficult for her to hold or grasp a cup by herself. In an interview on 7/1/16 at 1:15 p.m. with the Restorative Nursing Aide (RNA), the RNA stated, prior to the burns, Resident A would ambulate approximately 150 feet with a front wheeled walker (FWW) with assistance before taking a break and resuming walking. The RNA stated Resident A has not ambulated since she was burned due to pain caused by the friction of the skin on the thighs touching. In an interview on 7/1/16 at 1:40 p.m. with the ADM, the ADM stated she knew it was an avoidable accident. Therefore, the Department determined the facility failed to adequately supervise and prevent an accident when Resident A was left unsupervised with a hot cup of coffee contrary to her plan of care. This violation caused the resident to sustain second degree burns, which resulted in severe pain, decreased mobility, and an increased potential for infection. This violation had direct or immediate relationship to the health, safety, or security of residents. |
| 060001034 |
ENRICHING, INC. III |
060012331 |
B |
15-Jun-16 |
LFRG11 |
18217 |
W331 - The facility must provide clients with nursing services in accordance with their needs. According to the National Pressure Ulcer Advisory Panel (NPUAP) dated 4/13/16, pressure injuries (pressure ulcer) have been defined as localized damage to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, or perfusion, co-morbidities and condition of the soft tissue. Review of the facility's undated P&P (policy and procedure) titled Skin Care and Wound Care: Will Prevent Skin Breakdown and Comply with Treatment of Wounds According to Our Nursing Manual Guidelines, showed wound treatment will be documented on a wound care record which includes the type of wound, location, size, color, and the treatment provided. Any open wound will require immediate intervention by a physician and follow up treatment orders will be instituted. Staff training of wound care procedures must be implemented by the RN (registered nurse) who will develop a care plan for skin integrity. If the physician refers the client to a wound care clinic, it will be determined whether the facility can provide necessary supplemental wound care or if the client's wound care needs will be appropriately provided at a Skilled Nursing Facility until the wound is healed. This will be determined by licensing restrictions as to the level of wound care the facility can manage. On 4/25/16 at 1515 hours, an unannounced visit was made to the facility to investigate an ERI (entity reported incident) regarding Client 1 having a Stage 3 pressure ulcer (full thickness skin loss involving damage to the subcutaneous tissue that may extend to the underlying connective tissue) to his left ankle. 1. On 4/25/16 at 1520 hours, an observation and concurrent interview was conducted with Client 1. Client 1 was observed sitting in his electric wheelchair in his room. Client 1 was verbal and able to answer the surveyor's questions. Client 1 was observed with a left lateral (outer side) ankle wound that measured 1 cm (length) by 0.5 cm (width). The periwound (the tissue surrounding the wound itself) was observed to be beefy red. When asked how he got the wound, Client 1 stated he always slept on his back and the bed was too hard. Client 1 further stated he was unable to move his feet. Client 1 stated the wound on his ankle had been there for a long time and "it hurt before." In addition, Client 1 was observed with a right lateral plantar (sole of foot) wound that measured 5 cm (length) by 2 cm (width) with a purplish center. The skin on the right lateral ankle was intact and had no redness. Clinical record review for Client 1 was initiated on 4/25/16. Client 1 was a 29 year old with diagnoses including mild intellectual disability (a person with an IQ score of 55 to 70), Becker's muscular dystrophy (a genetic, degenerative disease characterized by slow progressive muscle weakness of the legs and pelvis), and morbid obesity. Client 1 was non-ambulatory, unable to move his lower extremities or reposition himself independently, utilized a power (electric) wheelchair for mobility, and had a history of pressure ulcer to his left lateral ankle. Review of the DCS (direct care staff) Program Notes dated 4/2/16, showed Client 1 had a "2 cm sore" to his left ankle and redness to his right ankle. The documentation showed the RN had been notified of the skin problems on the right and left ankles. However, there was no documentation addressing Client 1's right lateral plantar wound. Further review of the clinical record showed the most recent nurse's notes in the clinical record were dated 1/31/16. There was no documented evidence the RN had completed a quarterly review of Client 1's health status since 12/30/15. There was no documented evidence in the clinical record to show RN 2 had completed the assessments of Client 1's wounds on the right and left lateral ankles after RN 2 was informed on 4/2/16. There was no documentation addressing the physical characteristics of the wounds including the type of wound, location, size, color, and the treatment provided if any, as per the facility's P&P. There was no documented evidence the physician was consulted for immediate interventions for Client 1's wounds on the right and left lateral ankles from 4/2 through 4/11/16, as per the facility's P&P. There was no documented evidence the RN had monitored the progress of the wounds. There was no documented evidence in the clinical record the RN developed a care plan to address the pressure ulcer and initiate interventions to promote healing of Client 1's pressure ulcer as per the facility's P&P. There was no documentation in the clinical record to show any interventions were initiated to promote the healing of Client 1's pressure ulcer. Review of the Physician's Consultation Report showed Client 1 had a consultation visit with a dermatologist (a physician who specializes in the diagnosis and treatment of skin diseases and related systemic diseases) on 4/12/16. Review of the dermatologist's progress note dated 4/12/16, showed Client 1 had a Stage 2 pressure ulcer (a blister or partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough [layer of dead skin]) to his left lateral ankle and a Stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a boney prominence) to his right lateral ankle. The dermatologist ordered two donut hole pillows to offload Client 1's ankles, Silvadene cream (antimicrobial cream) to be applied to the wounds three times a day, and was referred to the wound care clinic for continued wound care management. There was no documentation the physician had assessed Client 1's right lateral plantar wound. Review of the MAR (Medication Administration Record) for April 2016 showed the Silvadene cream was not provided three times daily as per the physician's order. The documentation showed the wound treatment to the left ankle was provided one time a day on 4/12, 4/13, 4/14, 4/15, 4/18, 4/19, 4/20, and 4/21/16, and two times a day on 4/17 and 4/18/16, instead of three times daily as per the physician's order. There was no documented evidence the IDT (Interdisciplinary Team) had met to determine whether the facility could provide the necessary supplemental wound care or if the client required a transfer to a Skilled Nursing Facility where Client 1's wound care needs could be met appropriately, until the wounds were healed. Review of the physician's progress note from the wound care clinic dated 4/21/16, showed the Stage 2 pressure ulcer to Client 1's left lateral ankle had gotten worse and was now a Stage 3 pressure ulcer. The wound measured 0.7 cm (length) by 0.4 cm (width) by 0.2 (depth). The physician ordered an x-ray of the client's left ankle, Santyl ointment (ointment that continuously remove dead tissue/s, maintaining a clean wound bed) to be applied during the wound care daily, and requested for the facility to purchase heel protector rings to offload the client's ankles. There was no documentation to show Client 1's lateral plantar wound was assessed by the physician. On 4/25/16 at 1533 hours, an interview was conducted with RN 2 who had been working at the facility since the first week of February 2016. RN 2 stated she was notified by the staff on 4/4/16, regarding Client 1's left ankle pressure ulcer. RN 2 stated she instructed the staff to arrange for Client 1 to see the dermatologist. RN 2 stated she was at the facility on 4/13/16, to treat the wound (nine days after she was notified about the client's left ankle pressure ulcer). RN 2 stated she was just stopping by the facility on 4/13/16, and had no time to document her assessment or treatment she had administered. RN 2 verified there was no documentation of her visit. RN 2 stated she assessed Client 1's wounds; however, she did not measure the wounds to monitor the progress of the wounds nor did she develop a nursing care plan. RN 2 verified the above findings and stated the only notes she had regarding Client 1's wounds were the text messages in her personal mobile phone. Further review of the clinical record failed to show wound care records indicating the type of wounds, location of the wound(s), size, color, and the treatment provided as per the facility's P&P. On 4/25/16 at 1730 hours, an interview with the Administrator was conducted. The Administrator stated when he asked Client 1 how he got the pressure ulcer, Client 1 stated he developed the pressure ulcer from his bed. The Administrator verified he did not document his conversation with Client 1. On 4/28/16 at 0700 hours, Client 1 was observed in bed, laying on his back, with his legs spread apart, his knees bent with the lateral sides of his knees resting on the mattress, and with the bottoms of his feet facing each other. His lateral ankles were resting on the mattress and not offloaded as per the physician's order. The mattress was firm to touch. Client 1 stated his mattress was hard, which caused the pressure ulcers to his ankles. A pump for the air mattress was observed hanging by the foot board of the bed; however, there was no air being pumped to the client's mattress. Client 1 was observed with a left lateral ankle wound, measuring 1 cm (length) by 0.5 cm (width) and a right lateral plantar wound, measuring 0.8 cm (length) by 1 cm (width). The center of the right lateral plantar wound was black and leathery. When Client 1 was asked if the RN had been to the facility to assess his wounds, he stated RN 2 had only seen him once and it was a couple of days ago. Further review of the clinical record showed a physician's order dated 4/9/10, for a hospital bed, air mattress, and heavy duty mechanical lift for transfers. Review of the Statement of Ordering Physician for the air mattress dated 4/16/10, showed the estimated length of need for the air mattress was for the client's lifetime. The delivery receipt in the client's clinical record showed the air mattress was delivered to the facility on 4/27/10. On 4/28/16 at 0720 hours, an interview was conducted with the Administrator. When the Administrator was asked if Client 1 had an air mattress, the Administrator stated Client 1 used to have an air mattress; however, it broke "a long time ago." The Administrator stated he was not sure how long ago the air mattress had broken and a new one had not been ordered yet because the insurance would not pay for it unless Client 1 had a Stage 3 pressure ulcer. When the Administrator was informed Client 1 was diagnosed with a Stage 3 left lateral ankle pressure ulcer on 4/21/16, he reiterated he had not ordered the air mattress since it was the RN's responsibility to order the air mattress. There was no documentation in the clinical record when Client 1's air mattress had broken. Review of the Physician's Interval Assessment Nursing Information forms dated 11/3/15 and 1/19/16, showed RN 1 had requested an order for a new air mattress from the physician. Further review of the clinical record failed to show RN 2 had followed up on RN 1's request for a new air mattress for Client 1 to help prevent the development and promote the healing of the left lateral ankle pressure ulcer and the right lateral plantar wound. On 5/5/16 at 0825 hours, an interview and concurrent clinical record review was conducted with the QIDP. The QIDP was informed of the above findings and the QIDP verified the wound care clinic did not evaluate Client 1's right lateral plantar wound. On 5/5/16 at 1337 hours, a telephone interview was conducted with RN 2. RN 2 was informed there was no documentation in the clinical record to show Client 1's right lateral plantar wound was assessed by the RN and/or the physician and had treatment orders. RN 2 stated she did not know Client 1 had a wound on the right lateral plantar. 2. On 4/25/16 at 1740 hours, Client 2 was observed in his room sitting in his wheelchair with his left pant raised above his knee. Client 2 was observed with a left anterior lower leg wound, measuring 2.5 cm (length) by 4 cm (width). The wound bed was red with discoloration to the periwound. When Client 2 was asked if his leg hurt, he nodded. On 4/25/16 at 1745 hours, an interview was conducted with the Administrator. The Administrator stated the day program had notified him of Client 2's left leg wound on 4/19/16. The Administrator further stated Client 2 was seen at the emergency department that same day, was diagnosed with cellulitis (a potentially serious, painful bacterial infection of the skin and the soft tissues underneath), and was referred to the wound care clinic. The Administrator stated the appointment at the wound care clinic had not been arranged because the facility had not received an authorization from the insurance company. Clinical record review for Client 2 was initiated on 4/25/16. Client 2 was a 65 year old with diagnoses including moderate intellectual disability (a person with an IQ of 40 to 55), cerebral palsy (a disorder of movement, muscle tone or posture that is caused by an insult to the immature, developing brain, most often before birth), and stasis dermatitis (inflammation of the skin of the lower legs caused by chronic venous insufficiency, and symptoms are itching, scaling, hyperpigmentation, and sometimes ulceration). Client 2 also had a history of stasis ulcers (an ulcer [crater] that develops in an area in which the circulation is sluggish and the venous return [the return of venous blood toward the heart] is poor). Client 2 was non-ambulatory and utilized a manual wheelchair for mobility. Review of the progress note from the emergency department visit on 4/19/16, showed Client 2 was diagnosed with cellulitis. The physician ordered Keflex (antibiotic medication) 500 mg four times daily and Bactrim DS (antibiotic medication) 160-800 mg twice daily at 2015 hours. The documentation on the MAR showed the first dose of the Bactrim DS and Keflex were not administered within four hours as per the facility's P&P. Review of the MAR for April 2016 showed to administer the Bactrim DS two times a day at 0700 and 1900 hours, and Keflex 500 mg four times a day at 0700, 1600, 1900, and 2100 hours. The documentation on the MAR showed the first dose of Bactrim DS was administered on 4/20/16 at 1900 hours, and the first dose of Keflex was administered on 4/21/16 at 0700 hours. Client 2 received the first dose of Bactrim DS medication 22.75 hours after the antibiotic medication was ordered by the physician on 4/19/16, instead of four hours as per the facility's P&P. In addition, Client 2 received the first dose of Keflex medication 34.75 hours after the antibiotic medication was ordered by the physician on 4/19/16, instead of four hours as per the facility's P&P. Further review of the clinical record showed the RN was informed of Client 2's left anterior lower leg wound on 4/14/16; however, there was no documentation in the clinical record to show RN 2 had completed an assessment of Client 2's wound, including the type of wound, location, size, color, and treatment provided if any as per the facility's P&P. There was no documented evidence RN 2 had monitored the progress of the left anterior lower leg wound. On 4/28/16 at 0715 hours, Client 2 was observed to have a right anterior lower leg wound, measuring 0.5 cm (length) by 1 cm (width), in addition to the left anterior lower leg wound. On 4/28/16 at 0945 hours, an interview was conducted with RN 2. When RN 2 was asked if she completed an assessment of Client 2's wounds on the left and right anterior lower legs, she verified she did not measure and/or document the assessment of Client 2's wounds. The facility failed to ensure the RN provided preventative health care services for two of two sampled clients (Clients 1 and 2), including timely follow up on reported medical concerns, conducting wound assessments, monitoring progress of wound healing, monitoring medication orders, and providing training to the DCS as evidenced by: * The facility's RN failed to complete a timely assessment of Client 1's pressure ulcer when the RN was notified of the pressure ulcer on 4/2/16, failed to assess Client 1's right lateral plantar wound, and failed to monitor Client 1's pressure ulcer to evaluate the effectiveness of the wound treatment. * The facility's RN failed to ensure the physician was consulted timely for wound treatments when the RN was made aware of Client 1's left lateral ankle pressure ulcer and right lateral plantar wound as per the facility's P&P. * The facility failed to provide a pressure relieving mattress for Client 1 and offload the client's ankles. * The facility failed to ensure the physician was consulted timely for wound treatment for Client 1's right lateral plantar wound leaving it untreated. * The facility's RN failed to develop a care plan to prevent the development and promote healing of Client 1's pressure ulcer to the left lateral ankle and the right lateral plantar wound. * The facility's RN failed to conduct a timely assessment of Client 2's open wound to his left and right lower legs when the RN was notified on 4/14/16, and failed to consult with the physician regarding treatment of the wounds. This resulted in Client 2's wounds left untreated. * The facility's RN failed to complete a quarterly review of the health status for Clients 1 and 2. * The facility failed to ensure the medications were administered without error for Client 1. * The facility's RN failed to ensure Client 2's antibiotic medication was administered within four hours of the physician's order as per the facility's P&P. The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated health care services to its clients. This failure had a direct and immediate relationship to the health, safety, and security of the clients. |
| 060001574 |
ELM STREET HOME |
060012706 |
B |
1-Nov-16 |
4OUN11 |
23371 |
W331 - The facility must provide clients with nursing services in accordance with their needs. On 9/7/16, the Council on Aging sent an incident report to the CDPH regarding the facility not following up on a physician's order and getting medical services in a timely manner for Client 1. On 9/13/16 at 0910 hours, an unannounced visit was made at the facility. The facility's policy and procedure (P&P) titled Notification of Client Change of Condition updated 1/12/16, showed it is the Company's policy to notify the physician and inform the client and client representative, and the client's Regional Center Service Coordinator of significant change in the client's physical, mental, and psychological status including accidents and when there is a need to alter treatments significantly. The P&P defined significant change related to physician notification as "the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician in the medical treatment plan." The P&P listed notification procedures that included: - It is the responsibility of the person observing the change to immediately report that change to the Registered Nurse (RN). - The RN will immediately assess the report of the condition and determine what nursing interventions are appropriate. - The RN will be responsible for making all notification of changes to the physician, the client, client representative and Regional Center Service Coordinator. - Before notifying the physician, the nurse must observe and assess the overall condition utilizing physical assessment and chart review. Notification of non-emergency changes will be made on the shift in which it occurred; - Document in the client's clinical record the assessment of the client's condition and the information given to the physician; - All attempts to notify the physician and client representative will be noted in the client's chart. Notification will include the date, time, method of communication, and name of the person contacted; and - Client care plans will be updated and the alert charting procedure will be initiated to assure follow-up monitoring. The P&P listed examples of changes, which may include but are not limited to: - Unusual occurrences including accidents/incidents/falls; - Musculoskeletal changes, including deformities, gait, and functional status changes. Review of the facility's Special Incident Report and Investigation Information form dated 8/24/16, showed Client 1's Job Coach reported to the RN and Qualified Intellectual Disabilities Professional (QIDP) that Client 1 was in pain on her right arm. Documentation showed the RN was immediately notified and the QIDP started to ask the staff who worked that morning if there was any incident that happened during their shift that may lead to the client's pain. It was also documented staff stated there was no event that day that could lead to any injury. Review of the facility's Special Incident Report and Investigation Information form dated 8/25/16, showed Client 1 came home from the Day Program with swollen fingers and was in pain. Documentation showed all staff were asked for any possible instances that would lead to the client's possible injury. Two staff on duty stated there was no incident on their shift. On 9/13/16, the clinical record for Client 1 was reviewed. Client 1 was admitted to the facility on 5/20/15, with diagnoses including severe intellectual disability (person with an IQ score of 25 to 40). Client 1 was nonverbal and dependent on caregivers for all her needs. Review of the QIDP Progress Notes form dated 8/24/16 (no time), showed the QIDP visited Client 1's Day Program and the Job Coach informed the QIDP that Client 1 seemed to have pain on her right arm. The QIDP documented there was no redness noted to Client 1's right arm and the RN would be notified. Review of the Nurse's Notes form dated 8/24/16 (no time), showed the RN was informed the QIDP visited the Day Program and was informed Client 1 was "maybe in pain" and not wanting to move her right arm. The RN documented the facility was visited at 1800 hours to assess Client 1 and the client was able to move her right arm and elbow, no bruising, no tenderness, and no redness observed. The RN documented she advised the direct care staff (DCS) to continue monitoring Client 1, give her pain medications as needed, and to report any changes. The RN documented the primary care physician (PCP) would be making rounds the next day and would have him check Client 1. Review of the QIDP Progress Notes form dated 8/25/16 (no time), showed the QIDP saw Client 1 after she came home from the Day Program and the Job Coach reported the fingers on Client 1's right hand was swollen. The QIDP documented the RN was notified and the QIDP was informed the PCP would be at the facility that day to do rounds and Client 1 would be seen by the PCP. Review of the Nurse's Notes form dated 8/25/16 at 1730 hours, showed the PCP made rounds and assessed Client 1's right arm. The RN documented there was no swelling, no redness, and no sign of injury, and Client 1 allowed the PCP to manipulate her right arm to check for range of motion and no issues were identified. The RN documented the PCP ordered x-ray of the right shoulder/arm "just in case." The RN also documented she advised the QIDP to order the x-ray in the morning and to keep Client 1 at home the next day. Review of the Physician Progress Notes form showed an entry dated 8/25/16 at 1800 hours. The PCP documented he had examined Client 1 because the staff noticed she was not moving her right arm. Review of the recapitulated physician's orders dated 9/1 to 9/30/16, showed the PCP wrote an order dated 8/25/16 at 1800 hours, for x-ray of the right shoulder. Review of the Nurse's Notes form dated 8/26/16, showed at 1000 hours the RN faxed the x-ray order to the mobile x-ray service and advised the facility staff to let her know when the x-ray service came. The RN documented at 1830 hours, the facility staff informed her the x-ray mobile service had not gone to the facility so the RN called the x-ray mobile service and was informed they needed an authorization from Cal-Optima. The RN documented it was too late to get an authorization and would try on Monday (8/29/16), four days after the PCP ordered the x-ray. The RN documented she notified the QIDP that Client 1 should be taken to the Urgent Care for the x-ray and the QIDP told the RN she would get the House Manager to take Client 1 since there were no drivers available on the weekends. However, there was no documented evidence the RN had assessed the client's current condition, i.e., pain, increased swelling, nor was there documented evidence to show the PCP was notified the order for the x-ray had not been carried out because of health insurance issues. Review of the Nurse's Notes form dated 8/27/16 at 1507 hours, showed the RN received a text message from the QIDP that no one was available to take Client 1 to the Urgent Care until Monday. Again, there was no documented evidence to show the RN had reassessed the client's right arm nor was there documentation to show the physician was notified the order for the x-ray of the arm was delayed. Review of the Nurse's Notes form dated 8/28/16 at 1723 hours, showed the RN was notified by the DCS that Client 1's mother had visited the facility and will take Client 1 to the Urgent Care. The RN notified the QIDP; however, there was no documentation to show the PCP was notified. Review of the Nurse's Notes form dated 8/28/16 at 2100 hours, showed the RN received a text message from the QIDP indicating Client 1 was with her mother at the general acute care hospital's emergency room (ER) and the x-ray result showed the client had a dislocation of the right shoulder. Review of the Nurse's Notes form dated 8/28/16 at 2230 hours, showed the QIDP had notified the RN of Client 1 being admitted to the hospital because the ER staff could not reduce the dislocation and the client would need to be sedated. Review of the Nurse's Notes form dated 8/29/16 at 1310 hours, showed the RN visited Client 1 at the hospital. The RN documented the hospital RN informed her that Client 1 was having a closed reduction of the dislocated shoulder under anesthesia later that afternoon. Review of the Nurse's Notes form dated 8/30/16 at 1000 hours, showed the RN was informed by the QIDP that Client 1's mother took Client 1 home after her surgical procedure and would not be returning the client back to the facility. On 9/13/16 at 1040 hours, the QIDP and RN were asked why it took so long to notify Client 1's mother regarding the client's change of condition. The QIDP stated she notified Client 1's mother on 8/26/16, regarding Client 1 being seen by the PCP the night before to check her right arm and keeping the client home to get the x-ray done that day. The QIDP stated Client 1's hand was puffy. When asked why she did not want Client 1 to go to Urgent Care like the RN had suggested, the QIDP stated she told the RN she was going to find transportation the next day since it was already around 1830 hours when she was informed. When asked how Client 1 was that night, the QIDP stated Client 1 was quiet, ate well but did not want to be touched. The QIDP stated Client 1 was usually loud. When asked if she had anyone available for transportation that evening, the QIDP stated no, and they did not have anyone to be with the client at the hospital. The QIDP stated she only had two staff on the PM shift and if one staff went with Client 1 they would be out of compliance with staffing. The RN stated the physician came to the facility and examined Client 1 on 8/25/16, and the physician stated he could not find anything wrong with the arm but ordered the x-ray. On 9/13/16 at 1050 hours, the QIDP and RN were informed of the concern regarding the physician ordering the x-ray on 8/25/16, the order was not faxed to the mobile x-ray company until 8/26/16 at 1230 hours, and the RN was not notified until 1830 hours that the x-ray had not been done. The QIDP stated she was surprised the x-ray service did not come to do the x-ray and the RN is new at the facility. Both stated they thought one of them would follow up and they depended on the DCS because they were in the facility more than the QIDP and RN. The RN stated on 8/24/16, during her assessment of Client 1, the client pulled away when the RN touched the client. The RN stated she asked the DCS if that was normal and she was told Client 1 did not like to be touched. The RN stated she did not see any swelling. The RN stated she instructed the DCS to give Client 1 Tylenol (pain medication) if the client looked like she was in pain, and if there was any change of condition they should send her to the acute care hospital's ER. On 9/13/16 at 1100 hours, the QIDP and RN were asked if they decided to have Client 1 transported to the Urgent Care on Monday (8/29/16, which was four days after the PCP ordered the x-ray of the right arm), since they did not have transportation available the evening of 8/26/16. The QIDP stated they could have called 911 to have the client taken to the ER. The surveyor informed the QIDP and RN that they did not do it. On 9/13/16 at 1115 hours, the QIDP was asked to clarify the staffing issues. The QIDP stated it was frustrating to have to borrow staff from another sister facility to cover. The QIDP stated sometimes she got lucky when the staff had worked when needed but it did not happen often because the staff have family and have other jobs. The QIDP stated the House Manager worked Monday through Friday and worked one day on the weekends. The QIDP stated getting extra staff does not happen all the time, they tried and found people that would work or borrowed staff from their sister facilities. The QIDP stated they had a company driver that worked Monday through Friday. However, the driver had his own schedule, like taking clients to their appointments, and sometimes when they called to add their client for an appointment the client was not taken to that appointment because the driver's schedule was already full. The QIDP also stated the facility had a van but it was kept in Placentia and the other nearest van was in Fullerton. The QIDP stated she only had two staff working on 8/26/16, and both staff were not certified to drive. On 9/13/16 at 1125 hours, the QIDP was asked if she notified Client 1's mother of the x-ray not being done that evening. The QIDP stated she did not. During a telephone interview on 9/13/16 at 1330 hours, the QIDP was requested for copies of the DCS progress notes. The QIDP stated the DCS did not write progress notes. When asked how the DCS communicated if something happened with the clients, the QIDP stated the DCS would call the RN and the RN would instruct the DCS on what to do. On 9/14/16 at 1545 hours, the facility was visited. At 1545 hours, the QIDP was asked if an investigation was conducted to find out how Client 1 dislocated her right shoulder. The QIDP stated the Program Coordinator was the person to complete it but did not think it was done yet. At 1555 hours, the QIDP was asked to clarify how the DCS communicated with the RN regarding Client 1. The QIDP stated the DCS called the RN and the RN told the DCS what to do. Further review of Client 1's clinical record on 9/14/16, showed the following: The MAR for August 2016 showed Client 1 was given pain medications on the following days: - 8/24/16 at 1500 hours, Ibuprofen (pain medication) 200 mg two tablets by mouth for possible pain and the medication was effective. - 8/25/16 at 1400 hours, Ibuprofen 200 mg two tablets by mouth for possible pain and the medication was effective. - 8/27/16 at 2000 hours, Ibuprofen 200 mg two tablets by mouth for possible pain and the medication was effective. - 8/28/16 at 0500 hours, Ibuprofen 200 mg two tablets by mouth for possible pain and the medication was effective. The QIDP was asked if there was a care plan that addressed Client 1's right shoulder. The QIDP looked in the clinical record and could not find any documentation. The QIDP stated the RN may have just given verbal instructions to the DCS. On 9/14/16 at 1645 hours, DCS 1 was interviewed. When asked how Client 1 was on 8/24/16, DCS 1 stated when she was putting Client 1 to bed, she tried to lift Client 1's right arm, and the client flinched and pulled her body away. DCS 1 stated the client might have pain at that time. When asked if the RN assessed Client 1's right arm, DCS 1 stated the RN did not come on Wednesday (8/24/16). DCS 1 stated Client 1 attended the Day Program the next day (Thursday) and her arm was swollen from her upper arm to just below her elbow. DCS 1 stated the RN and PCP were at the facility on 8/25/16, and examined Client 1. DCS 1 stated Client 1 always clapped her hands, tapped her head, and made sounds; however, since that Wednesday (8/24/16) the client was quiet than usual. When asked if they did anything to make sure Client 1 was comfortable, DCS 1 stated they gave her medications for pain and placed ice on her arm. DCS 1 was asked if she worked on Friday (8/26/16) and how was Client 1. DCS 1 stated Client 1's arm was still swollen. DCS 1 stated when she came back on Sunday (8/28/16), Client 1's arm was more swollen from her upper arm to her wrist. When asked if Client 1's right hand was swollen, DCS 1 stated she did not remember but stated Client 1 still did not move her arm. DCS 1 stated Client 1's mother came to the facility, fed the client then took Client 1 with her when she left the facility. On 9/14/16 at 1705 hours, DCS 2 was interviewed. DCS 2 stated the following: - On Wednesday (8/24/16), the RN called and asked if Client 1 was in pain. DCS 2 stated Client 1 looked normal; however, when she touched Client 1's right arm to lift it she flinched and moved her body away. DCS 2 stated the RN told her to give Client 1 the Ibuprofen and apply the cold compress to the right arm. When asked if the RN went to the facility on Wednesday (8/24/16) evening to assess Client 1's right arm, DCS 2 stated the RN did not come to the facility on Wednesday. When asked how Client 1 was on Thursday (8/25/16), DCS 2 stated Client 1's hand was a little swollen and it was noticeable compared to her other hand. DCS 2 stated Client 1 only moved her fingers. DCS 2 stated the PCP and RN were at the facility, and when the physician saw Client 1's arm he immediately said x-ray. DCS 2 stated later that evening she gave Client 1 the Ibuprofen and applied cold compress to her arm. - On Friday (8/26/16), the RN informed her that Client 1's right arm would be x-rayed and the x-ray imaging service would be coming to the facility to do it. Later that evening, DCS 2 stated she called the RN to inform her the x-ray imaging service had not come yet. DCS 2 stated the RN stated maybe they will come the next day in the morning. - On Saturday (8/27/16), when she came to work Client 1 was on bed rest. Client 1's right arm was noticeably swollen from her upper arm to her wrist. When asked if there was any bruising or discoloration, DCS 2 stated no. When asked how Client 1's appearance was, DCS 2 stated Client 1 was quiet. When asked if Client 1 was usually quiet, DCS 2 chuckled and stated no, and for Client 1 to be quiet was unusual since the client usually shouts, cries, and says mama all the time. DCS 2 stated later in the evening she called the RN to inform her the x-ray imaging service did not come to the facility. DCS 2 stated the RN said the x-ray imaging service needed authorization. - On Sunday (8/28/16), Client 1's mother came. DCS 2 stated when Client 1's mother asked her how Client 1 was, she told her that Client 1's right arm was swollen. DCS 2 stated Client 1's mother went to Client 1's room to see her. DCS 2 stated Client 1's mother said "they could not do anything for her these four days. I am going to feed her and take her." DCS 2 stated Client 1's mother fed her, asked for some medical information, then took Client 1 with her. DCS 2 stated she called the QIDP and RN to inform them of Client 1's mother taking Client 1. On 9/14/16 at 1935 hours, a telephone interview was conducted with DCS 2. When asked if she reported to the RN about Client 1's right arm being swollen the days she cared for the client, DCS 2 stated yes. When asked what the RN told her, DCS 2 stated the RN instructed her to give Ibuprofen and put cold compresses. On 9/15/16 at 1035 hours, Client 1's Day Program was called to speak with her Job Coach; however, the Job Coach was not available. The Program Coordinator stated she could help. The Program Coordinator stated the Job Coach had notified her of Client 1 acting differently than usual. When asked if the Job Coach stated what was different, the Program Coordinator stated the way Client 1 was holding herself and she did not want to use her right arm. The Program Coordinator stated Client 1 was quiet but it was her mannerism of how she was acting. When asked if the QIDP came on 8/24/16, the Program Coordinator stated the QIDP visited the day program and the Job Coach told the QIDP about Client 1's right arm. Further review of Client 1's clinical record was conducted on 9/16/16 at 1045 hours. There was no documentation addressing Client 1's pain and the swollen right arm. Review of the data collection sheets for Client 1's active treatment objectives showed the following: - An objective that Client 1 will touch a quarter for one second with hand over hand assistance, two out of eight times per month. The data collection showed Client 1 performed the objective on 8/1 through 8/24/16, but Client 1 refused to perform the objective on 8/25, 8/26, and 8/27/16. - An objective that Client 1 will walk with two staff from her bedroom to the dining room area, twenty-five out of sixty times per month. The data collection showed Client 1 performed the objective from 8/1 through 8/19/16, and 8/21 through 8/25/16. Client 1 did not perform the objective on 8/26 and 8/27/16. Review of the facility's sleep pattern form for the month of 8/16 showed on 8/27/16, Client 1 slept from 2100 hours to 2300 hours and was awake from 2400 hours to 0600 hours. On 9/16/16 at 1140 hours, review of the job description for the facility's RN showed the following: - The Summary of the nursing RN position was to assess health problems and needs of person(s) served, develop and implement nursing care plans, and maintain medical records; administer nursing care to person(s) served; advise person(s) served and staff on health maintenance and disease prevention and or provide case management. The RN job responsibilities included the following: - Ensures the provisions of nursing/health services ordered by physicians and other health professional consultants. - Monitors the individual health status through provision of general nursing services as outlined/ordered. - Reports changes in health status and pertinent information to attending physician and other health professionals as needed and in timely manner. - Ensure aggressive management of individual health needs when indicated by possible adverse changes in the medical/health status of a person served. - Arranges for and ensures completion of specialist, doctor appointments and follow ups. - Monitors incident reporting procedures for timeliness, completeness, and accuracy and examines individual involved in incidents. - Ensures the accurate and timely documentation of nursing/health assessments and evaluations. - Ensures the routine documentation of individual's health status in nurse's notes. On 9/19/16 at 1235 hours, a telephone interview with the RN was conducted to clarify whether she went to the facility to assess Client 1 on 8/24/16. The RN stated she went to the facility on 8/24/16, to assess Client 1's right arm. The RN was informed the DCS stated during an interview that the RN did not visit that day. The RN again stated she went to the facility to see Client 1 on 8/24/16. On 9/22/16 at 1515 hours, a telephone interview with DCS 1 and 2 was conducted. When asked to clarify if Client 1 attended the Day Program on 8/25/16 (Thursday), both DCS stated, yes but not on Friday. When asked if the RN visited Client 1 at the facility on 8/24/16 (Wednesday), both DCS stated, no the RN was here on Thursday (8/25/16). The facility RN failed to assess and/or reassess Client 1 and provide timely interventions when Client 1 was identified with pain to the right arm and swelling to the right hand. The PCP ordered an x-ray to Client 1's right arm; however, the x-ray was not done until three days later when the client's mother visited the client at the facility and decided to bring the client to the general acute care hospitals ER, where Client 1 was identified with a dislocated right shoulder requiring a surgical procedure. This failure resulted to Client 1's dislocated right shoulder to not be diagnosed timely and caused further pain to Client 1. The above violations, either jointly, separately, or any combination had a direct or immediate relation to the patient's health, safety, or security. |
| 070000780 |
EDEN VALLEY CARE CENTER |
070011728 |
B |
05-Oct-15 |
JW3D11 |
4756 |
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed report incidents of alleged abuse promptly to the administrator/designee and within 24 hours to the California Department of Public Health (CDPH), the local law enforcement agency, and the local ombudsman as required by law and in accordance with the facility policy. Three certified nurse assistants (CNAs) did not report their observations of CNA C's alleged rough handling and yelling at Residents 2 and 11.Review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 9/1/15, indicated she had memory problems, severe difficulty in daily decision making skills and required two person extensive assistance with transferring, i.e., from wheelchair to bed.The Interdisciplinary (IDT, a group of health care professionals working in a coordinated fashion toward a common goal for the patient) Progress Notes dated 9/8/15, indicated family member A (FM A) reported a staff member was "rough" with Resident 2 during care, "they shoved her and treated her like an animal and just threw her to bed." The facility filed form SOC 341 (Alleged Abuse Form) and faxed this to the Department on 9/9/15. During an interview on 9/14/15 at 4:40 p.m., the director of nurses (DON) stated after she received FM A's report, she held a meeting with the CNAs the afternoon of 9/8/15 to relay an allegation of an unknown staff member mistreating a resident. After the meeting ended, CNA F told the DON she recently saw CNA C "tucking" Resident 2 in bed from her feet to her waist level and placing a wheelchair and bedside table along the bed to prevent her from moving. The DON stated CNA F "felt guilty" for not reporting the incident to any staff in the facility. During an interview on 9/16/15 at 7 a.m., CNA D stated about two weeks prior she witnessed CNA C getting near Resident 2's face and telling her to be quiet. She did not report the incident to any facility staff.The DON was interviewed on 9/16/15 at 3:30 p.m. She stated she was unaware of these incidents but the CNAs should have reported any incident of alleged abuse. Review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 7/16/15, indicated he had memory problems, severe difficulty in daily decision making skills and required two person total assistance with transferring.During an interview on 9/16/15 at 8:40 a.m., CNA F stated on 8/31/15 at approximately 5 to 6 a.m., she heard Resident 11 say to CNA C "You're too rough" after he was transferred from his shower chair. CNA F did not report this incident to any facility staff.The DON was interviewed on 9/16/15 at 3:30 p.m. She stated she was unaware of these incidents but the CNAs should have reported any incident of alleged abuse. The facility filed form SOC 341 and faxed it to the Department on 9/16/15. The undated policy, "Elder Abuse Policy" indicated the facility would not condone resident abuse by anyone including staff members. All personnel must promptly report any incident or suspected incident of resident abuse to the administrator/designee. The administrator/designee was to notify the ombudsman, CDPH, and local law enforcement of an allegation of elder abuse within 24 hours of notice. This violation had a direct or immediate relationship to the health, safety or security of residents. |
| 070000050 |
EMPRESS CARE CENTER, LLC |
070013288 |
B |
15-Jun-17 |
9LDD11 |
3961 |
F226, 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES
483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to implement their policy and procedure in reporting an elopement (to leave a long term care facility without permission) and unusual occurrence for Resident 1, when the resident left the facility without the knowledge of the staff. Resident 1's elopement was not reported to the California Department of Public Health (CDPH).
Resident 1's clinical record was reviewed. The resident was admitted to the facility onXXXXXXX17. He had diagnoses of paranoid schizophrenia (is a kind of mental illness, in which the mind does not agree with reality and affects the mind and the behavior) and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) disorder.
Review of Resident 1's Minimum Data Set (MDS, assessment tool) dated 4/8/17, indicated he had severe cognitive impairment.
Review of Resident 1's Progress Notes dated 5/18/17, at 5:50 a.m., indicated the resident was missing and the staff performed a facility search but could not locate the resident.
Review of Resident 1's Progress Notes dated 5/18/17, at 7:30 a.m., indicated the resident was found and brought back to the facility by two policemen. There was no documented evidence the elopement was reported to the CDPH.
During an interview with licensed vocational nurse A (LVN A) on 6/7/17, at 1:50 p.m., she stated on 5/18/17, around 6 a.m., Resident 1 was missing. LVN A stated she called the police station and the director of nursing (DON). LVN A stated she did not know if the DON reported the resident's elopement to the CDPH.
During an interview with licensed vocational nurse B (LVN B) on 6/1/17, at 1:20 p.m., she stated Resident 1's elopement was considered an unusual occurrence and should be reported to the CDPH.
During an interview with the Ombudsman on 6/8/17, at 8:20 a.m., she stated Resident 1's elopement was reported by the facility to the Ombudsman on 5/25/17.
Review of the facility's policy "Elopement/Wandering Resident" dated 12/2014, indicated the administrator/designee notifies all agencies in accordance with state and federal requirements and laws.
Review of the facility's policy "Unusual Occurrences" dated 04/2012, indicated occurrences that constitute an interference with facility operations that affect the welfare, safety, or health of residents must be reported to the Department and Ombudsman within 24 hours of its occurrence. Report will be initiated by calling the CDPH by phone or fax.
Therefore, the facility failed to implement their policy and procedure in reporting an elopement (to leave a long term care facility without permission) and unusual occurrence for Resident 1, when the resident left the facility without the knowledge of the staff. Resident 1's elopement was not reported to the California Department of Public Health (CDPH).
The violation of this regulation had a direct or immediate relationship to the health, safety, or security of the patients. |
| 080000030 |
ESCONDIDO POST ACUTE REHAB |
080009842 |
B |
17-Apr-13 |
14N311 |
14226 |
F323 ?483.25 (h) Accidents The facility must ensure that (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to: Provide adequate supervision to prevent 2 sampled residents (A and B), from leaving the facility without the knowledge of the staff; Ensure that Residents A and B wore identification bands, per the facility policy; Ensure that staff responsible for Resident B were aware of the physician's order for the resident not to leave the facility without a responsible party; Ensure the licensed nurses (LN) were familiar with the needs and care plans for residents identified as wanderers; and Ensure residents with wanderguards were still in the facility when the staff discovered the wanderguard alarm at the front door was not working. As a result: Resident A, who was confused with a history of wandering, was seen on 1/20/13, wandering the streets, 1.3 miles from the facility, with his front wheel walker, and his pants around his ankles. The resident had no identification and when the police determined his residence, after phone calls to local facilities, the staff did not know the resident was missing; and Resident B frequently left the facility without a responsible party and on 2/21/12 was picked up by the police in a parking lot 2.2 miles from the facility, 5 hours after he was last seen in the facility.1. Resident A was admitted to the facility on 12/14/12, with diagnoses which included dementia (memory problem), per the Record of Admission. Resident A's clinical record was reviewed on 3/20/13 and 3/26/13. A facility licensed nurse (LN) documented in the admission assessment that Resident A had a history of wandering, wandered aimlessly about the facility and/or exhibited night wandering, and was physically able to leave the building on his own. Additionally, per the assessment, Resident A required the use of an assistive device, such as a walker, when ambulating. According to the Elopement Risk care plan, initiated on 12/16/12, Resident A wandered with no rational purpose, seemingly oblivious to safety needs. Additionally, per the plan, Resident A needed to be checked frequently and had a wanderguard bracelet on his left wrist (a device that set off an alarm when a resident attempted to exit through a monitored doorway). On 2/8/13, Certified Nursing Assistant (CNA) 1 documented on the back of Resident A's CNA Activities of Daily Living (ADL) tracking form, "Resident multiple times tried elopement." CNA 1 documented he notified the charge nurse. There was no documentation in the clinical record to show the facility staff addressed Resident A's elopement attempts on 2/8/13. Twelve days later, on 2/20/13 at 4:30 P.M., LN 1 documented in the Nurse's Notes that Resident A, "Came in escorted by police." At that time, no one in the facility was aware Resident A was missing. The Director of Nursing (DON) was interviewed on 2/26/13 at 8:05 A.M., and was unable to explain how Resident A got out of the facility on 2/20/13, or how staff were unaware he was missing.On 2/20/13, the facility staff developed a short term care plan for Resident A's elopement. The plan included monitoring Resident A every 15 minutes for 72 hours; however, there was no plan to protect Resident A from wandering after 72 hours.On 2/26/13 at 2:45 P.M., the Assistant Director of Nursing (ADON) stated that on 2/20/13 when Resident A eloped, she discovered at 3:45 P.M., the wanderguard alarm at the front door was not working, but failed to check to see if residents with wanderguards were missing.On 2/27/13 at 1:07 P.M., Police Officer (PO) 1 stated in a telephone interview, someone in the community notified the police department at 4:20 P.M. on 2/20/13, that a man was walking down the street with a walker, and had his pants around his ankles. PO 1 stated Resident A was found at a location, "A long way away," and, "Must have been gone a long time." PO 1 stated in the same interview, that Resident A did not have any identification, and was unable to say where he lived. PO 1 said the police officers who located Resident A then telephoned local skilled nursing facilities and found Resident A lived at the facility. PO 1 said the officers returned Resident A to the facility at 5:17 P.M., not 4:30 P.M. as LN 1 documented. According to the undated facility Elopement Prevention and Search policy, "All residents at risk for wandering must maintain accurate identification at all times including the name of the resident, name and phone number of the facility..." On 3/21/13 while maintenance was repairing the front door and the wanderguard was disabled, Resident A eloped again. According to the facility Maintenance Director, Resident A walked across the parking lot to the grassy area next to the sidewalk before a CNA, who was returning from lunch, intercepted him and brought him back to the facility. A licensed nurse documented in the Nurses Notes at that time, "Resident found by CNA walking around near the parking lot."Resident A's room was on Station 4, which was located at the very back of the facility. Resident A passed 4 nursing stations, as well as the receptionist's desk, to exit out the front door. On 3/21/13, a second short term care plan was developed for this incident and the intervention was, "Frequent visual checks." The plan did not specify how often the visual checks should occur. The ADON stated on 3/26/13 at 5:05 P.M., Resident A walked out of the facility on 3/21/13 while all the Station 4 CNAs were busy working.On 3/27/13 at 9:37 A.M., the facility receptionist stated one of her duties was to monitor the front door and intercept those residents who wore a wanderguard bracelet and attempted to exit the front door. The receptionist said that on 3/21/13, the day the front door wanderguard was disabled and Resident A exited the front door, she had stepped away from her desk. LN 1 was interviewed by telephone on 3/27/13 at 4:15 P.M. LN 1 said he was assigned to Resident A's care on 2/20/13, which was the date of the first elopement.LN 1 stated he did not see Resident A when he did his initial rounds that day.LN 1 said he asked CNA 1 about Resident A's whereabouts and was told that Resident A was in the rose garden. LN 1 stated he, "Took the CNA's word."LN 1 stated, during the same interview, he worked on Station 4 approximately 3 - 4 times per month and was responsible for 46 total residents. LN 1 could not identify which residents on that station were, "Wanderers." LN 1 stated there were a lot of residents who were a fall risk, wandered, were confused and had aggression. LN 1 said, "It's overwhelming," and he was, "Not surprised Resident A got out." LN 1 also stated, "We did not know he was gone." LN 1 added he was so busy in that station that, "They (the residents) get by without noticing."According to the facility Resident with Wanderguard list, updated 3/12/13, the facility had a total of 24 residents who were an elopement risk and had a wanderguard bracelet. Eight of the 24 residents were housed on Station 4. CNA 1 was re-interviewed on 3/13/13 at 3:20 P.M. CNA 1 was in the Station 4 hallway and identified 4 different residents who had immediate needs at that same time. CNA 1 was the only CNA observed on Station 4 and no other CNA could be located. CNA 1 said there were 2 other CNAs assigned to Station 4; however, one was busy passing ice to residents and the other was busy passing nourishments. CNA 1 stated he was the only available CNA to assist residents with needs for Station 4 at that time. CNA 1 said, "You can see how it would be hard to keep track of the residents." On 3/13/13, the staffing assignments for the day were reviewed. There were 46 residents who lived on Station 4. On the evening shift, there was one LN assigned to pass medications and oversee the care of the 46 residents. There were 3 CNAs assigned to provide care to 43 residents (3 of the 46 residents were assigned to a CNA on Station 3). LN 2 stated on 3/13/13 at 3:25 P.M., that 46 residents was a lot to manage and, "It would be very easy to lose track of a resident when you have so many." LN 4, who was a Station 4 Unit Manager, stated in an interview on 3/20/13 at 6:05 P.M., "We have major problems with staffing levels." Additionally, LN 4 said it was difficult to, "Meet the needs and know where the residents (sic) are at all times." LN 4 said there were half the number of LNs for the evening shift as were scheduled for the day shift. The Director of Staff Development stated on 4/11/13 at 3:30 P.M., that 46 residents to care for on Station 4 was a lot and that the staffing for the station was unreasonable. According to the facility Staffing policy, revised 2007, "Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met." On 3/27/13 at 3:30 P.M., LN 3, who worked the Station 4 evening shift, was able to identify 2 of the 8 residents who were an elopement risk and had a wanderguard bracelet. LN 3 was unsure which residents, who were under her care, required monitoring for wandering. During an interview on 4/11/13 at 5:10 P.M., the Administrator stated the facility staff raised concerns that there was not enough staffing . The Administrator stated she disagreed with the staff. The Administrator stated she did not feel there were inadequate numbers of staff, but felt that problems with staffing were related to personality conflicts between staff members. 1.Resident B was admitted to the facility on 11/9/10, with diagnoses which included dementia, psychosis, and schizoaffective disorder. Resident B was conserved (deemed by the court as incapable of caring for self), and his responsible party was a public guardian, per the Record of Admission. Resident B was cognitively intact, per the Minimum Data Set assessment, dated 1/7/13. LN 8 stated in an interview on 2/26/13 at 10:40 A.M., Resident B was previously allowed to leave the facility by himself, but sustained a fall when he went outside the facility on 2/27/12. On that date, Resident B's physician ordered, "May go out on pass only with responsible party." Between 4/9/12 and 6/19/12, Resident B signed himself out and left the facility without his responsible party, against physician orders, on 6 occasions, per the Release of Responsibility for Leave of Absence forms. On 2/21/13 at 11 P.M., LN 6 documented in the Nurses Notes, she was informed at 8 P.M., Resident B couldn't be located when LN 7 went to pass medication due at 5 P.M. LN 6 documented she notified Resident B's physician at 10 P.M. which was 5 hours after the facility staff identified Resident B was missing. According to the documentation, the police were notified at 10:25 P.M, which was over 7 hours after Resident B was last seen in the facility. The police told facility staff Resident B was taken to a local hospital. LN 6 stated in an interview on 2/26/13 at 5:07 P.M., she last observed Resident B in the facility at 3:10 P.M. on 2/21/13.On 2/22/13 at 2 A.M., upon Resident B's return to the facility, LN 10 documented Resident B had a blood blister and abrasions to his feet. PO 1 stated during a telephone interview on 2/27/13 at 12:26 P.M., the police received a call at 8:25 P.M. on 2/21/13, that there was, "A drunk at an auto dealer (sic)." PO 1 said Resident B was found over 2 miles from the facility on the opposite side of a major interstate freeway, confused, and with no identification. According to PO 1, Resident B could not provide any information about where he lived. PO 1 stated Resident B was taken to a local hospital at 9 P.M. that night. CNA 2 stated in an interview on 2/26/13 at 5 P.M., when she arrived for her shift on 2/21/13 at 3 P.M., she did not see Resident B. CNA 2 stated she thought Resident B was at the store because, "He always goes out." CNA 2 said whenever Resident B requested to go to the store she, "Let him." CNA 2 said she notified the LN on 2/21/13 at 5:30 P.M., when she was unable to locate Resident B. CNA 2 stated she was unaware Resident B was not supposed to leave the facility without his responsible party. LN 7 stated on 3/27/13 at 11:30 A.M., when she started her evening shift on 2/21/13, she did not see Resident B. LN 7 said she was unable to locate Resident B between 5 and 5:30 P.M., when she went to pass medication. When she questioned CNA 2 regarding Resident B's whereabouts, CNA 2 told her Resident B, "Goes out by himself and he will be back soon." LN 7 stated she, "Depended," on her CNAs to know more about the residents than she did and was unaware Resident B was not supposed to leave the facility without his responsible party. LN 7 stated she became worried about Resident B's whereabouts around 8:30 P.M, which was 5 hours after the start of the shift.LN 6 stated in an interview on 3/27/13 at 11:45 A.M., LN 7 notified her at 8 P.M. that Resident B was missing from the facility. LN 6 stated the police were not notified until 10:25 P.M., because she was waiting for a staff member, who was searching for Resident B to come back. When the police were finally called, the police told the facility they took Resident B to a local hospital. LN 6 stated, "It was very busy that night."The facility failed to ensure sufficient staff were scheduled to monitor and supervise residents identified as wanderers, and were at risk for elopement.The facility staff allowed Resident B to leave the facility against physician orders. The nursing staff were unaware of which residents required monitoring for wandering; The facility further failed to ensure residents with wanderguard were still in the facility at the time the wanderguard alarm at the front door was found to be broken and failed to ensure residents wore identification bands, per facility policy. As a result, Resident A and B eloped from the facility, without knowledge of the staff. Resident A was found 1.3 miles from the facility, without identification, was returned by the police, and then subsequently eloped a 2nd time, one month later. Resident B eloped from the facility, without identification, was found by the police hours later, 2.2 miles from the facility, and was taken to a local hospital for his protection. |
| 080000030 |
ESCONDIDO POST ACUTE REHAB |
080010278 |
B |
26-Nov-13 |
82DL11 |
8077 |
F 309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure a licensed nurse (LN 1) immediately assessed 1 sampled resident (5) when she found him unresponsive and lying on the floor of his room.In addition, the facility also failed to ensure 1 of 3 emergency carts had an Ambu bag (a device used to assist with breathing in an emergency) available for use to assist with cardiopulmonary (heart and lung) resuscitation (CPR).As a result, there was a delay in initiating life saving measures such as CPR, in accordance with the Resident 5's wishes.Resident 5, a 75 year old, was admitted to the facility on 10/6/13, with diagnoses including atrial fibrillation (irregular and often fast heart beat), and congestive heart failure (heart is unable to supply the body with enough blood), per the Record of Admission. Resident 5's clinical record was reviewed on 10/17/13. The record contained a History and Physical (H & P), dated 10/2/13, from the hospital prior to admission to the facility. Per the report, Resident 5 had a right below the knee amputation (removal of a limb) and a chronic (long standing) left foot wound. Resident 5 had the capacity to understand and make decisions, wanted full cardiopulmonary (heart and lung) resuscitation (CPR) and full treatment in the event of an emergency, per the Physician Orders for Life-Sustaining Treatment document, dated 10/6/13. The document was signed by Resident 5 and his physician. According to the Skilled Licensed Nurse (LN) notes, dated 10/14/13, Resident 5 was at risk for falls, and was not able to transfer himself out of bed independently and required the assistance of 2+ persons to do so. On 10/14/13, at 11:30 P.M., LN 1 documented in the Nurse's Notes she attempted to administer a nicotine patch (a patch used to assist in quitting smoking), to Resident 5 and found him, "Lying on the floor on his side unresponsive." There was no documentation to show LN 1 immediately assessed Resident 5 to determine why he was lying on the floor and unresponsive. Ten minutes later, at 11:40 P.M., LN 1 documented, "911 called & CPR done in the room." LN 1 stated in an interview on 10/17/13 at 3:45 P.M., she went to Resident 5's room at 11:30 P.M. on 10/14/13, to administer a nicotine patch. LN 1 said, when she entered the room, Resident 5 was lying on the floor, on his right side, facing the window. LN 1 said she called out Resident 5's name twice, and told him she was there to apply his patch. LN 1 said Resident 5 did not respond, and she assumed he was sleeping, and left him on the floor. LN 1 said she did not check to see if Resident 5 was breathing or perform any other assessment at that time. LN 1 said she then left the room, located Resident 5's assigned Certified Nursing Assistant (CNA 1) and asked her, "Why is he (Resident 5) sleeping on the floor?"According to the facility policy, entitled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), revised December 2006, "If an individual is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR...exists for that individual; or b. There are obvious signs of irreversible death..." When LN 1 found Resident 5 unresponsive she failed to check for a pulse, as required per facility policy, to determine whether or not she should initiate CPR in accordance with the resident's wishes.CNA 1 was interviewed by telephone on 11/4/13 at 3:09 P.M. CNA 1 stated, on 10/14/13, as she was doing rounds, she came out of another resident's room and was approached by LN 1. CNA 1 said LN 1 told her, "Hey CNA 1 (sic), your patient (resident) is sleeping on the floor." CNA 1 said she told LN 1 at that time, "That can't be, he's an amputee." CNA 1 said she then went to Resident 5's room, and found him lying on the floor. CNA 1 said Resident 5 was unresponsive after she called out his name many times. CNA 1 said she yelled out to LN 1, "He's unresponsive - call 911." CNA 1 said LN 1 came into the room, checked Resident 5 for a pulse, couldn't find one, and left. CNA 1 said she heard a supervisor call a, "Code Red," (an announcement of a fire) on the overhead paging system, and staff arrived carrying fire extinguishers. LN 2 was interviewed on 11/4/13 at 3:54 P.M. LN 2 said she was working on Station 4, located at the back of the facility, on the evening of 10/14/13. LN 2 said she heard a Code Red paged to nursing Station 1 which was at the front of the facility. LN 2 stated when she arrived at Resident 5's room, the resident was lying on the floor. LN 2 said she checked Resident 5 for a pulse, and was unable to locate one. LN 2 stated she started chest compressions (a component of CPR where pushing down on the chest wall helps to circulate the blood).LN 2 said when she arrived at Resident 5's room, there were 3 CNAs present in the room, and none were performing CPR. LN 2 said when staff realized it was not a Code Red, but a Code Blue (medical emergency), somebody brought the emergency cart in to the room. LN 2 said the Ambu bag (a bag to assist in providing breaths during CPR) which should have been on the cart, was missing.LN 2 said CNA 2 took over the chest compressions while she ran to look for an Ambu bag and located one on Nursing Station 2, which was roughly 157 feet away, around the corner and down the hall from Resident 5's room. According to the 2010 American Heart Association CPR guidelines,..."Rescuers should start CPR immediately if the adult victim is unresponsive and not breathing...CPR improves the victim's chance of survival by providing heart and brain circulation."Additionally, per the guidelines, "Rescuers who are able should add ventilations (breaths) to chest compressions. Highly trained rescuers working together should coordinate their care and perform chest compressions as well as ventilations in a team-based approach." A local fire department clerk stated in an interview on 11/7/13 at 8:30 A.M., the facility called 911 at 11:38 P.M., which was 8 minutes after LN 1 said and documented, she left Resident 5 lying on the floor of his room. On 11/13/13, the facility provided a list of the contents which should be stocked on the emergency carts. Included on the list, was an Ambu bag. The facility Vice President of Quality (VPQ) stated in a telephone interview on 11/13/13 at 4:50 P.M., it was the responsibility of the night shift nursing staff to check the contents of the emergency carts in each nursing station to ensure all equipment was present. The VPQ stated the facility did not have a policy for checking emergency carts or any documentation to show the carts were checked. On 10/14/13, LN 1 found Resident 5 lying on the floor and unresponsive, when she went to administer a medication. LN 1 failed to assess the resident to determine why he was on the floor and why he didn't respond. LN 1 left the resident on the floor, without providing any assistance. It wasn't until CNA 1 went to Resident 5's room after LN 1 told her the resident was, "Sleeping on the floor," that staff were alerted to the medical emergency. Staff initially responded with fire extinguishers when a Code Red was called in error. LN 2, who was working on another nursing Station at the back of the building, was the first LN to initiate CPR. When LN 2 attempted to implement the use of an Ambu bag breathing assistance as part of the CPR process, it was missing from the emergency cart.When paramedics responded to the 911 call, received at 11:38 P.M. and arrived at the facility, they assumed responsibility of administering CPR to Resident 5. The resident failed to respond and was pronounced dead at the scene.The above violation had a direct relationship to the health, safety, or security of residents. |
| 080000030 |
ESCONDIDO POST ACUTE REHAB |
080010451 |
A |
13-Feb-14 |
D6TF11 |
11562 |
F 309 483.25Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. An unannounced visit was made to the facility to investigate Complaint Number CA00377568 on 11/21/13. The complaint alleged the facility failed to remove staples from a surgical incision for over 2 months which caused a severe infection. As a result of the investigation, the Department determined the facility failed to: 1. Obtain a physician's progress note in a timely manner, and perform skin assessments of a surgical site for Resident 1; and 2. Provide treatment as prescribed by the treating physician. As a result of these failures, 31 staples were retained in Resident 1's left hip surgical incision site for 72 days (usually removed 7 to 14 days after surgery, per the surgeon) after the surgeon ordered the removal of the staples.In addition, 94 year old Resident 1's incision dehisced (split open), and he underwent a 2nd surgical operation for irrigation, debridement (flush and remove dead tissue from a wound), in the left hip incision site under general anesthesia (use of medications to make a person unconscious and unable to feel pain during a surgical procedure). The resident remained in the hospital for 4 days and was treated with a 6 week course of antibiotics for an infection at the incision site. Resident 1 was admitted to the facility on 4/20/05, according to the Record of Admission. Resident 1's clinical record was reviewed on 11/21/13. Resident 1 sustained a fall with a fracture while residing in the facility. The resident was transferred to the hospital, and underwent a left hip hemiarthroplasty (surgical repair of hip fracture) on 8/22/13, per the hospital physician's Operative Report, dated 9/3/13. Resident 1 returned to the facility on 8/28/13, with diagnoses including status post (after) fall with hip hemiarthroplasty, and anemia (low red blood cells, which assist in carrying oxygen throughout the body), according to the Record of Admission. On 9/3/13, Resident 1 was seen in his surgeon's office and returned to the facility with orders for, "Suture/staples removal (L) (left) hip." On 9/3/13 at 3:30 P.M., Licensed Nurse (LN) 1 documented in the Nurses Notes, "Back from...appt (appointment)...sutures/staples were removed..." LN 1 stated in an interview on 11/26/13 at 4:45 P.M., she interpreted the surgeon's orders as the sutures/staples were removed. LN 1 said when a resident had surgical staples removed she was supposed to re-assess the skin to ensure wound healing, and to monitor for signs and symptoms of infection.LN 1 said when a resident went out of the facility for a physician's appointment she was supposed to obtain a progress note from the physician. LN 1 said if a resident returned from an appointment without a progress note, she was supposed to follow up with the physician to obtain one or place the information on a calendar for another nurse to follow up.LN 1 also said she did not assess Resident 1's incision site when he returned from his surgeon's appointment, and did not obtain the physician's progress note or place it on the calendar for another LN to follow-up and obtain it. There was no documentation in the resident's clinical record of a progress note for the surgeon's office visit on 9/3/13.According to the American Health Information Management Association's Long-Term Care Health Information Practice and Documentation Guidelines, updated 10/2010, "If a resident requires a consultation with a specialist,...the medical record must contain documentation of the visit, progress notes and recommendations." Also, "For consultations that occur out of the facility, a separate referral/consultation record can be sent to the physician obtain documentation for the resident's long-term care record." According the Status Post Left Hip Hemiarthroplasty (after left hip surgery) care plan, dated 9/3/13, the facility staff should monitor Resident 1 for signs and symptoms of infection.Between 9/5/13 and 9/15/13, the facility LNs documented on 4 separate occasions that Resident 1 did not have signs and symptoms of infection and/or complications at his left hip surgical site. In an interview on 11/21/13 at 2:35 P.M., LN 2 stated she documented 3 of 4 nursing notes which reflected Resident 1 did not have signs and symptoms of infection and/or complications at his left hip surgical incision site. LN 2 said she never looked at the hip wound and documented her assessment based on Resident 1's lack of fever or complaints of pain. LN 2 said, "You can't say there were no signs of symptoms of infection if you don't look at it (the wound)." According to the facility policy, entitled, Surgery-Related (Pre- and Postoperative) Management Clinical Protocol, revised, April 2009, "The staff...will monitor for, and address, postoperative risks and complications such as infections...failure of surgical wounds to heal...."According to the facility policy, entitled, Pressure Ulcer Risk Assessment, revised March 2005, "Skin will be assessed...on a weekly basis or more frequently if indicated." There were nine Weekly Progress Note forms (a summary completed once per week which would reflect all aspects of a resident's care), dated between 9/8/13 and 11/10/13, in Resident 1's clinical record.Each form had a section to document a skin assessment, which included a sub-section for the documentation of a surgical wound assessment.On 10/13/13, LN 6 documented in the Skin Assessment section of the Weekly Progress Note. The surgical wound assessment section was blank. LN 6 stated on 12/5/13 at 2:24 P.M., she did not conduct a skin assessment because Resident 1 refused. LN 6 said she was supposed to check a surgical incision site, but could not recall why she did not check Resident 1's incision. LN 6 said she should have documented Resident 1 refused a skin assessment. On 10/27/13, LN 4 documented in the Skin Assessment section of the Weekly Progress Note. The surgical wound assessment section was blank. LN 4 stated on 11/21/13 at 3:25 P.M., a head to toe, full body inspection of the skin was supposed to be evaluated as part of the weekly summary documentation. LN 4 said she completed the weekly summary, but did not inspect Resident 1's skin because he was sleeping. On 11/3/13, LN 3 documented in the Skin Assessment section of the Weekly Progress Note that Resident 1's skin was, "Intact (healthy skin in which there are no breaks, scrapes, cuts, or abnormal openings)." LN 3 stated during an interview on 11/21/13 at 1:45 P.M., Resident 1 refused to have his skin checked on 11/3/13.LN 3 said that on 11/3/13, she reviewed Resident 1's treatment sheets (forms used to document treatments provided, such as treatments to the skin), the Certified Nursing Assistants (CNA) documentation forms, which included shower sheets (forms utilized by the CNAs to document care and skin evaluations during showers).LN 3 said she documented on the Weekly Progress Note that Resident 1's skin was, "Intact," because Resident 1 denied any skin problems, there was no documentation of any skin treatments, and no documentation by the CNAs that Resident 1 had any skin issues. LN 3 said she should have documented Resident 1 refused a skin check. On 11/10/13, LN 5 documented in the Skin Assessment section of the Weekly Progress Note. The surgical wound assessment section was blank. LN 5 stated during an interview on 11/21/13 at 3:50 P.M., she was supposed to look at Resident 1's skin from head to toe. LN 5 said she did not do a full body skin assessment and only looked at the parts of his body that were uncovered, such as his arms and face, etc. On 11/14/13, Resident 1 sustained a fall during an outing from the facility, per a Change in Condition - Post Fall/Trauma report. Per the report, Resident 1 had a moderate amount of bleeding on the left hip surgical site. LN 7 stated on 11/26/13 at 3:59 P.M., she did a full body assessment on Resident 1 after his fall on 11/14/13. LN 7 said when she viewed Resident 1's left hip surgical incision site after the fall and saw the staples, she reviewed his clinical record, saw the order for staple removal and removed a total of 31 staples.LN 7 said she observed roughly 1 - 1.5 inches of a dehisced area of the incision at that time. The facility sent Resident 1 to his surgeon's office (MD 1) on 11/15/13. The physician transferred Resident 1 to the hospital directly from his office because upon assessment of Resident 1's incision, the physician observed the incision site was dehisced 3 inches, and he suspected it was infected.According to a hospital Operative Report, dated 11/15/13, Resident 1 underwent a left hip open irrigation and debridement, under general anesthesia. According to the report, the dead tissue in Resident 1's hip wound extended into a serous (clear fluid) collection in a bursa (fluid-filled sacs or cavities positioned in joints throughout the body), and an antibiotic was started. On 11/20/13, 5 days after Resident 1 was transferred to the hospital, the facility obtained Resident 1's surgeon's progress note, dated 9/3/13, per the fax notation at the top of the page.Had the facility obtained the progress note in a timely manner, they could have identified the surgeon did not remove the staples, because the physician documented in the note Resident 1's pants were never removed during the office visit. On 11/26/13 at 5:25 P.M., the facility Administrator and Vice President of Quality (VPQ) were interviewed. The VPQ stated, when a resident was sent out of the facility for a physician's appointment, it was expected that a progress note, as well as physician orders, should be obtained from the outside physician.The VPQ also stated, if orders and a progress note were not received when the resident returned to the facility, the LNs should follow up with the physician and obtain them. Both said, "It's a standard of practice (level of performance or an expectation for professional intervention, formulated by professional organizations based upon current scientific knowledge and clinical expertise)." MD 1 stated in an interview on 12/17/13 at 11:17 A.M., the facility did not remove the staples as he ordered on 9/3/13. MD 1 said the facility staff should have assessed and monitored Resident 1's incision site and should have identified the staples remained in his hip. MD 1 said, as a result of the staples remaining in place for an extended period of time, the resident developed a seroma (a pocket of clear serous fluid) and MRSA (Methicillin-resistant Staphylococcus aureus-a type of bacteria that is resistant to the antibiotics commonly used to treat ordinary infections) infection. The facility's failure to obtain the 9/3/13 surgeon's progress note, which reflected the surgeon never removed Resident 1's pants, resulted in the misinterpretation by the LN of the surgeon's order for removal of the staples. The facility failed to ensure the LNs monitored Resident 1's wound/incision site as required per facility policy, and the failure to follow the plan of care resulted in the failure to identify staples remained in Resident 1's left hip incision site for 72 days after the surgeon ordered the removal of the staples. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 080000030 |
ESCONDIDO POST ACUTE REHAB |
080010680 |
B |
01-May-14 |
Z2X911 |
2857 |
California Health and Safety Code Section 1418.91 (a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a residentof the facility to the department immediately, or within 24 hours. (b) A failure to comply with requirements of this section shall be a class "B" violation. The facility failed to report an allegation of abuse to the Department within 24 hours, as required per regulation and facility policy, for 1 sampled patient (1). As a result, there was a potential for a delay in the investigation of the allegation by the Department. Patient 1 was admitted to the facility on 11/9/14. Patient 1 was transferred to the hospital on 11/15/13, and returned to the facility on 11/19/13, with diagnoses including status post (after) cerebral vascular accident (stroke - sudden death of a portion of the brain cells due to a lack of oxygen), per the Record of Admission. Patient 1's clinical record was reviewed on 12/11/13. On 11/20/13, the physician documented in the history and physical, Patient 1 was capable and independent in making her own decisions. On 12/7/13, the facility social worker (SW) documented on the Cognition/Communication care plan, " Pt (patient) made accusation that she was, 'bitten,' and someone put a blanket over her head." The SW wrote in the the Goals section of the care plan, "Investigate with full body check..." According to the facility policy, entitled, Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal or State Laws Involving...Abuse...., "This facility will ensure that all, 'alleged' or 'suspected' abuse...are reported immediately to the Executive Director or designee of the facility." Also, per the policy, "The Administrator of the facility shall report all 'alleged' or 'suspected' abuse of a resident to the Department (sic)...immediately, or within 24 hrs (hours). The facility SW was interviewed on 1/9/14 at 4:35 P.M. The SW stated Patient 1's daughter reported to her on 12/7/13 that her mother (Patient 1) told her someone put a blanket over her head. The SW said that during the investigation of the event she learned that Patient 1 also alleged someone bit her. The SW said she knew she should have reported the allegation to the Department and discussed reporting the allegation of abuse with the facility Administrator, who was the abuse coordinator. The SW said the facility Administrator told her she didn't need to report the allegation to the Department. The SW said she should not have allowed the Administrator to talk her out of reporting the allegation of abuse. Facility staff, including the Administrator who was the Abuse Coordinator, became aware of an allegation of abuse on 12/7/13, but failed to report the allegation to the Department until 12/9/13, which was more than 24 hours later. |
| 080000030 |
ESCONDIDO POST ACUTE REHAB |
080010694 |
B |
01-May-14 |
5MRR11 |
9259 |
483.13(c) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This Requirement is not met as evidenced by: The facility failed to follow their policies and procedures for investigating, assessing, and protecting Resident A and Resident B after two allegations of abuse were made by each resident: 1. Resident A accused CNA 1 of hitting her [Resident A] several times with an open hand. The facility failed to investigate and assess Resident A after the allegation was made, and failed to protect Resident A and other residents after the allegation of abuse and. 2. Resident B accused CNA 2 of wetting and twisting a wet towel and hitting Resident B in the face. The facility also failed to conduct a thorough investigation, and failed to protect Resident B and other residents, when Resident B made an allegation of abuse by a CNA 2. The facility also failed to suspend the CNA 2 pending an investigation and by allowing the alleged abuser to continue providing care for 9 residents.1. Resident A was a 62 year old female admitted to the facility on 9/17/13, per the Record of Admission. Resident A was transferred from an acute care hospital with diagnoses that included status post (after) cerebral vascular accident (stroke-loss of brain function due to a disturbance in the blood supply to the brain).According to the most recent Minimum Data Set Assessment (a standardized assessment to determine level of function) dated 2/1/13, Resident A's Cognitive Patterns score (to determine resident attention, orientation, and ability to register and recall information) was 13 out of 15. (a score of 13 and above=cognitively intact).On 3/12/14 at 1:45 P.M., the Social Services Director (SSD) was interviewed. He stated he was interacting with Resident A in planning her upcoming discharge from the facility. The SSD stated that on 3/7/14, Resident A told him that earlier that morning at approximately 2 A.M. Certified Nursing Assistant 1 (CNA 1) hit her several times with an open hand. The SSD stated that he immediately reported the allegation to the acting Director of Nursing (DON), Ombudsman, the Department, and the police. On 3/12/14 at 2:55 P.M. Resident A was interviewed. Resident A stated that CNA 1 hit her with an open hand on her chest and thigh.On 3/27/14 at 3:30 P.M., an interview was conducted with the Vice President of Quality (VPQ) regarding the facility's investigation of the alleged abuse. When the VPQ was asked for documentation of the investigation he stated "I don't have it". When asked about the "Verification of Investigation" form referred to in the facility policy and procedure the VPQ stated "I didn't do it". The VPQ acknowledged that there was not any documentation of an investigation of this incident. On 4/02/14 at 2:45 P.M., the Unit Manager (UM) was interviewed. UM stated she did not have any knowledge of Resident A's allegation of abuse. UM further said, if she knew, she would had interviewed the resident and documented her findings in the nurse's notes.On 4/02/14 at 3:10 P.M., Licensed Nurse 1 (LN1) was interviewed via telephone. LN 1 stated she was the charge nurse on 3/7/14. LN 1 said she did not have any knowledge that Resident A alleged any abuse. LN 1 stated she did not do a physical assessment or update the care plan because she was not aware of the allegation.On 4/1/14 at 3:45 P.M., the VPQ was again interviewed. He stated he was the acting DON at the time of the alleged abuse of Resident A. The VPQ stated he informed the charge nurse that the resident alleged that a CNA hit Resident A. The VPQ was not able to locate any nursing documentation related to alleged abuse in the resident's medical record. The VPQ acknowledged that where was no documentation of a nursing assessment or an update in the care plan after the alleged abuse. According to the facility policy and procedure entitled Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal or State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, dated July 2009: 1) "The documentation of the investigation shall be kept in the Administrator's office in an administrative file...The attached Verification of Investigation form shall be completed after the investigation is complete and provided to survey agencies when requested..." 2) "The D.O.N., or his/her designee, shall initiate a care plan to reflect the resident's condition and measure to be taken to prevent recurrence, where appropriate."2. Resident B, 84 year old male, was readmitted to the facility on 3/11/13 with diagnoses that included depression and dementia, according to the Record of Admission. According to the Minimum Data Set (MDS) assessment dated 2/26/14, the facility assessed Resident B with mild-moderate impaired cognitive skills. Resident B was dependent on staff for bathing, dressing, toilet use, and personal hygiene.Resident B stated during an interviewed on 3/27/14 at 8:13 A.M. "CNA 2 wet a towel, twisted it and hit me across my eyes and almost blinded me." The Unit Manager (UM) 1 was interviewed at the facility on 3/27/14 at 8:55 A.M. UM 1 stated that on 3/20/14 CNA 2 reported to her that Resident B had made an allegation of abuse. UM 1 said CNA 2 reported to her that Resident B accused CNA 2 of hitting him. UM 1 said she conducted the investigation and found the allegation to be false. UM 1 further said, there were two other CNAs in the shower room while CNA 2 was with Resident B and were witness to the allegation being false. The shower room had 3 stalls separated by walls and curtains. UM 1 said the abuse policy speaks to suspending the alleged abuser, but since there were two witnesses, suspension was not necessary. UM 1 further stated she did not interview other residents that CNA 2 was assigned to that day. CNA 2 was assigned to 9 residents. UM 1 said CNA 2 only showered Resident B that day. CNA 3 stated during an interview on 3/27/14 at 9:45 A.M., "I was in there (shower room), but not the whole time." CNA 3 said, "UM 1 did not ask if I was there the whole time. I did tell her that while I was there, I did not see anything. I was there for a few minutes; I was finishing my resident up and then left with him." CNA 4 stated during an interview on 3/27/14 at 9:50 A.M., that UM 1 did not ask if she was in the shower room the whole time. CNA 4 stated, "I left before CNA 2 finished. When I returned with another resident, CNA 2 was finished with Resident B." The UM 1 was again interviewed on 3/27/14 at 10 A.M. UM 1 said she did not ask if the other two CNAs were in the shower the whole time. She further said she did not interview other residents because, "He [CNA 2] only showered 1 resident that day." UM 1 said she was surprised to find that CNA 3 and CNA 4 had stated that they were not in the shower room the whole time CNA 2 showered Resident B.The Administrator was interviewed on 4/02/14 at 2:40 P.M. The Administrator said the allegation of abuse was reported to her but that UM 1 had conducted a complete investigation and said that the alleged abuse did not happen. The Administrator acknowledged the facility's policy and procedure indicated the staff member would be suspended until a thorough investigation could be conducted. The Administrator said she was told that there was no way the alleged abuse occurred because there were two witnesses. CNA 2 stated during an interview on 4/8/14 at 10:40 A.M., "I was giving him a shower. He was trying to get up and I was trying to hold him. After the shower he said I hit him." CNA 2 further stated, "We all three (CNA's 2, 3, and 4) were in the shower room at the same time, actually, I finished first before them. I showered eight residents that day." The facility's policy and procedure, California Policies and Procedures Regarding Investigation... dated, July 2009; "The facility will investigate each such alleged violation thoroughly and report the results of all investigations to the executive director or designee." "Protection: If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigatory suspension while completing the investigation..." The facility failed to follow their policies and procedures after an allegation of abuse was made by Resident A and Resident B. The facility failed to conduct an investigation into the allegation of abuse made by Resident A. The facility also failed to ensure a thorough investigation was conducted regarding the allegations of abuse made by Resident B. The facility failed to ensure that CNA 2 was removed from direct patient care during the investigation of the abuse allegations made by Resident B which allowed the alleged abuser to continue to care for other residents unsupervised within the facility.As a result, the facility failed to protect not only Resident A and Resident B but also all facility residents by failing to follow their abuse policies and procedures.The result of these failures had a direct relationship to the health, safety and security of patients. |
| 090000020 |
Eldorado Care Center, LP |
090009478 |
B |
06-Sep-12 |
M9RZ11 |
9631 |
Patient's rights - 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to ensure that Patient 1's rights were protected and he was free from physical harm. Patient 1 reported an allegation of a twisted left arm as evidenced by multiple reddened and bruised marks to his left hand.Patient Care Policies and Procedures - 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement their policy and procedure related to abuse for 1 sampled patient (1). As a result, two alleged employees remained at work for direct patient care until the rest of their shift after a reported allegation of twisting a patient's left arm as evidenced by two noted red and bruised marks to the left hand. Patient 1 was admitted to the facility on 11/3/11 with diagnoses that included chronic airway obstruction (a type of pulmonary disorder in which the upper or lower airway is chronically obstructed), dementia and depression per the Record of Admission.Patient 1's MDS (minimum data set) assessment dated 12/14/11 indicated that Patient 1 was oriented to the year, month, and day and was able to recall words without cueing. The same MDS assessment indicated that Patient 1's activities of daily living (ADL) under functional status required limited assistance with bed mobility and extensive assistance with transfers.On 12/29/11 at 2:17 P.M., during a visit to the facility with a health facility evaluator supervisor (HFES), Patient 1 approached the State agency employees limping and reported an incident that according to Patient 1 happened a few minutes prior at the patio. Patient 1 was observed to hold his left arm, moaning, shaking, and complaining of pain. Patient 1 stated that one of the male CNA (certified nursing assistant)s who stood on his left hand side (named the CNA), twisted his left arm and instructed him to go back to his station.On 12/29/11 at 2:20 P.M., an interview and joint visual inspection of Patient 1 was conducted with the HFES. Patient 1 stated that a few minutes prior after lunch, he went to a patio to visit some friends. Patient 1 stated that while talking to his friends, he was approached by CNA 1 (named the CNA) who came from the same station and instructed him to go back to the station where he came from. Patient 1 stated that he was called the name "you white son of a bitch" by the same CNA when he refused to leave the patio and asked him "you want to hit me? Go ahead" in a loud tone of voice. Patient 1 stated that he never got the chance to ask why he was grabbed and asked to leave the patio immediately which caused him to become upset. Patient 1 stated that he felt the staff was physically abusive to him by the way he was treated and the pain and marks inflicted on him. Patient 1 described CNA 1 who stood on his left hand side, held his left arm tight, twisted, and dragged him out of the patio and pushed him in to the dining room while CNA 2 followed them on his right hand side. Patient 1 stated that he was pushed in the dining room by CNA 1 who was upset with him and held and twisted his left arm after he was instructed to go back to his station. While Patient 1 was talking to the state staff persons, he complained of feeling nauseous, holding his left arm, shaking and moaning of pain stating ("it hurts") on the left arm. He requested to talk to the administrator. A visual inspection of Patient 1's left arm indicated a limited range of motion and redness on the left dorsal area of the palm below the index and small fingers. Approximately an inch at the base of the index finger was a reddened elongated nickel shaped mark with a visible small arch shaped scratch mark on top of it that formed in a slanted position. The reddened mark was surrounded with slight bruising on the area. Another redness was noted on the left hand at the base of the small finger with an irregular shape that measured a dime in size as he complained of pain. Patient 1 repeatedly stated "that CNA (named the CNA) hurt me...I think I have a broken shoulder." A male staff was notified about Patient 1's concern. On 1/11/12 at 4:00 P.M., a follow-up visit and interview was conducted with Patient 1. Patient 1 stated that he recalled the incident that happened two weeks prior (stated the month) but was unable to remember the date. Patient 1 stated that he recalled the incident "I remember you and another State employee that I spoke to and reported the CNA that twisted my left arm." Patient 1 was consistent with his statement and the whole incident that happened on 12/29/12. Patient 1 stated that he went to the patio after lunch and visited some friends and sat with them when a male CNA approached and asked him to leave the patio. Patient 1 stated that when he refused to leave the area, another male CNA (named the CNA) came out to the patio, grabbed his left arm, twisted, and dragged him out of the patio to the dining room with another male CNA on his right side. Patient 1 stated that CNA 1 called him a name in a loud tone of voice "you white son of a bitch" and asked him "you want to hit me? Go ahead."On 1/12/12 at 2:30 P.M., an interview was conducted with CNA 1 to discuss the incident. CNA 1 replied "that's easy" and smiled. CNA 1 stated that he was in the smoking patio on 12/29/11 after lunch. CNA 1 stated that he was assigned to the patio that day and had observed Patient 1 seated in the patio with some patients "looked like he was just socializing." CNA 1 stated "the licensed nurse (named the nurse) (LN) saw Patient 1 passing out cigarettes" when it was not even time for smoking. CNA 1 stated that he overheard the LN talk to CNA 2 (named the CNA) to stop Patient 1 from giving cigarettes out to other residents; CNA 2 approached Patient 1 and overheard Patient 1 to say "fuck you" words and was instructed to leave the area. CNA 1 stated that he approached Patient 1 and stood on his left side while CNA 2 was on right side and "took the cigarettes out of his hand." CNA 1 stated that Patient 1 became argumentative, raised his hand and swung at him but CNA 1 was able to block his hand from hitting him. CNA 1 stood up and demonstrated how he held Patient 1's hand by showing a pinch like touch of both thumb and index finger and stated "that's how I did it" then laughed. CNA 1 stated that Patient 1 was escorted both by the CNAs (CNA 1 and CNA 2) up to the dining room. CNA 1 also stated that after the incident, he went back to the patients in his station until the rest of the shift. ON 4/30/12 at 11:15 A.M., a telephone interview was conducted with CNA 2. CNA 2 stated that on 12/29/11 after lunch, he was in one station and observed Patient 1 seated in the patio with 1 or 2 residents when he was observed to take cigarettes out of his pocket and light one cigarette. CNA 2 stated that Patient 1 had his own lighter and cigarettes in his pocket that should not have been allowed. CNA 2 stated that it was not a scheduled time for smoking and approached Patient 1 and instructed him to go back to his station to smoke there. CNA 2 stated that Patient 1 told him "I'm just visiting, don't worry about it." CNA 2 stated that Patient 1 did not leave as instructed. CNA 2 then stated that CNA 1 stepped up to Patient 1's left side and he was on the right hand side of the patient. CNA 2 stated that Patient 1 stood up, upset, swung his hand at CNA 1, and both of them escorted Patient 1 out of the patio to the dining room.CNA 2 stated that after the incident, he went back to his station and checked on other residents until the rest of the shift.On 5/15/12 at 8:00 A.M., an interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated that she was at work when the incident happened on 12/29/11. LN 1 stated that on 12/29/11 after lunch, she was seated at the nurse's station desk and observed Patient 1 to walk in the patio. LN 1 stated that Patient 1 was seated with other residents passing out cigarettes.LN 1 stated that she approached CNA 1 to talk to Patient 1 to leave the patio.LN 1 stated that two CNAs escorted Patient 1 out of the station . On 8/16/12 at 3:50 P.M., an interview was conducted with the administrator (ADM). The ADM stated that any staff involved in an allegation of abuse must be removed as soon as the incident had been reported. A review of CNA 1's personal file was conducted. The form "Procedure When Abuse is Suspected" indicated "1. Make sure resident is safe. 2. ...If alleged perpetrator is staff, remove from work site."The form was signed and dated by CNA 1 on 10/18/11. A review of the facility's policy and procedure (P&P) entitled "Abuse Reporting" was conducted. The P&P dated 9/2004 indicated "3. If the allegation of abuse involves any facility employee on duty, that employee will be removed from his or her assignment immediately. The employee will clock off his or her shift and be sent home pending investigation of the incident to prevent any further abuse."The above violations either jointly, separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 090000018 |
Edgemoor Hospital DP/SNF |
090011003 |
B |
10-Oct-14 |
None |
5875 |
CLASS B CITATION -72315(m) Patient call signals shall be answered promptly.The facility failed to ensure that staff answered Patient A's call light promptly, within 3 minutes per the facility's call light policy. The call light for Patient A was answered 25 minutes after Patient B (Patient A's roommate) called for help. The facility also failed to implement Patient A's plan of care for keeping the call light within reach of the resident. Patient A's call light cord was coiled up on the wall behind Patient A's bed, where it was not accessible to the patient. Staff failed to respond to Patient A's call light in a timely manner.A review of Patient A's clinical record was conducted on 6/30/10 at 1:45 P.M. Patient A was admitted to the facility on 1/17/08, with diagnoses that included a history of bilateral tibia-fibula (both lower leg) fractures from a motor vehicle accident, suffered in December 2006. Patient A had chronic osteomyelitis (pus filled inflammation of the bone) of his right lower leg, with chronic drainage and abscess (infection). Patient A had an incision from a recent medical procedure of debriding (cleaning and removing dead tissues and pus) from the wound down to the muscle level. The wound was drained by the wound specialist on 5/20/10, per Patient A's Discharge and Death Summary.On 7/8/10 at 11:00 A.M., Patient B, who was Patient A's roommate, was interviewed. Patient B did not have short term memory or long term memory problems, per the Minimum Data Set (MDS) sheet, dated 5/16/10. Patient B stated he did not hear the sound of Patient A's fall from the bed, and he did not know how long Patient A was on the floor. Patient B stated that he heard Patient A yell and call out to him to use his (Patient B's) call light to call the staff, at 4:00 A.M. on 5/30/10.A review of "Nurse Call Executive Information System: Detailed Patient Activity Report," dated 5/30/10, indicated that Patient B used his call light at 3:59 A.M., and the staff answered the light at 4:24 A.M., therefore, it took 25 minutes for the staff to answer the call light. The report also indicated that Patient A did not use his call light since 5:15 P.M. on 5/29/10.On 7/7/10 at 9:25 A.M., the licensed nurse (LN) 1 who was assigned to Patient A on the night shift on 5/30/10 was interviewed. LN 1 stated that she did not check or give any attention to Patient A's call light location or placement, when she made rounds at 12:00 A.M. on 5/30/10. LN 1 also stated that she did not check Patient A after 12:00 A.M., until the fall incident occurred. On 7/14/10 at 1:00 P.M., the certified nursing assistant (CNA) 2 who was assigned to Patient A and B, was interviewed. CNA 2 stated that she checked on Patient A at 12:30 A.M. on 5/30/10, and then she just stepped in and out of Patient A's room at 3:30 A.M. CNA 2 stated that she did not check the placement of the call light for Patient A. CNA 2 stated, "I don't make rounds every 2 hours because Patient A and B called me all the time..." CNA 2 further stated that she left her pager (connected to the call light system and beeped if Patient A or B used the call light), on the counter at the nursing station from 3:30 A.M. until 4:00 A.M. on 5/30/10. CNA 2 stated that she did not notify other staff members working with her that she left the pager at the nursing station.On 7/14/10 at 3:30 P.M., CNA 1 was interviewed. CNA 1 stated that she answered Patient B's call light at 4:30 A.M. on 5/30/10, and saw that Patient A was lying on the floor. CNA 1 stated that she noticed that Patient A's call light was coiled, hanging on the wall, and out of reach of the Patient. On 7/9/10 at 8:45 A.M., the director of staff development was interviewed. The DSD stated that "Staff had to answer the call light in 3 minutes...The facility has a 3 minute answering policy..."A review of facility's undated policy titled: "Call Light" indicated: "...Call lights shall be placed within easy reach of the patient. Call lights shall be answered in a timely manner...Check call light with contacts with patient to assure it is placed in reach and functional..."A review of the staff in-service training record dated 6/16/10, and titled: "Call Light and Pager In-service," indicated: "Call light response time is within 3 minutes...We have to answer the call light immediately #1 for safety and to attend to their needs on time. You have to carry your pager all the time. If you go to your break you have to leave the pager to who is ever assigned as your reliever. Who is ever carrying that pager and if that pager is being paged you have to respond immediately..."On 7/14/10 at 1:55 P.M., the Assistant Administrator (AA) was interviewed. The AA stated that there was no report of malfunction of the call light system including the pagers, on 5/30/10. The AA acknowledged that the staff did not answer Patient B's call light within 3 minutes as directed by the facility's policy. The AA also acknowledged that the staff did not ensure that Patient A's call light was placed in reach.The facility's failure to comply with Patient A's nursing plan of care, facility policy and answer call lights promptly, delayed emergency care being rendered to Patient A when he could not reach his call light and fell out of bed. Patient A was placed in an emergent condition when he could not reach his call light and fell out of bed.The facility staff failed to answer the call light by:1. Failure to implement Patient A's nursing care plan to respond to call lights promptly 2. Failed to follow the facility's policy for call light placementwithin reach of the patient 3. Failed to ensure staff pagers had been turned over to another staff member during break time to ensure that the call lights would be answer timely.A violation of these regulations had a direct or immediate relationship to the health, safety or security of the patient. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110007167 |
B |
29-Jul-13 |
5PHQ11 |
8368 |
72311(a)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to follow Resident 1's nursing plan of care to provide the necessary supervision for Resident 1, who had a pattern of striking and exhibiting aggressive behaviors towards other residents when Resident 1 punched three residents resulting in: 1) Resident 2 was hit in the jaw that left a raised area on Resident 2's jaw; 2) Resident 3 was hit in the chest; and 3) Resident 5 was punched and caused bruising. In addition, Resident 4, who was bedbound complained of being afraid and unsafe at night due to Resident 1's pattern of wandering into other residents rooms and hitting residents.Findings: During an observation, on 4/6/10 at 8:45 a.m., Resident 1 was seated in the activity/dining room in a chair by the sliding glass door, asleep. There were seven residents in the activity/dining room with no staff present.The admission record dated 12/29/09, indicated that Resident 1 was admitted to the facility on 12/17/09, with admission diagnosis including dementia with behavior disturbance. The admission minimum data set (MDS) dated 12/3/09, an evaluation tool included mood and behavior patterns of persistent anger with self or others with verbal and physical abuse. Resident 1 exhibited behaviors of wandering.The nursing plan of care for resident to resident altercation dated 3/6/10, when Resident 1 attempted to hit another resident. The interventions were: 1) Keep resident away from other residents with history of resident to resident altercation; and 2) Enhanced observation. The goal was that there were to be no episodes of resident to resident altercation daily for 14 days. First Resident to Resident Altercation During an interview, on 4/6/10 at 9:00 a.m., Activity Director stated that on 4/4/10 at 10:15 a.m. she left the activity room to make a telephone call across the hallway. There were no other staff members present. She heard Resident 2 hollering her name and immediately returned. Resident 1 was standing over Resident 2, who was seated in a wheelchair, with his right fist upheld and clenched, but she did not witness any physical contact. When Resident 2 was asked if Resident 1 had hit him he stated yes and pointed to his left cheek. Activities Director heard Resident 2 cry for help.Resident 2's nurses notes, dated 4/5/10, included a late entry for 4/4/10 at 10:30 a.m., when questioned Resident 2 stated that Resident 1 hit me in the face pointing to his left cheek which had a slightly raised area about 3 cm (centimeters) x .5 cm. Resident 1's nursing plan of care revised on 4/4/10 indicated that Resident 2 stated that Resident 1 hit Resident 2 in the jaw. The interventions included: 1) Staff were to provide Resident 1 visual check monitor every 15 minutes; and 2) Activity personnel would not leave the activity room while this resident is in attendance. The goal was that Resident 1 will have no episodes of patient to patient altercation daily for 14 days. Resident 2's Interdisciplinary Team Notes, dated 4/5/10, included the notation: "Activity Director strongly reminded not to leave Activity room while the other resident (Resident 1) is in attendance because of that resident's unpredictable aggressive behavior." During an interview on 4/6/10 at 2:30 p.m., Administrative Staff A, stated that they did not have a policy, but did have an unwritten protocol, that a staff person must be in the activity room at all times during activities, and if staff had to leave the activity room they were required to have another staff member present before leaving.During an interview, on 4/6/10 at 3 p.m., Administrative Staff B stated that the Activity Director should not have left the room without other staff members present, and did not follow the Resident Care Plan, for Resident 1, which included: "Keep resident away from other residents with a history of resident to resident altercations."During an interview, on 4/6/10 at 12:15 p.m., CNA D stated that she was not present in the activity room at that time, but had been assigned to care for Resident 1 on that day. When asked if she had witnessed Resident 1's aggressive behaviors she stated that she had witnessed several recent aggressive episodes of punching and pushing residents. Second Resident to Resident Altercation Nurses' notes dated 4/15/10, revealed that Resident 1 had punched Resident 3 in the chest and pushed him. A nurse heard someone yelling and witnessed Resident 1 attacking Resident 3 who had just come into the building. Resident 1 punched and pushed Resident 3 without any word or warning.During an interview, on 4/21/10 at 1:30 p.m., Resident 3 stated that on 4/15/10 he had been outside walking with his walker, when Resident 3 entered the building Resident 1 was at the door with no expression on Resident 1's face. Resident 1 just came up to Resident 3 and punched Resident 3 two times in the left upper chest, and pushed Resident 3 for no reason. When asked if Resident 3 was afraid of Resident 1 Resident 3 stated that Resident 3 had learned to stay far away from Resident 1, but could not avoid Resident 1 when Resident 1 was waiting at the door and got Resident 3 as soon as Resident 3 entered the building. In addition, Resident 3 stated that he had seen Resident 1 try to strike others many times.Resident 1's Care Plan 4/15/10 regarding Resident 1 hit Resident 3 in the chest. The interventions to 1) Staff were to provide visual checks every 15 minutes; 2) Place on 5150 (an involuntary psychiatric hold for danger to self or others) if agitation escalates; and 3) 1:1 care as needed and staff were to continue to closely monitor activities.During an interview, on 4/21/10 at 12:15 p.m., Administrative Staff A stated that: "... He is hitting everybody, it is not safe." When asked if the facility had put Resident 1 back on one to one observation, she stated that it required administrative approval and that it had not been approved when she requested it. Administrative Staff A also stated that the facility did not require a physician order and did not have a policy for one to one observation. During an interview, on 4/21/10 at 2:05 p.m., the Activity Director stated that another resident, Resident 4, identified by the facility as alert and oriented, told her that Resident 4 was very afraid of Resident 1.During an interview, on 4/21/10 at 2:15 p.m., Resident 4 was bedbound and stated that everyone at the facility was afraid of Resident 1. Resident 4 stated that Resident 1 could be heard all night long prowling the hallways, which did not allow Resident 4 to feel safe while trying to sleep. Resident 4 stated that Resident 1 was known to wander into other residents' rooms and take things or get into a bed. Resident 4 stated that Resident 4 was not able to get out of bed which made Resident 4 feel helpless.The nursing plan of care dated 5/10/10, indicated that Resident 1 pushed a resident. The interventions were that staff were to watch Resident 1 closely, 1:1 supervision. The goal was that Resident 1's aggression would stop harm to self and other residents. Third Resident to Resident Altercation The nurses' notes revealed dated 5/12/10 at 7:45 a.m., that Resident 1 walked across the inner courtyard and entered a special care unit through an alarmed side patio door and punched Resident 5 in the face. During an interview on 5/18/10 at 9:30 a.m., Administrative Staff A stated that Resident 5 had a small bruise on his face.Therefore, the facility failed to follow Resident 1's nursing plan of care to provide the necessary supervision for Resident 1, who had a pattern of striking and exhibiting aggressive behaviors towards others residents when Resident 1 punched three residents resulting in: 1) Resident 2 was hit in the jaw that left a raised area on Resident 2's jaw; 2) Resident 3 was hit in the chest; and 3) Resident 5 was punched and caused bruising. In addition, Resident 4, who was bedbound complained of being afraid and unsafe at night due to Resident 1's pattern of wandering into other residents rooms and hitting residents.The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110008463 |
B |
30-May-12 |
POAP11 |
7517 |
72527(a)(11) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to treat Resident 1 with respect and dignity when Administrative Staff A pointed her finger at and scolded Resident 1 in the public lobby/TV area, in the presence of other residents, visitors, and staff. This resulted in Resident 1 becoming fearful and upset (as exhibited by crying, shaking her head, "No," and firmly squeezing Family Member 4's hand).Resident 1 was an 84 year old who was admitted to the facility on 6/29/11. Resident 1 had diagnosis that included anxiety and advanced dementia. During an interview on 7/27/11 at 8:50 a.m., Administrative Staff A stated Resident 1 was admitted to the facility on 6/29/11 and was "not bed-bound, but very ambulatory." Administrative Staff A stated that about a week ago, Resident 1 tried to sit in another resident's favorite spot on a couch in the lobby/TV area. The other resident (Resident 2) got angry and put his foot out to block the wheel of Resident 1's walker preventing her from getting any closer to him. Administrative Staff A stated she put herself between the two residents and put her hand on Resident 1's walker to prevent her from moving forward. She stated that Resident 1 grabbed her right arm "so tightly she left a bruise." Administrative Staff A stated she had tried to talk to Family Member 3 about transferring Resident 1 out of the facility to an Alzheimer's facility, but "I can't get [Family Member 3] to agree to the transfer."During the same interview on 7/27/11 at 8:50 a.m., Administrative Staff A stated, "This past week" (exact date was 7/11/11) Resident 1's "granddaughters" [actually Family Member 4 and Friend 5] were visiting her and were upset about the transfer.Administrative Staff A was also asked if she pointed her finger at Resident 1 and said to her, "I'm going to tell on you for what you did [grabbed Administrative Staff A's arm]." Administrative Staff A stated "I would never talk like that." She added, [Resident 1] might have "had some awareness of [Family Member 4] and/or the situation and she got teary....[Family Member 4] might have said, 'She's telling on you' (to Resident 1)." Administrative Staff A also stated she told Family Member 4 and Friend 5 about the incident in which Resident 1 grabbed her arm. She told them that she "had concerns about the fact that [Resident 1] hurt [Administrative Staff A] and could hurt other residents." According to Administrative Staff A, [Family Member 4] stated, "What are we supposed to do? We work full time and can't provide care for [Resident 1] at home." During an interview on 7/27/11 at 9:50 a.m., Family Member 3 stated "[Administrative Staff A] was "irate" about [Resident 1] grabbing her arm. She seemed to take great pleasure in beating [Resident 1] down."During a telephone interview on 7/27/11 at 10:22 a.m., Family Member 4 stated she and Friend 5 were visiting Resident 1 in the lobby of the facility on 7/11/11. During the visit, Administrative Staff A came up to Resident 1 and her visitors and said, "We've had some issues with [Resident 1]." Family Member 4 stated Administrative Staff A stood about 3-4 feet away from Resident 1 and pointed her finger at her and said, "You know what you did. You know that I'm tattling on you." Family Member 4 stated she felt "frustrated because [Resident 1] was afraid and had tears rolling down her face." She added that Resident 1 "had instant fear and was upset. [Resident 1] started bawling and squeezed my hand." She added that she was "shocked at how [Administrative Staff A] spoke and acted" and felt that the conversation should have been handled in private rather than in the lobby.The above information was corroborated in written declarations, dated 8/22/11, by Family Member 4 and Friend 5. In Family Member 4's declaration, she stated: "...standing in the middle of the common area 4 feet from [Resident 1], [Administrative Staff A] squinted her eyes, sneered and pointed at her and said, 'You know that I'm telling on you and you don't like it, you know what you did.' [Resident 1] looked terrified and immediately started crying. Huge tears were running down her face...[Administrative Staff A] pointed to her wrist and said, 'You can see where she grabbed me,' which I could not...I was holding back tears of sorrow and total frustration at the way [Administrative Staff A] chose to handle this situation...we simply want [Resident 1] to be treated fairly and with kindness, love and compassion." In Friend 5's declaration, dated 8/22/11, she stated: "On 7/11/11 I went with [Family Member 4] to visit [Resident 1] at [the name of the facility]. When we arrived we found [Resident 1] sitting in a chair that seemed to be the TV lounge area watching TV with 3-4 other patients. During the visit...we were approached and introduced to [Administrative Staff A]. [Administrative Staff A] asked [Family Member 4] if she was [Resident 1's] [family member] in a very abrasive way. [Resident 1] seemed to be upset by [Administrative Staff A]...[Administrative Staff A] wanted to tell [Family Member 4] about an altercation with herself and [Resident 1]...[Administrative Staff A] then started to squint her eyes at [Resident 1] and shake her finger at her (in front of the entire lounge) and scolded her like a child. I believe [Administrative Staff A] said, 'Yeah you know I'm telling on you, don't you? You know what you did don't you?' [Administrative Staff A] also shook her finger during this statement also. At this point I focused on [Resident 1] as she was now crying and petting her forehead and would look at me and shake her head, 'No'...I remember [Administrative Staff A showing us her wrists that she claimed are bruised, but I personally saw nothing..." During a concurrent observation and interview on 7/27/11 at 12:07 p.m., Administrative Staff A tilted her head towards Resident 1 who was sitting in the lobby watching TV, and said: "This is my little challenge." At the time, Resident 1 was sitting quietly on the couch watching TV. Another resident was sitting next to her in a wheelchair and Resident 2 was sitting in his usual place on another couch. All residents were quiet and watching TV.Review on 1/19/12 of the "Interdisciplinary Plan of Care Review Form," dated 7/28/11, indicated: "Family expressed concern to DPH for: 1. Perceived method of approach by staff to [Resident 1] as inappropriate.The facility failed to treat Resident 1 with respect and dignity when: 1. Administrative Staff A pointed her finger at and scolded Resident 1 in the public lobby/TV area in the presence of other residents, visitors, and staff; and 2. As a result of this behavior, Resident 1 became fearful and upset as exhibited by crying, shaking her head, "No," and firmly squeezing Family Member 4's hand.This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1. |
| 110001255 |
Evergreen Lakeport Healthcare |
110008617 |
AA |
16-May-13 |
6MV911 |
6068 |
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. F333 ?483.25(m)(2) Provide Care/Services for Highest Well Being The facility must ensure that residents are free of any significant medication errors. The facility violated the regulation by failing to: 1) Follow physician's orders and administer the correct pain medication to the correct resident when the licensed nurse did not accurately identify Resident 1 prior to administering methadone (methadone is a controlled substance opioid pain medication) 30 milligrams(mg) by mouth that was not ordered by the physician; and 2) Transfer Resident 1 to the acute care hospital for further evaluation and treatment after licensed nurses identified the medication error. Resident 1 remained at the facility for 8 hours and exhibited signs and symptoms of decreased oxygen saturations and increased sedation and was not treated with a reversal agent to prevent adverse effects of methadone. These failures resulted in delay in treatment of acute methadone toxicity and resulted in Resident 1's death. Resident 1 was admitted to the facility on 8/1/11 with the diagnoses including coronary artery bypass graft, pacemaker for sick sinus syndrome, and atrial fibrillation. A history and physical dated 7/18/11, indicated Resident 1 was alert, independent, spry, and lived with her daughter.Resident 1's record of medications ordered by the physician indicated no orders for Methadone. During an interview on 8/11/11 at 5:30 p.m., Licensed Nurse A stated she was in the hall passing medications on 8/8/11 at 1:30 a.m., when a CNA informed her that Resident 2 needed something for pain. Licensed Nurse A stated that she finished what she was doing and then prepared and gave the medication (Methadone 30 mg) for pain. Licensed Nurse A stated she used the picture with the medication administration records to identify the residents. She stated she looked at the picture for Resident 1 then went to the room and gave the medication to Resident 1. Licensed Nurse A stated that about fifteen minutes later a CNA again asked about the pain medication for Resident 2, and that is when she realized that she had given Resident 1 the medication (Methadone 30 mg). She stated that at that time she called the Nurse Practitioner, and the Director of Nursing. The Nurse Practitioner gave orders to monitor Resident 1's vital signs and for signs of respiratory depression every hour. Nurse's Notes dated 8/8/11, written by Licensed Nurse A revealed that Resident 1 received the "wrong RX" (prescription) orally. Nurses notes dated 8/8/11 at 9:15 a.m., indicated that Resident 1's oxygen saturation levels did not increase from 86% (Normal range 92-100%) and Resident 1 was started on 3 liters of oxygen by mask. Resident 1 was sedated but would open his/her eyes to Resident 1's name. Approximately 8 hours later, Resident 1's blood pressure at 10:30 a.m., had decreased to 62/54 (normal range 120/80) with episode of apnea (no breathing). Licensed staff called 911 and Resident 1 required cardiopulmonary resuscitation. The physician pronounced Resident 1 at 10:45 a.m. During an interview on 8/9/11 at 9:00 a.m., the Nurse Practitioner stated that she decided to monitor Resident 1 every hour for vital signs, oxygen saturation, and mental status. During an interview on 8/10/11 at 8:20 a.m., the Director of Nurses stated that the facility does not have a specific policy for resident identification. The Director of Nurses stated the facility practice is that staff is to use the picture of the resident that is kept with the residents records or the identification bracelet. Lexicomp online indicated that concerns related to adverse effects of methadone are: 1) Central nervous system depression which may impair physical or mental abilities; 2) Hypotension; 3) Severe Respiratory depression. Geriatric considerations that the elderly may be particularly susceptible to central nervous system depression. A physician's orders for life sustaining treatment (POLST) dated 8/1/11, indicated that Resident 1 signed the document and the plan was "Full Treatment...Transfer to hospital if indicated. Includes intensive care." The County Coroner's report dated 8/10/11 indicated that the Nurse Practitioner gave a statement to the County Coroner as follows: "She [Nurse Practitioner] did not give Narcan (reversal agent) as we don't usually do that... I should have sent [resident named] to the hospital immediately but decided to watch and take her vitals to see how she would progress. I see so many advanced age residents here all year long that are sent to the hospital and sent right back by them as the patients are at our facility for comfort care." The County Coroner indicated "Based on autopsy and toxicological investigation, the cause of death is determined to be ACUTE METHADONE TOXICITY." Therefore, The facility violated the regulation by failing to: 1) Follow physician's orders and administer the correct pain medication to the correct resident when the licensed nurse did not accurately identify Resident 1 prior to administering methadone (methadone is a controlled substance opioid pain medication) 30 milligrams(mg) by mouth that was not ordered by the physician; and 2) Transfer Resident 1 to the acute care hospital for further evaluation and treatment after licensed nurses identified the medication error. Resident 1 remained at the facility for 8 hours and exhibited signs and symptoms of decreased oxygen saturations and increased sedation and was not treated with a reversal agent to prevent adverse effects of methadone. These failures resulted in a delay in treatment of acute methadone toxicity resulted in Resident 1's death. These violations presented an imminent danger to the Resident and were a direct proximate cause of the death of the Resident. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110008823 |
B |
02-May-12 |
MUR211 |
4186 |
72311(a)(1)(A) Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 72311(a)(1)(B) Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. 72311(a)(3)(B) Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.The facility violated the regulation by failing to develop a plan of care when Resident 1 sustained a skin tear on the right leg. The facility did not provide an ongoing assessment or treatment of the wound. The physician was not notified for eleven days until the wound exhibited signs of infection, heat, and purulent drainage.Resident 1's clinical records were reviewed on 12/21/10, 4/13/11, and 12/7/11. The resident was her own responsible party, had a history of falls, blood clots in her legs, chronic pain, and muscle weakness.Review of a document initiated by Family Member A, on 12/8/10, revealed Resident 1 acquired a gash on the right leg.During concurrent interviews, with Licensed Staff B, C, and D, on 12/21/10 at 3 p.m., the staff members stated that Resident 1 acquired a wound on the right shin from running into the bed.During interview, on 12/21/10 at 4:20 p.m., Licensed Staff C stated that Resident 1 sustained the gash on the leg, on a weekend, when the resident was in the wheelchair and accidentally ran the leg into the bed. Licensed nurses notes, dated 11/14/10, indicated Resident 1 had a skin tear on the right shin. There was no documentation of a description or size of the skin tear. The notes indicated that the resident stated "caught on footrest of w/c (wheelchair)." The wound was cleaned, a dressing was applied, and "Fax to MD." There was no evidence of a Fax sent to the resident's physician regarding the injury. Resident 1's weekly summary, dated 11/15/10, indicated treatment was pending for the wound on the right leg. There were no physician notes addressing the injury, no orders for treatment, or any other documentation regarding assessment or treatment of the wound until 11/25/10, eleven days later.Nurses notes, dated 11/25/10, indicated Resident 1's physician was called regarding her right shin wound.The wound had signs and symptoms of infection including "heat" and "purulent discharge [pus]." The physician wrote orders for ten days of oral antibiotics (doxycycline [used primarily for the treatment of bacterial infections] 100 mg, twice a day) and ten days of wound care. Nurses notes, dated 12/7/10, indicated the wound was still present on Resident 1's right leg, "and it is not unexpected the wound will take time to heal." During interview, on 4/13/11 at 1 p.m., Licensed Staff B was notified of the lack of documentation of the wound assessment, treatment, and physician notification, between 11/14/10 and 11/25/10, when the wound was noted to be infected. On 4/13/11 at 1:25 p.m. and 12/7/11 at 3 p.m., Licensed Staff B stated that she was unable to find any further evidence of wound assessment, treatment, or physician notification. Failure to plan care for Resident 1 when she sustained a skin tear on her right leg, failure to provide on-going assessment of the wound, failure to plan treatment, and failure to notify her physician had a direct relationship to the health, safety, or security of Resident 1. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110009412 |
B |
16-Aug-12 |
SN7K11 |
1829 |
1418.21(a)(1)(C) HEALTH & SAFETY CODE (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. 1418.21(b) HEALTH & SAFETY CODE (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2. Based on observation and staff interview, the facility failed to post the overall facility rating information [Five Star Rating] in an area used by residents for communal functions, such as dining, resident council meetings, or activities. This had the potential to prevent residents from having access to the information. Findings: Observation on 7/16/12 at 4:45 p.m., revealed, the facility Five Star rating was not posted in the dining room/activity room, utilized by the majority of residents. During observations on 7/17/12 and 7/18/12, the Five Star rating was not posted in the dining/activity room. Concurrent observation and interview, on 7/19/12 at 2 p.m., revealed that there were no Five Star postings in the dining/activity room. Management Staff A stated that the ratings had been posted in two places in the dining/activity room and he did not know why they were no longer there. Violation of this section shall constitute a class B violation. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110009547 |
B |
19-Dec-12 |
L6WH11 |
3616 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of Staff B touching residents in an inappropriate manner to the State Survey and Certification Agency, with the potential for continuing practice towards residents. During an interview on 1/5/11 at 9:30 a.m., Staff A stated that, while orienting on his first night shift at the facility (10/9/10-10/10/10), he observed Staff B touching both male and female residents in what he thought was an inappropriate manner when he performed perineal care (cleaning the urinary and rectal orifices).Staff A stated that he did not speak to Staff B concerning what he thought was inappropriate touching. He stated that he reported what he observed to Licensed Staff C and stated that Licensed Staff C instructed him to fill out an abuse report and submit the report to Administrative Staff D. Staff A stated that he did not submit the report to Administrative Staff D but sent the abuse report to the facility's legal department. Staff A stated that he did not report the allegation to the Ombudsman, law enforcement or to any other State Agency.Staff A stated that he had called Administrative Staff D and the facility's compliance supervisor in January 2011 and stated he was told that the incident he reported in October 2010 was being investigated. Staff A stated that he was unable to identify any of the residents and could not recall the room numbers of residents he thought had been touched in an inappropriate manner.During an interview on 1/5/11 at 10:30 a.m., Administrative Staff D stated that the facility conducted an investigation on 10/10/10 during which Staff B was placed on leave until a resolution had been made concerning the allegations of touching residents in an inappropriate manner. Administrative Staff D stated that the investigation was still in progress as of 10/15/10. Administrative Staff D stated that Staff A had submitted a report alleging resident abuse by Staff B to the facility's compliance department but not to the Ombudsman, law enforcement or the State Agency. Administrative Staff D stated that "Staff A did not follow procedures on reporting". He stated that the facility sent a SOC Form 341 (report of suspected dependent adult/elder abuse) to the State Agency. The Department was unable to verify the receipt of the SOC 341. Administrative Staff D was unable to produce a copy of the document upon request.During a document review on 1/6/11, the policy "Abuse Prevention" dated 5/1/08, indicated that "All mandated reporters are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible, to the local Ombudsman or the local law enforcement agency and 2) by written report, Department of Social Services Form (SOC 341), "Report of Suspected Dependent Adult/Elder Abuse" sent within two (2) working days and the center shall maintain a copy of this report with the Center's investigation" and "The Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours". The facility failed to report the allegation of inappropriate touching, towards Resident 1, to the State licensing and certification agency, with the potential for continuing abuse. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110009717 |
B |
21-Feb-13 |
LSZ011 |
1338 |
Health and Safety Code 1418.91 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of sexual abuse within 24 hours, as required. This failure put Resident 2 and other residents at risk for further abuse.During an interview on 2/18/11 at 1 p.m., Administrative Staff A stated that in the beginning of January 2011 Resident 1 and Resident 2 had started to hold hands. Licensed Staff B saw both residents on 2/9/11, in Resident 1's bed fully clothed. The staff pulled the bed curtains for privacy, checked Resident 1 and Resident 2 every 15 minutes for safety, and both residents ended up naked. The Department was notified on 2/18/11, 9 days after the event involving Resident 1 and Resident 2.Review of the facility Policy and Procedure for Abuse Prohibition notification to Staff, Residents and Family (dated 2/2007) revealed the following: The Executive Director, Director of Nursing or designee who is in charge of the facility during their absence reports all instances of abuse...to the appropriate state agency as required by federal or state statue... |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110009718 |
B |
21-Feb-13 |
LSZ011 |
3746 |
72315(b) NURSING SERVICE - PATIENT CARE (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to protect and keep a resident free from sexual abuse when Resident 1 and Resident 2 were observed in bed and licensed staff pulled the privacy curtain around the residents. This caused Resident 2 to become agitated and Resident 2 managed to punch the code for the dining room alarm and manage to get out to the patio and to the other station. Resident 2 had increased anxiety was irritated and required one to one supervisionAn Admission Face Sheet, dated 11/3/10, indicating that Resident 1 was resident's own responsible party. Resident 2 had diagnoses which included: Dementia. Nursing Notes dated 2/2/11, indicated Resident 1 had continued to seek out male attention.Nursing Notes dated 2/7/11, indicated that Resident 1, "Up, sits in hallway, sits outside male's (Resident 2's) room and attempts to get male resident up and dressed and lead him around." During an interview on 2/18/11 at 1 p.m., Administrative Staff A stated that "In the beginning of January 2011 Resident 1 and Resident 2 started to hold hands. On 2/9/11 Licensed Staff B saw Resident 1 come into the dining room and lean forward to unzip Resident 2's pants. After dinner (5 p.m.,) Licensed Staff B saw both residents in Resident 1's bed fully clothed. Facility staff pulled the bed curtains for privacy, checked Resident 1 and Resident 2 every 15 minutes for safety, and both residents ended up naked and asleep. Resident 2 was escorted back to his room." Nurse's Notes, dated 2/9/11 at 8 p.m., (after the intimate episode with Resident 1) indicating that, "Resident 2 agitated and Resident 2 managed to punch the code for the dining room alarm and manage to get out to the patio and to the other station. Increased anxiety is irritated. Provided 1:1 attention until he calmed down. Interdisciplinary Team Notes, dated 2/10/11, signed by Administrative Staff A, Unlicensed Staff D, and Licensed Staff E in which they, "Were made aware that Resident 2's relationship with another female resident (Resident 1) has become sexual in nature and that Resident 2 has diminished capacity secondary to dementia with no family or Responsible Party involvement. Although demented Resident 2 can show objection to staff and other residents if put into a disagreeable position by yelling out or hitting. Nursing Notes dated 2/15/11 indicated Resident 1 continued to seek out a male's attention (Resident 2), wake him up and Resident 1 was told not to enter the room, Resident 1 continues to sit in hall way, until it is clear, and staff busy with others and Resident 1 will take the male resident with dementia (Resident 2) into her room.The facility's policy and procedure title, Abuse Neglect and Prohibition Policy revealed that "Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, and sexual assault... Facility supervisors immediately intervene and correct reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring." Therefore, the facility failed to protect and keep a resident free from sexual abuse when Resident 1 and Resident 2 were observed in bed and licensed staff pulled the privacy curtain around the residents. This caused Resident 2 to become agitated and Resident 2 managed to punch the code for the dining room alarm and manage to get out to the patio and to the other station. Resident 2 had increased anxiety was irritated and required one to one supervision. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110010516 |
A |
30-Jul-14 |
5OC111 |
9831 |
72319(j)( 2) - Nursing Service General ? Restraints and Postural Supports(j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: (2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions.The facility failed to ensure the care plan for Resident 1 included the specific data to be collected for use to evaluate the occurrence of adverse reactions to medications, Risperdal and Ativan, used to control behavior. As a result staff did not recognize that Resident 1 had potential adverse side effects from the antipsychotic medication, Risperdal and the antianxiety medication, Ativan, and continued to administer these medications in the presence of adverse side effects which required acute hospitalization for treatment.The clinical record for Resident 1 was reviewed on 2/6/14 at 9:30 A.M. The Face Sheet (resident identifying information), indicated Resident 1 was 70 years old, admitted with diagnoses that included dementia, anxiety, and depression.Physician admission orders, dated 12/5/12, included: "Risperdal 1 mg (milligram), 1 tab PO (by mouth) Q A.M. (every morning) for Anxiety (BBW) (Black Box Warning)". A handwritten notation on the Risperdal entry on the Medication Administration Record (MAR) indicated: "M.B. (manifested by) restlessness". Physician orders included: "Risperdal 2 mg, 1 tab, PO Q HS (every hour of sleep) for anxiety (BBW)", for a total daily dose of 3mg of Risperdal. Risperdal is an antipsychotic medication prescribed to treat mental states characterized by impaired contact with reality, and other mental and emotional conditions.BBW, "Boxed Warning", (also called "black box" warning), is the most serious warning required by the Food and Drug Administration, (FDA), to be placed on a product label for a medication. Boxed warnings document potential problems with the specified medication that can lead to serious injury or death.Physician orders included "Ativan 1 mg PO BID (two times a day) as needed". Ativan, a brand name for Lorazepam, is used for short term management of anxiety symptoms.A Patient Care Plan, for Resident 1, dated 12/6/12, titled "Psychotropic", (a chemical substance that crosses the blood-brain barrier and acts primarily upon the central nervous where it affects function, resulting in alterations in perception and behavior), noted "Use of antianxiety medication, (Ativan)", and "Depression". The preprinted list of interventions included "Medicate as ordered" with "Ativan 1 mg PRN" written in, as well as "monitor gait, balance during transfer and ambulation".The Patient Care Plan did not include any notation regarding the use of Risperdal.A preprinted sheet titled Psychotropic Side Effects was included in Resident 1's clinical record. The Psychotropic Side Effects sheet noted one of the potential side effects of Ativan as ataxia, an unsteady gait.The form listed Risperdal as an atypical antipsychotic medication and included Akathesia and Parkinsonism, as potential adverse neurological side effects from the medication. Resident 1's name was not on the form, it was not dated, and Risperdal was not circled or highlighted to indicate it was a medication Resident 1 received.Akathesia refers to a feeling of internal restlessness which may appear as constant motion, the inability to sit still, fidgeting, pacing and disturbed sleep patterns. Parkinsonism refers to the development of medication induced Parkinson-type symptoms, including tremors, shuffling gait, and postural unsteadiness according to an article at ncbi.nlm.nih.gov titled Extrapyramidal Symptoms Are Serious Side Effects of Antipsychotic and Other Drugs, Nurse Practitioner 1992, Nov;17(11):56, 62-4, 67. (Extrapyramidal symptoms [EPS] are various movement disorders.)Lexicomp Online, an online medication reference for health professionals, noted the following warnings and precautions for Risperdal: "May cause increased anticholinergic effects (confusion, agitation...). May cause extrapyramidal symptoms including Pseudoparkinsonism...Akathesia". During interview, on 2/6/14 at 2:55 p.m., Licensed Staff A stated she had done the admission assessment with Resident 1, and came to know her well during her stay at the facility. Licensed Staff A stated Resident 1 was confused and forgetful, and frequently expressed the desire to be with her family. Licensed Staff A stated Resident 1 often required 1:1 care because she paced and attempted to leave the facility. Licensed Staff A described Resident 1 as being unable to sit still for even a minute, and unable to concentrate on any diversional activity. Licensed Staff A stated at the end of her stay at the SNF, Resident 1 became more confused and lethargic until she was not responsive, at which time Resident 1 was transferred to an acute care hospital.Review of the clinical record on 2/16/14 at 9:30 A.M., revealed Nurse's Notes that documented Resident 1's progression from walking alone to stumbling along the hall after 51 days at the facility.Nurse's Notes dated 12/8/12, indicated Resident 1 ambulated independently, three days after admission to the facility. Nurse's Notes dated 12/13/12 indicated Resident 1 was "unsteady" when walking. Nurse's Notes dated 1/3/13 indicated Resident 1 was up at 3:30 a.m. pacing the halls, and had become "very unsteady" when walking. Nurse's Notes dated 1/5/13 noted Resident 1 grabbed at things and other people when walking. Nurse's Notes dated 1/11/13 indicated Resident 1's dose of Risperdal had been increased to 4 mg every night, an increased dose could increase side effects. Nurse's Notes dated 1/12/13 indicated Resident 1 was "very agitated and confused". Nurse's Notes, dated 1/24/13 indicated Resident 1 was "weak and wobbly". Progress Notes dated 1/26/13 indicated Resident 1 was "more unstable on feet today, close to falling as she stumbles all over the hallway". Nurse's Notes on 1/28/13 at 1830 (6:30 P.M.) indicated Resident 1 was pale, cold to the touch and shivering in blankets as she lay in a Geri chair, (a wheelchair that reclined). The Nurse's Note indicated Resident 1 had "decreased from baseline, orientation had declined", and she was unable to stand. Facility staff notified the physician of Resident 1's change of condition and Resident 1 was sent to an acute care hospital.Review, of the acute care hospital Admission History and Physical, dated 1/29/13, indicated Resident 1 was minimally alert and had an abnormal gait, "likely due to psychiatric medications". The Physician Plan included withholding all Resident 1's antipsychotic medications. Two doses of Ativan were ordered to be given. Subsequently Resident 1 was continued on low dose Ativan 0.25 mgm three times a day, for intermittent agitation.A hospital Physician Progress Record dated 1/31/13 indicated Resident 1 was not speaking, and was described as "almost catatonic" (characterized by lack of movement, activity or expression). Physician Progress Notes indicated Resident 1 was observed to have bilateral cogwheel movement in the upper extremities, a symptom of Pseudoparkinsonism associated with the use of Risperdal. (When a muscle was stretched the muscle responded with cogwheel like jerks.)Review of subsequent Physician Progress Notes in the hospital record indicated as the antipsychotic medications cleared from her body, Resident 1 became more alert, and began communicating. A Discharge Note, dated 2/6/13 indicated Resident 1 was up, out of bed and walking and talking, with some residual cogwheel movement in the arms. Resident 1 remained off of Risperdal.During an interview, on 2/6/14 at 9:15 A.M., the Director of Nursing (DON) stated she remembered Resident 1. The DON discussed the care Resident 1 had received at the acute care hospital and stated, "Akathesia or something," as her understanding of the acute care hospital's diagnosis for Resident 1.Review, of the facility policy titled "Behavior/Psychotropic Drug Management", last revised 11/1/13, indicated the policy specified resident care plans for psychotropic medications would include adverse reactions, and any side effects of the medication(s).There was no evidence that facility staff monitored the decline in Resident 1's functioning as possible medication side effects as documented in the care plan because the care plan did not specify what data was to be collected to use in the evaluation of adverse reactions.The facility failed to ensure Resident 1's care plan documented the potential adverse effects of psychotropic medications (Risperdal-an antipsychotic indicated for the treatment of major mental illnesses such as schizophrenia and Ativan-an antianxiety medication) so staff could monitor Resident 1 for the presence of these side effects (Akasthesia: a side effect of Risperdal-an inner restlessness that is manifested by the inability to sit still and by the urge to constantly move: Pseudoparkinsonism: a side effect of Risperdal-manifested by muscle rigidity, Cogwheeling or ratcheting of the muscles, and difficulty in walking among other things; and decreases in mental acuity: a side effect of Risperdal and Ativan). As a result, Resident 1, who was alert and able to walk on admission on 12/8/12, became obtunded and unable to stand 51 days later, on 1/28/13. The facility sent Resident 1 to the hospital where Resident 1 was diagnosed as suffering from side effects to the medication. When the hospital discontinued the medication, Resident 1 became alert, and was able to talk, and was able to walk at the time of discharge from the hospital.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. |
| 010000657 |
Estes House |
110010557 |
B |
04-Apr-14 |
3HZB11 |
5871 |
A008 Welfare & Institution 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, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to keep Client 1 safe from harm, on 11/30/11, when transport staff did not close the right-side passenger door of the van, while unfastening Client 1's wheelchair tie down straps, which resulted in Client 1 falling out of right side of the van, onto the pavement, between the van and the curb. Client 1 landed on her right side, while still strapped in her wheelchair, sustained a head injury on the right side and complained of pain in her right arm/shoulder. The facility is an Intermediate Care Facility for people with developmental disabilities who also require around-the-clock nursing care and is licensed to provide care and services for up to six clients with varying degrees of physical and developmental disabilities.A review of Client 1's medical record indicated she had multiple medical diagnoses which included cerebral palsy and profound cognitive disability. A review of Client 1's most recent Comprehensive Functional Assessment, dated 8/3/11, indicated under, "Personal Living Skills," that she was dependent upon staff for all personal care.During an observation on 12/2/11 at 2:08 p.m., Client 1 was crawling in her room, which was a customary mode of mobility. Client 1 had swelling under her right-side hairline.During an interview on 12/2/11 at 3:03 p.m., Licensed Staff A stated that sometimes when Client 1 was in the wheelchair she would, "bob from side to side." During an interview on 12/2/11 at 2:09 p.m., DCS B (Direct Care Staff) stated that she went out of the facility to bring Client 1 from curbside and into the house. DCS B stated that she saw Client 1 in the wheelchair in the street between the van and the curb. DCS B stated it was unusual because when she came out to the van, Client 1 was usually at the back of the van where the (electric) wheelchair lift was. DCS B stated she noticed that DSP C (Direct Support Personnel/bus driver) appeared shaken. DCS B stated DSP C told her that Client 1 had fallen out of the side of the van. DCS B stated she did not witness the fall, and by the time she saw Client 1 in the wheelchair, the wheelchair was upright. DCS B stated she saw blood on the right side of Client 1's mouth. During an interview on 12/2/11 at 2:37 p.m., DSP D, another bus driver, explained the wheelchair had two tie downs in the front and two in the back to secure the wheelchair in the van. DSP D stated that if the front tie downs were unfastened and the back tie downs remained tied down, a wheelchair would remain in place. When all tie downs were unfastened, the wheelchair was no longer secured to the van. During an interview on 12/19/11 at 10:28 a.m., DSP C, who unfastened the tie downs at the time of Client 1's fall, stated that he opened the right side doors of the van, and unfastened the hooks/tie downs from the front of Client 1's wheelchair. DSP C stated that he then entered the van from the right side (where the double doors were open) and went behind Client 1 in order to unfasten the rear tie downs. DSP C stated he did not enter from the rear of the van. DSP C stated that after unfastening the rear wheelchair tie downs, he checked the wheelchair brakes, turned his back, and as he was putting the tie downs into a storage bag, he turned back toward Client 1 and, "she was already falling and half-way out the door." DSP C stated that Client 1 had behaviors where she would rock in her wheelchair, and he believed that she rocked hard to the right and fell out. DSP C stated that her wheelchair was also tied down, "too close," to the step edge on the right side of the van. DCS C stated that after the accident he now closed the side door after unfastening the front tie downs of the wheelchair.A review of Nursing notes, dated 11/30/11, revealed Client 1 grimaced when her right shoulder area was touched and when the right side of her head was touched. The notes indicated she had a large bump, "golf ball in size," approximately one inch above her right ear, with blood noted. Client 1 was transported to the hospital emergency room for evaluation. A review of the Emergency Room visit report, dated 11/30/11, indicated Client 1 was diagnosed with a, "contusion with hematoma" (bruising and swelling filled with blood), of the right parietal area of the skull (right side of the skull).A review of the document, "Rights of the Developmentally Disabled," dated 8/4/10, indicated that each person residing at the facility had rights including the right to humane care. The facility failed to keep Client 1 safe from harm, when transport staff, in preparation for assisting Client 1 out of the parked van, did not close the right-side passenger door of the van while unfastening Client 1's wheelchair tie down straps. Client 1 fell out of right side of the van, onto the pavement, between the van and the curb and landed on her right side, while still strapped in her wheelchair, sustained a head injury on the right side and complained of pain in her right arm/shoulder. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110010655 |
A |
16-Sep-14 |
P3QU11 |
18355 |
72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility violated the regulation by failing to implement their policies and procedures for "Antipsychotic Medications" and "Behavior Management," when Resident 1, who had dementia with behavioral disturbances, received three antipsychotic medications (Risperdal, Zyprexa and Seroquel) to control aggressive behaviors. Twenty one days after adding Zyprexa and 11 days after doubling the dose of Risperdal, Resident 1 had a sudden change of condition and was unable to walk and required a mechanical lift and two staff to transfer from bed to wheelchair and was dependent on staff for eating. The aggressive behaviors stopped and the physician continued the three antipsychotic medications at the same dosage, without documenting the clinical rationale, in the presence of side effects that indicated the dose should be decreased or the drug discontinued, which was contrary to the facility policy and procedure regarding antipsychotic medications. These failures resulted in Resident 1 exhibiting antipsychotic side effects of Parkinsonism symptoms that included being mute, not able to stand, pill rolling, and muscle rigidity.The Face Sheet revealed that Resident 1 was admitted to the facility on 4/16/12 with admitting diagnosis of dementia with behavior disturbance following an emergency room evaluation, on 4/15/12 at 9:00 a.m., for combative assaultive behavior.Admission Minimum Data Set (MDS - an evaluation tool), dated 4/26/12, indicated that Resident 1 was not able to understand others or be understood. Resident 1 exhibited behavioral symptoms and wandered daily. Resident 1 was able to walk with supervision. The May 2012 Psychotherapeutic Drug Summary Sheet for the medication Risperdal (antipsychotic) noted 44 episodes of acute physical aggression. The May 2012 MAR revealed that the physician increased Seroquel (antipsychotic) to 75 milligrams (mg) three times a day (TID) on 5/7/12, and on 5/27/12, the second antipsychotic Risperdal was changed from 1 mg three a day (TID) to 1.5 mg BID (total of 3 mg daily) for verbal hostile outbursts. The physician order, dated 4/19/12, for the as needed Risperdal 0.5 mg every four hours as needed continued. The June 2012 MAR noted doses of the as needed Risperdal 0.5 mg were administered on 6/9/12 at 8 a.m. and 12 noon; 6/10/12 at 8 a.m., and 12 noon; 6/11/12 at 8 a.m., and 11:30 a.m.; 6/12 at 12 noon; 6/14/12 at 8 a.m.; 6/21/12 at 8:45 a.m. and 6/28/12 at 7:30 a.m. A third antipsychotic medication, Zyprexa 2.5 mg twice a day (bid) was noted as administered starting 6/12/12 for acute agitated physical aggression. Nurses notes dated 6/11/12, indicated that Resident 1 had closed fists during dining and hit a staff member and Resident 1 walked with a steady gait.Physician Orders dated 6/11/12 for the third antipsychotic, Zyprexa at 2.5 mg BID, for acute agitated physical aggression. Nurses notes dated 6/12/12 indicated that Resident 1 had exhibited aggressive behavior in the dining room and was given an additional dose of the as needed Risperdal 0.5 mg, with good effect.A fax dated 6/16/12 was sent to the physician noting that [psychiatric nurse practitioner] recommends to D/C [discontinue] Risperdal 1.5 mg BID and increase to Risperdal to 2 mg BID for one day, then 2.5 mg BID for one day, and then 3 mg BID and to discontinue the Zyprexa. The physician noted "OK with Risperdal, keep Zyprexa for now." June 2012 Physician orders for Risperdal included: On 6/19/12 the Risperdal was increased from 1.5 mg BID (3 mg daily) to 2 mg BID (total of 4 mg daily), on 6/20/12 the Risperdal was increased to 2.5 mg BID (total of 5 mg daily), and on 6/21/12 the Risperdal was increased to 3 mg BID (total of 6 mg daily).The June 2012 MAR noted that doses of the as needed Risperdal 0.5 mg were given on 6/21/12 and 6/28/12 for behaviors of yelling and fidgeting. (Risperdal manufacturer insert: May increase dosages above 1.5 mg twice daily [3 mg daily] at intervals of one week or longer...Adverse reactions, the most common adverse reaction in clinical trials were Parkinsonism...). During an interview, on 9/10/12 at 11:10 a.m., the Facility Pharmacy Consultant stated that the increase of Risperdal in June from 1.5 mg twice a day to 3 mg twice a day, within a 3 day timeframe, was very rapid and not consistent with the drug specifications. In June 2012 Resident 1's antipsychotic medications included Risperdal, Zyprexa, and Seroquel. All three carry a US Food and Drug Administration black box warning, the strongest warning they require. Warnings/Precautions [U.S. Boxed Warning]: Elderly patients with dementia-related psychosis treated with antipsychotic's are at an increased risk of death compared to placebo. Included with the warning: Risperdal, Zyprexa, and Seroquel are not approved for the treatment of dementia-related psychosis. Nurses notes dated 7/2/12, indicated (21 days after adding Zyprexa and 11 days after the increased doses of Risperdal to 6 mg per day) "Resident observed not being able to ambulate this shift. Unable to self-transfer, requires 2 person extensive assist with transfer, feeding total dependent ...Notified [name of physician] via fax ...Meds [medications] held this shift due to lethargy." During an interview, on 9/7/12 at 3 p.m., Certified Nursing Assistant (CNA) A stated that she was assigned to Resident 1 daily and worked full time. Resident 1 was ambulatory when first admitted but had a rapid decline in July 2012. Resident 1 required a mechanical lift to transfer from bed to wheelchair. Resident 1 was in the wheelchair from early morning, before breakfast until after dinner at night, with 2 person assist with a mechanical lift to transfer from wheelchair to toilet after breakfast and lunch. CNA A stated that Resident 1 spent his day in the wheelchair in the activity room and "doesn't want to do much, he just sits there." During an interview, on 9/10/12 at 10 a.m. Licensed Nurse (LN) C stated that Resident 1 had a significant change in condition on 7/2/12, Resident 1 suddenly could not walk, could not transfer, needed a mechanical lift to move from wheelchair to bed and that medications were held that day due to lethargy and a fax had been immediately sent to the physician. When queried, LN C stated that the Care Plans were not updated, following this change, to include preventative measures for potential complications due to the sudden immobility, such as blood clots to the legs. "I should have thought of that but just didn't, we didn't change the Care Plans." LN C also stated that in June 2012 the behavioral health nurse practitioner had recommended discontinuing the Zyprexa and starting a gradual dose reduction of Seroquel, and the attending physician replied no to both. During an interview, on 9/10/12 at 1 p.m., Rehabilitation Nursing Assistant (RNA) D stated that Resident 1 walked upon admission, but in July had a severe decline in ability to ambulate, which required a mechanical lift to transfer from bed to wheelchair.A fax, dated 7/3/12, was sent to the physician noting a change in condition: "Res [Resident 1] has had a decline in ADL's [Activities of Daily Living] of ambulation. Requires 2 person transfers ..." The physician responded "OK" on this fax form. The MAR's for June 2012 and July 2012 noted zeros in the side effect monitoring for the three antipsychotics by the licensed nursing staff.During an interview, on 9/13/12 at 3:30 p.m., LN B, when queried about symptoms of Parkinsonism side effects to medications, stated that Resident 1 had a decline in ability to walk and that was a symptom of Parkinsonism. LN B had not recorded this on the MAR under side effects for antipsychotic medications for Resident 1. LN B concurred that Resident 1 required extensive assist of 2 staff for transfers from bed to wheelchair. During an interview, on 9/10/12 at 2:40 p.m., LN C stated that the inability to walk should have been noted as a side effect of the antipsychotic medications, but had not documented this on the MAR's. On 7/11/12 a fax was sent to the physician and noted that the psychiatric nurse practitioner recommended a gradual dose reduction (GDR) of Seroquel. The physician responded no, with no clinical rationale noted, in the presence of side effects that would indicate the dose should be decreased or the drug discontinued. The physician monthly progress note, dated 7/14/12, noted "calmer than before, no altercations, not ready for physical therapy yet...continue current plan." This note did not address the change in ADL's that were reported via facsimile on 7/2/12, or the three antipsychotic medications. The Behavior Management Evaluation and Review, conducted by the Interdisciplinary Team (IDT) on 7/25/12, noted that Resident 1 had a "demential decline," behaviors had stabilized since physical decline, and no adverse side effects of medications were observed. Resident 1's geriatric physician (Physician E), from another facility, note dated 7/26/12, included a general exam with the following findings: speech - mute, not able to stand, masked facies [immobile facial expression - usually occurring with Parkinson's], muscle wasting, with mild to moderate muscle rigidity throughout, pill rolling [a Parkinsonism tremor of the hand - also a Parkinsonism symptom], significant bradykinesia [slow movement] and resting tremor [tremor present when muscles are resting].This physician also noted that the toes on the right foot were purplish and required further medical evaluation. Physician E's plan included sending a letter to the physician at the facility.Another physician (Physician F), from this other facility, added a progress note, dated 7/26/12: "I evaluated [Resident name] in person and agree with assessment and plan...with rapid decline over last 3 months most consistent with over sedation and high doses of antipsychotic's. Recommend tapering off to a lower dose and using one antipsychotic..." (Secondary Parkinsonism is similar to Parkinson's disease but it is caused by certain medicines, which include antipsychotics. Common symptoms include: Decrease in facial expressions, difficulty starting and controlling movement, loss or weakness of movement (paralysis), soft voice, stiffness of the trunk, arms, or legs and tremor.http://www.nlm.nih.gov/medlineplus) Physician E submitted a letter to the attending physician at the facility, dated 7/26/12, and noted "noticeably Parkinsonism due to antipsychotics."The recommendations included: "To minimize poly-pharmacy and reduce Parkinsonism, decrease Risperdal to 0.5 to 1 mg by mouth twice a day with Risperdal 0.5 mg when needed for agitation, consider tapering off Seroquel." Physician E also recommended a follow up to evaluate the right foot which was purple and swollen, and that if Resident 1 was experiencing pain, this could be another reason for episodes of agitation.Physicians orders dated 7/29/12 decreased the Risperdal to 0.5 mg BID for verbal, hostile outbursts and continued the as needed Risperdal 0.5 mg every eight hours. A Doppler ultrasound (test to examine the blood flow in arteries and veins), done on 7/30/12, indicated deep vein thrombosis (blood clots) involving right upper leg veins and left knee vein.(Deep Vein Thrombosis (DVT): occurs when a blood clot or thrombus (a stationary blood clot against the wall of a blood vessel), develops in the large veins of the legs or pelvis. When a blood clot travels from the legs and lodges in a lung artery, the condition is known as a "pulmonary embolism," a potentially fatal condition if not immediately diagnosed and treated. Causes include individuals on bed rest or those who are confined and unable to walk for prolonged periods of time...Vascular Disease Foundation - DVT). The July 2012 MAR revealed that on July 30, 2012 Resident 1 received Lovenox 100 mg, a blood thinner, by injection one time a day, and another blood thinner, Coumadin 7.5 mg by mouth at bedtime. A physician progress note dated 8/4/12 noted a new diagnosis of deep vein thrombosis and drug induced Parkinson's disease. A drug regimen review dated 8/10/12 was conducted by the pharmacy consultant, who noted that Resident 1 was on two or more antipsychotic medications, Risperdal, Zyprexa and Seroquel, and "if this therapy is to continue, it is recommended that the prescriber document an assessment of risk versus benefit, indication that it continues to be a valid therapeutic intervention for this individual..." This form was sent to the physician via fax and the physician noted on this form, dated 8/13/12, "no changes, responding to current plan." A fax sent to the physician dated 8/20/12 indicated that Resident 1's behaviors were stable and that the Interdisciplinary Team (IDT) requested a gradual dose reduction of the antipsychotic medication Seroquel. The physician indicated no on the form, without clinical rationale noted on the fax or the medical record. A physician progress note dated 9/1/12 noted "quiet, less agitation...," with no changes to antipsychotic medications ordered. During an observation, on 9/5/12 at 3:20 p.m., Resident 1 was seated in a wheelchair in the Activity Room, with no facial expression. Resident 1 was not engaged in any activity, and did not respond to other residents or staff during the activity. During an observation, on 9/13/12 at 3:40 p.m., Resident 1 was seated in a wheelchair in the smaller activity room; Resident 1 had no facial expression, appeared blank, and was sitting quietly, with no apparent movements. During an interview, on 3/18/13 at 2 p.m., Resident 1's physician stated that Resident 1 was hurting others from admission on 4/16/12 and the medications were increased to prevent these behaviors. When queried about the presence of Parkinsonism side effects, the physician stated that Risperdal always caused parkinsonian symptoms. The physician stated that the medication increase was justified due to Resident 1's violent behaviors, and that the three antipsychotic medications were used to control those behaviors. A facility policy and procedure, titled "Psychotropic Medications" dated 11/05, indicated: ... "8. General psychotropic information iii Initiate medication with lower class [lower class not defined] and only gradually increase the dose with documented information ... 2. When these drugs are used outside recommended doses, documentation should show valid reasons for increased dose and positive outcomes. 3. Residents receiving these medications must be monitored for significant side effects with documentation; including...e. Parkinson's... 4. Dose may exceed recommended dose if documentation shows necessity for maintenance or improvement in the resident's functional status... 5. Examples of evidence that would support a justification of why a drug is being used outside the guidelines, but in the best interest of the resident include:a. A physician's note indicating the use of the drug, or continued use of the drug is clinically appropriate, and the reasons why this use is clinically appropriate. This note must demonstrate the physician has carefully considered the risk/benefit to the resident in using drugs outside these guidelines.b. A medical or psychiatric consultation or evaluation confirming the physician's judgment that use of a drug outside the guidelines is in the resident's best interest...e. Documentation (including MDS documentation) showing resident's subjective or objective improvement of function while taking the medication.f. Documentation showing a resident's decline or deterioration is evaluated by the IDT to determine whether a particular drug, or a particular dose or duration of the medication may be the cause...9. Gradual dose reduction.a. Gradual dose reductions consists of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether.b. Residents taking a psychotropic medication must, unless clinically contraindicated, undergo a gradual dose reduction...e. A resident need not undergo a gradual dose reduction or behavioral intervention if: ...iii. The resident's physician provides a justification why the continued use of the drug and dose are clinically appropriate. The justification should include: ...3. A description of the justification for the choice of a particular treatment, or treatments, 4. A discussion of why the present dose is necessary to manage the resident's symptoms..." A policy and procedure, titled "Behavior Management" dated Revised 11/05, indicated:"9. If the resident has an order for psychotropic medications, the side effects should be noted and monitored on the Medication Administration Record (MAR). These MARs should be reviewed for evidence of signs and symptoms of side effects related to psychotropic medication as part of the IDT review process."The facility violated the regulation by failing to implement their policies and procedures for "Antipsychotic Medications" and "Behavior Management," when Resident 1, who had dementia with behavioral disturbances, received three antipsychotic medications (Risperdal, Zyprexa and Seroquel) to control aggressive behaviors. Twenty one days after adding Zyprexa and 11 days after doubling the dose of Risperdal, Resident 1 had a sudden change of condition and was unable to walk and required a mechanical lift and two staff to transfer from bed to wheelchair and was dependent on staff for eating. The aggressive behaviors stopped and the physician continued the three antipsychotic medications at the same dosage, without documenting the clinical rationale, in the presence of side effects that indicated the dose should be decreased or the drug discontinued, which was contrary to the facility policy and procedure regarding antipsychotic medications. These failures resulted in Resident 1 exhibiting antipsychotic side effects of Parkinsonism symptoms that included being mute, not able to stand, pill rolling, and muscle rigidity.This violation presented either imminent danger of death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110011120 |
A |
18-Nov-14 |
7QKK11 |
6789 |
72311(a) (1) (A) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.The facility failed to incorporate preventative measures to avoid Resident 1, who was a double below the knee amputee, from falling off the commode chair (a movable chair with arm rest and a back that has a hole in the seat and fits over the toilet as an aide for people with mobility limitation). On 5/3/11, Resident 1 received a laceration to the right forehead, requiring 20 sutures and cervical spine fractures after he fell to the floor in the bathroom. The medical doctor ordered Resident 1 to the emergency department for his injuries.Review of Resident 1's admission record dated 4/13/2011, indicated the need for skilled wound care, physical and occupational therapy for a newly left leg below the knee amputation. Other diagnosis included; a right below the knee amputation, end stage renal disease with dialysis, diabetes mellitus which requires insulin [medication that lowers sugar in the blood], high blood pressure, atrial fibrillation (very rapid heart rate), spine disc disease, generalized muscle weakness and difficulty walking. Review of Resident 1's "Minimum Data Set" (a resident assessment and screening tool to determine how much help is needed with activities of daily living) dated 4/26/11, reflected; no mental decline and a functional status of total dependence on two staff at a time for toileting which included cleanses after elimination.Review of Resident 1's "Occupational Therapy Evaluation, Plan Care..." dated 4/14/11, reflected impairments in range of motion in both shoulders, elbows and wrists. His back was kyphotic (exaggerated outward curvature of the thoracic region of the spinal column resulting in a rounded upper back) with lordosis (exaggerated forward curvature of the lumbar and cervical regions of the spine.)During a review of the clinical record for Resident 1, the "Physical Therapy Short Term Care Plan" dated 4/14/11 indicated, that Resident 1 had problems related to: impaired mobility, decreased strength and endurance, decreased balance and coordination, joint mobility limitation and gait issues. During an interview on 5/31/11 at 11:45 a.m., when asked about assisting Resident 1 to the toilet on 5/3/11, Certified Nurse Assistant Staff A (CNA) stated, with assistance from another CNA they lifted Resident 1 using a gait belt (a belt that fastens around the waist to prevent holding on to a person under-arms) and a bed sheet beneath his legs to transfer him onto a shower/toilet chair. When asked if she put on Resident 1's right leg prosthesis, Staff A replied no. Staff A stated that she stood outside the closed bathroom door to give Resident 1 privacy, while on the toilet, and instructed him to call for help. I heard him fall and asked him how he fell. Staff A stated Resident 1 replied that he was reaching for toilet paper...thought I could do it myself.During a review of the clinical record for Resident 1, the "Fall Evaluation" dated 4/13/11 reflected a total score of 12, which indicated routine fall precautions.Review of the "Nurses' Notes" dated 4/15/11 at 11:20 p.m. reflected that Resident 1 fell out of bed while sleeping. Review of the facility's "Fall Management" policy and procedure indicates to consider residents who have fallen in the past 3 months high potential for falls and to implement appropriate care plan interventions for fall management.Review of " Resident 1's Care Plan Dated 4/15/11 did not include updated or additional approaches to reflect being at a high risk for falls.During an interview on 5/12/14 at 2 p.m., when asked if Resident 1's right leg prosthesis may have prevented him from falling off the toilet, Physical Therapist (PT) Staff D replied that the prosthesis would have helped decrease the chance of falling since the center of gravity (the point at which the entire weight of a body may be considered as concentrated so that if supported at this point the body would remain in equilibrium in any position) moves to the upper body when the lower limbs are removed. When asked if Resident 1 could prevent his fall by using grab bars, PT Staff D replied no, that he did not have the strength or range of motion to use a grab bar. When asked if he instructed staff or care planned for Resident 1 to use his right leg prosthesis to decrease fall risk, PT Staff D replied no. Review of the "Fall Risk Interdisciplinary Care Plan" dated 4/15/11, indicated Resident 1: had problems with falls within the past 3 months, problems standing and walking, and required assistive devices. The goals were to use assistive devices safely and not experience injuries from falls. Certified Nursing Assistant approaches were to, keep assistive devices within easy reach and encourage resident to wear non-slip safety shoes. The care plan did not mention safety approaches or interventions regarding safety while on toilet nor did it reflect to use the right leg prosthesis to prevent falling while seated on the toilet seat, or that he was a double amputee.During an interview and concurrent chart review on 5/17/14 at 12:15 p.m., when asked about Resident 1's initial fall risk score, the Director of Nurses (DON) stated that she felt it was too low for Resident 1's condition and after the first fall the score should have gone up to reflect high risk and that the risk assessment after the fall was not addressed in the care plan.When asked if the nurse should incorporate P.T. and O.T evaluations in Resident 1's care plan, the DON replied yes.Review of an untitled and undated page with six typed lines, supplied by the DON, reflected the following: Nursing service shall include... Planning of patient care... and include at least the following... Identification of care needs based upon an initial written and continuing assessment of the patient ' s needs with input as necessary, from health professionals involved in the care of the patient.The facility's failure to incorporate preventative measures to avoid Resident 1 from falling off a commode chair resulted in a laceration to his right forehead, requiring 20 sutures, and cervical spine fractures. The medical doctor ordered Resident 1 to the emergency department for his injuries.This failure presented imminent danger of death or serious harm to patients, or a substantial probability of death or serious physical harm to patients. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110011216 |
B |
15-May-15 |
030I11 |
10764 |
B825 T22 DIV5 CH3 ART3-72311(a)(1)(C) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to review, evaluate and update Resident 1's care planning related to falls and safety. Resident 1, known by staff to slouch, hunch over, and nap, while in the wheelchair before the fall (on 8/26/12,) was not provided care planning and supervision consistent with her specific conditions, risks, needs and behaviors to reduce her risk for falls. Resident 1, unsupervised in a wheelchair in her room, fell to the floor on 8/26/12, and sustained bruising around her right eye and a three centimeter stellate (star shaped) facial laceration to the forehead, which required sutures. Resident 1's face sheet (an informational document) indicated Resident 1 was admitted to the facility on 3/2/09. Resident 1 had multiple diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, depressive disorder, difficulty in walking, and muscle weakness. Physician orders, dated 3/2/09, indicated Resident 1 did not have capacity to understand and make healthcare decisions.The quarterly MDS, dated 7/16/12, indicated Resident 1's vision was highly impaired, her cognition skills for daily decision making were severely impaired, she had delusional behavior, she rejected care frequently, four to six days a week, she required extensive assistance with transfers, and she took psychotropic medications seven days a week. Fall risk assessments indicated on 4/9/12, Resident 1 was scored at 21, and on 7/19/12 (before the August fall), was scored at 15. (The assessment report indicated a score of 13 and above was considered a high risk for falls). A fax transmittal, dated 1/14/12, from the facility to the primary physician, indicated a request to discontinue the wheelchair alarm because Resident 1 no longer ambulated or attempted to transfer from the wheelchair. The request was signed by the physician.During an observation on 9/6/12 at 8:46 a.m., Resident 1 was in a low bed, awake, verbal and confused. Resident 1 had a healing wound, well approximated (the wound edges of the tissue drawn together with sutures), approximately 1/2-1 inches on the forehead, and had bruising around both eyes. On 9/6/12 at 9:46 a.m. Unlicensed Staff C stated Resident 1 would sometimes slouch in the wheelchair and not sit straight. Unlicensed Staff C stated Resident 1 did not use a seat belt in the wheelchair, and there was no wheelchair head rest.On 9/6/12 at 9:34 a.m. Licensed Staff D stated Resident 1 required maximum assistance for all care, which included toileting, dressing, feeding, hygiene, and transfers. Licensed Staff D stated Resident 1 did not walk, could not follow directions, and was confused. On 9/6/12 at 10:15 a.m. Therapist G stated Resident 1 did not follow directions, and when one asked Resident 1 to sit up straight, she would not do it. Therapist G said staff would have to really get her attention and give her physical cues to sit up. Therapist G stated Resident 1 had a tendency to flex her trunk, hunch over and lean to one side or the other. Resident 1, per the Physical and Occupational Therapy Evaluations, dated 2/12/12, received therapy services three times a week until 4/6/12. On 9/6/12 at 2:02 p.m., Unlicensed Staff A stated that he provided feeding assistance to Resident 1 on the day of her fall (8/26/12). Unlicensed Staff A stated Resident 1 was leaning over in her wheelchair like she was sleepy.During an interview on 9/6/12 at 3:12 p.m., Unlicensed Staff A stated that Resident 1 was napping in her wheelchair while she waited for her food (on the day of the incident, 8/26/12). Unlicensed Staff A stated that this was normal for her, and another staff took her to her room after dinner. On 9/6/12 at 10:50 a.m., Unlicensed Staff B stated he was the staff who took Resident 1 to her room, from the dining room, after the dinner meal on the day of the fall (8/26/12). Unlicensed Staff B stated he left her in her wheelchair, in her room, to get the mechanical lift and another staff to help get her to bed after dinner. Unlicensed Staff B stated Resident 1 did not have a seat belt on, and when he returned, Resident 1 was face down on the floor. Unlicensed Staff B stated he did not hear her fall or hear an alarm. Unlicensed Staff B stated she was moaning softly, not saying anything, and there was blood on the floor where her face was.The facility, "Unusual Occurrence Report," dated 8/26/12, indicated a Certified Nurse Assistant found Resident 1 on the floor, lying on her stomach. The report indicated Resident 1 was unable to explain what happened. Resident 1 obtained a laceration of 3 cm x 0.3 cm, to the her right eyebrow. A Physical Therapy (PT) Evaluation, dated 2/4/12, indicated Resident 1 was ordered PT due to significant weakness, impaired balance, and a history of falls. "Impairments," included decreased activity tolerance, impaired mobility, impaired posture, and poor safety awareness. A PT discharge summary, dated 4/6/12, indicated Resident 1 had improved, balance but her safety awareness did not improve and continued to be evaluated as, "poor." The PT discharge summary did not include any recommendations to support Resident 1 while in her wheelchair. Resident 1 was referred to the RNA (Restorative Nursing Assistant) for a maintenance program. An Occupational Therapy (OT) Evaluation, dated 2/4/12, indicated OT was ordered for Resident 1 due to general muscle weakness and functional decline. Resident 1 required moderate to maximum assistance with transfers and had, "Impairments," that included poor, "hunched," posture, poor activity tolerance, and poor standing balance. Resident 1's short-term goals included minimum to moderate assist with transfers and increased, "arm mobility for better self-care." Resident 1's long-term goal was to get back to her prior level of functioning and to have good safety skills (Prior level of functioning was walking with and without a walker). The evaluation indicated that wheelchair/management training was included as part of the plan.On 12/4/14 at 1:55 p.m. Therapist G stated she was the author of the OT documents. Therapist G stated Resident 1 was not able to stand. Therapist G stated, the poor/hunched posture described Resident 1's sitting posture. Therapist G stated Resident 1 did not have good balance when sitting.A review of the OT Discharge, dated 4/6/12, indicated Resident 1 required minimum to moderate assistance with transfers, which was an improvement. The summary indicated that Resident 1 required, "regular adjustments for tolerance and fatigue," but provided no recommendation on how staff was to do this. The report did not include a re-evaluation of Resident 1's sitting balance. The report did not include recommendations to provide improved postural support for Resident 1, while in her wheelchair, or provide monitoring Resident 1's for safety. The summary indicated that safety training was provided, but did not indicate if Resident 1's safety awareness had improved or not.A review of Resident 1's Fall Risk Care Plan, dated 10/27/11, and revised 1/12/12, and 4/12/12, did not account for the known problems of Resident 1's poor posture, such as slouching and napping in her wheelchair and included no interventions to reduce Resident 1's risk of falling from her wheelchair. The care plan did not include interventions regarding supervising Resident 1 while she was in her wheelchair. The Fall Risk Care Plan, under the section, "Problem/Need," indicated Resident 1's fall risk was scored as 16 (high risk), Resident 1 had previous falls, was wheelchair bound, had problems with standing and walking, had decreased coordination, had dementia, and was on medications that could contribute to falls: anti-psychotics, anti-anxiety and blood pressure medications. The "Problems" list did not include any notations regarding Resident 1's leaning or slouching posture while in her wheelchair. The section, "Approach/Plan," indicated nursing was to complete a fall assessment every quarter and as needed. The care plan did not have any interventions to minimize rocking, slouching, or leaning in the wheelchair, such as providing a reclining wheelchair and did not include interventions about supervising Resident 1 to prevent falling.A review of an IDT Progress Note regarding the facility investigation of Resident 1's fall, dated 8/28/12 (written after the fall,) indicated staff (unnamed) noticed Resident 1 was falling asleep at the dinner table and was, "kind of leaning forward ..." Resident 1 was taken to her room so she could be put to bed. The staff left Resident 1, who was in a wheelchair, and went out of the room to find a mechanical lift so Resident 1 could be put to bed. The IDT note indicated that staff would be reminded that, "if a resident is falling asleep in their wheelchair, they [should] not be left alone ..." The IDT note indicated that Resident 1 "should have remained in the dining room and supervised until the time she goes to bed without a break in supervision." On 9/6/12 at 11:30 a.m. Licensed Staff I was asked about Resident 1 being left alone. After Licensed Staff I reviewed the 8/28/12, IDT Progress Note, she stated that some things were common sense, and Resident 1 should have been kept in the dining room, supervised. The facility policy, "Fall Evaluation and Management," updated 9/2014, indicated if the total score was 13 or greater on a fall evaluation, the resident is considered to have a high potential for falls, and the facility will implement specific care plan measures in order to minimize the risk. Therefore, the facility failed to review, evaluate and update Resident 1's care planning related to falls and safety. Resident 1, known by staff to slouch, hunch over, and nap, while in the wheelchair before the fall (on 8/26/12,) was not provided care planning and supervision consistent with her specific conditions, risks, needs and behaviors to reduce her risk for falls. Resident 1, unsupervised in a wheelchair in her room, fell to the floor on 8/26/12, and sustained bruising around her right eye and a three centimeter stellate (star shaped) facial laceration to the forehead, which required transfer to the local emergency department for sutures. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of residents. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110011830 |
B |
24-Nov-15 |
LX0B11 |
2582 |
T22 DIV5 CH3 ART5-72527(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 regulation by failing to keep Resident 1 from being subjected to verbal abuse when one (Resident 2) resident began yelling profanities and threatened to kill Resident 1. This failure resulted in Resident 1 stating that she felt vulnerable and anxious.Resident 2's demographic record, dated 4/18/13 (resident identifying information),indicated that Resident 2 was a 41 year old male, admitted with a diagnosis of quadriplegia, Type 2 diabetes and paranoid delusions.During an interview on 4/11/13 at 2 p.m., Administrative Staff A stated that Resident 2 had a history of angry outbursts. Administrative Staff A stated that on 4/9/13 Resident 2 was yelling profanities from his bed out to the hallway directed at Resident 1. Administrative Staff A stated that Resident 2 has refused behavior consults.During an interview on 4/11/13 at 2:15 p.m., Police Officer B stated that they were called by Resident 2. Police Officer B stated that Resident 2 did not want the facilities administrator (Administrator C) to enter his room. Police Officer B also stated that the police department had received numerous phone calls concerning Resident 2's behaviors of angry outbursts, profanity and threatening manner. During an interview on 4/11/13 at 2:45 p.m., Resident 1 stated that on 4/9/13, she was in the hallway speaking with another resident when Resident 2 began yelling profanities, "Stupid white cunt. I want to kill you." Resident 1 stated that Resident 2 has a history of lashing out at staff members and now has started lashing out at the residents. Resident 1 also stated that she feels vulnerable and anxious. The facility violated the regulation by failing to keep Resident 1 from being subjected to verbal abuse when one (Resident 2) resident began yelling profanities and threatened to kill Resident 1. This failure resulted in Resident 1 stating that she felt vulnerable and anxious.This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 110001255 |
Evergreen Lakeport Healthcare |
110011974 |
A |
03-Mar-16 |
IIDI11 |
7834 |
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 Resident 2 from harm when the facility did not identify (in the resident's care plan), nor provide a need for adequate supervision for Resident 2, resulting in elopement from the facility. The resident fell, while in her wheel chair after leaving the facility, which resulted in a fractured hip.Review of Resident 2's "Face Sheet" in the resident's clinical record revealed the resident was a 83 year old woman with diagnoses that included dementia with behavioral disturbances, difficulty in walking, memory loss and cognitive communication deficit. Review of Resident 2's Minimum Data Set (an assessment tool), dated 8/14/15, indicated that Resident 2 had short and long term memory problems, with moderately impaired cognitive skills for making daily decisions, had disorganized thinking, inattention, and exhibited wandering behavior 4-6 days over a course of seven days. Resident 2's clinical record contained an Elopement/Exit - Seeking Evaluation form. The evaluations were performed on 1/12/15, 5/18/15, and 8/26/15. All evaluations indicated the resident was at risk for elopement.The resident's Physician Order Sheet included a physician order dated 3/6/15 for a code alert bracelet to alert staff of attempts to elope. The order further indicated "CODE ALERT BRACELET TO ALERT STAFF OF ATTEMPTS TO ELOPE. CHECK FOR PLACEMENT AND FUNCTION Q SHIFT. PLACED ON LEFT ARM." During an interview on 11/18/15 at 4:25 p.m., with Unlicensed Staff AD, she stated that on 11/16/15 at 6:09 a.m., she was in the staff break room when she heard the Wanderguard alarm (a Wanderguard is an alarmed monitoring system often used for residents with dementia to alert staff when a resident attempts to exit a door) sounded in Hall 4. She stated she went outside the exit door and found two nurses attending to Resident 2. During an interview on 11/19/15 at 7:40 a.m., Unlicensed Staff AF was asked how frequently residents with Wanderguards open the exit doors triggering the alarm. Unlicensed Staff AF stated "it could be three times a day or once a week." During an interview on 11/19/15 at 7:41 a.m., Unlicensed Staff AG was asked how frequently residents with Wanderguards open the exit doors triggering the alarm. Unlicensed Staff AG stated approximately once per shift. During an interview on 11/19/15 at 7:50 a.m., Management Staff I was asked how frequently residents with Wanderguards open the exit doors triggering the alarm. Management Staff I stated one to two times per week. During an observation and concurrent interview with Administrative Staff A on 11/19/15 at 10:45 a.m., the area outside the exit door at the end of Hall 4 revealed a groove in the soil to the right of the sloped concrete walkway. When asked if Resident 2 went off the curb into the driveway, Administrative Staff A stated: "I believe she did." He also corroborated the sloped concrete pathway leading from the exit door. During an interview on 11/19/15 at 4pm, Licensed Staff AC stated that on 11/16/15 at approximately 6am, she was standing at the Nurses Station near Hall 4 when she heard the Wanderguard alarm sound. She looked at the central alarm monitor at the Nurses Station and saw that the exit door at the end of Hall 4 had been breached/opened. Licensed Staff AC stated that Resident 2 was "a night owl" and saw her open the exit door and go out the door in her wheelchair. Licensed Staff AC stated she could not reach Resident 2 in time and by the time she got to the exit door, the door had closed and Resident 2 was outside. Licensed Staff AC stated the concrete path leading from the exit door to the outside was inclined and by the time she reached Resident 2, the resident, in the wheelchair, was found tipped on its side in the driveway. Licensed Staff AC stated one of the wheelchair's wheels went off the pathway into the dirt which caused the wheelchair to tip onto its side. Licensed Staff AC added "it was very dark outside still" and staff had a flashlight. After righting the resident and wheelchair, Licensed Staff AC stated she assessed Resident 2 who was found to have an abrasion on her forehead. Once inside, Licensed Staff AC stated she saw some blood on Resident 2's left foot. Review of the "nurse notes" dated 11/16/15 at 8:15 a.m, in Resident 2's clinical record, indicated that Resident 2 was "found with w/c (wheelchair) tipped over with skin tear on the right temple, abrasion right second toe, abrasion right knee, left inner foot abrasion, C/O (complaining of) pain to left lower extremity... Res (resident) with c/o increased pain to left lower extremity r/t (related to) fall at 0600AM. MD notified of increased pain, MD in facility at 0700, res assessment done by [Medical Director]. Received d/o (discharge order) to transfer to SLH (hospital)..." Review of a letter summarizing Resident 2's elopement incident on 11/16/15 addressed to the Department, dated 11/20/15, and signed by Administrative Staff A, indicated "Dr. [name] was in the facility at the time so he looked at her [Resident 2] and advised to send her to [local acute care facility] ER [emergency room] for X-ray. We were later notified by the hospital the resident had sustained a hip fracture and that she [Resident 2] would be having surgery the following morning. The resident has not returned to us as of 11/20/15 0800 but is anticipated to return to facility when ready."Resident 2's clinical record contained two Elopement/Wandering Seeking care plans. The initiation date on the handwritten care plan titled, "Wandering and Exit-Seeking" was 11/16/13 and was dated through 8/14/15. The "Goal" indicated: "Resident will be easily redirected to other areas in the facility as needed daily." "Approaches" included: 1. Evaluate and treat for any pain, 2. Redirect to activities, 3. Approach resident calmly, 4. Keeps resident's photo at nursing station and front office in a wanderes log, 5. Offer snacks throughout the day, 6 Encourage resident to participate in exercises, 7. Frequent assurance with each contact, 8. Rummage box, and 9. Encourage resident to attend musical programs. The second care plan titled, "Wandering," was initiated on 5/18/15 through 8/14/15. Checked "Behaviors/Symptoms" included: "Repeated entering other people's rooms (walking or wheelchair)" and "Roam through unit." "Casual Factors" included: "Changes taking place in brain." "Goals" included: "I will have meaningful relationships." "Interventions" included: "Frequent assurance with each contact" and "Offer snacks throughout the day." Neither care plan addressed Resident 2's "night owl" behavior, appropriate night-time interventions or appropriate supervision of the resident to prevent elopement incidents. The care plan lacked any interventions related to the type and frequency of supervision, based on the individual resident's assessed needs, and identified hazards in the resident's environment. The generalized care plan indicated an intervention "Scheduled visual check for location in Center," however the intervention was not checked. The facility violated the regulation by failing to create and implement a resident-specific care plan to address Resident 2's needs, and provide adequate supervision in order to keep Resident 2 safe. This lack of planning and supervision resulted in Resident 2's elopement from the facility with subsequent fall from her wheelchair and fractured hip.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. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110011981 |
A |
16-Jun-16 |
6S5Q11 |
6944 |
T22 DIV5 CH3 ART3-72301(f) Required Service (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. The facility violated the above regulation when it failed to ensure a physician was notified promptly of a resident's change in condition and when it failed to ensure staff promptly implemented the Physicians' Orders for Life Sustaining Treatment (POLST) when Resident 1 was discovered without signs of life, the staff nurse called Resident 1's relatives to inform them of the death instead of immediately initiating cardiopulmonary resuscitation and notifying the attending physician. Resident 1's medical record included an admission form entitled, "Face Sheet." The face sheet indicated Resident 1 was admitted on 5/25/12, with diagnoses including Dementia. The face sheet indicated, "Full Code - POLST."(Full code is a term that means medical personnel must perform life-saving measures for patients who have a cardiac or respiratory arrest. A "POLST", or Physician's Order for Life Sustaining Treatment, is an individual's written request that directs a health care provider regarding the specific resuscitative and life-sustaining measures that may or may not be initiated by the provider for that individual. Resident 1's medical record contained a POLST form, dated 12/22/11, which indicated orders for, "Attempt Resuscitation/CPR" and "Full Treatment." Nurse's notes, dated 11/19/13 at 6:15 a.m., indicated, "Summoned to room by CNA, res (resident) ceased breathing, no pulse, no vital signs. Telephone call to (relative) (name of relative) + (second relative) (name of second relative), unable to reach them, numbers incomplete for dials. T. C. (telephone call) to (relative)(name of relative), left message to call us back for emergency. Awating (sic) response." Notes at 6:35 a.m., indicated, "(Relative) returned call, awared (sic) of the above, wants to make Mortuary arrangement, (relative) will call back later after (relative) decides." A review of Facility Nurses' notes dated 11/19/13 (at 4 am,) indicated that Resident slept well, was alert and responsive, skin was warm and dry. The Notes further indicated that resident answered simple questions appropriately, and that antibiotic treatment was continued for left great toe infection without side effects noted, no rash, no nausea or vomiting. The Notes also reflected that a wound culture of the left great toe was completed in the morning of November 19, 2013. There was no complaint of pain, status post possible scabies treatment, no side effects noted, no rash, no complaint of itching and Resident 1 was noted to be compliant with care, all needs met. During an interview on 12/16/15 at 2 p.m., Registered Nurse A stated Certified Nursing Assistants (CNAs) told her to come and check Resident 1 about 6:15 a.m. on 11/19/13. Registered Nurse A stated, "I saw that he was already gone." Registered Nurse A further stated there was no signs of breathing and no pulse from Resident 1. Registered Nurse A stated Resident 1's pupils were fixed. Registered Nurse A stated she instructed a CNA to stay with Resident 1 while she called the family.During the interview, with Registered Nurse A, when inquiry was made as to the use of a stethoscope to listen for a heartbeat, Registered Nurse A stated she did not listen for a heartbeat. Registered Nurse A stated she felt for pulses and found none.Registered Nurse A stated she called the family and left messages. Registered Nurse A stated the day shift nurse, Registered Nurse B, arrived during that time. Registered Nurse A stated she and Registered Nurse B exchanged keys, counted medications, and gave report. Then Registered Nurse B took over and Registered Nurse A left the area to attend responsibilities on another hallway. Registered Nurse A stated she subsequently learned that after her shift ended at 7 a.m., someone checked Resident 1's POLST, called 911, and started CPR. Registered Nurse A stated her understanding was the paramedics responded to the 911 call and pronounced Resident 1 dead. Registered Nurse A's personnel file reflected a signed hand-written statement, dated 11/23/13, and authored by Registered Nurse A, in which the following statement was set forth:, "I did not check the POLST for resident's [Resident 1's] code status. This was a huge mistake of mine. Also, I did not call his Primary Physician first, I called his (relative) instead." During an interview on 12/16/15 at 12:30 a.m., Registered Nurse B stated she arrived at the nurse's station at about 6:40 a.m. Registered Nurse B stated Registered Nurse A was coming down the hall and stated Resident 1 had passed away. Registered Nurse B stated she went to look at Resident 1 who looked like he was "gone". Registered Nurse B advised the nurses could not pronounce death and that when she subsequently checked Resident 1's POLST, she determined that Resident 1 was a "full code." Registered Nurse B also advised she and others made the decision to call 911 and start CPR. Registered Nurse B further advised she remembered answering the phones and making calls and she stated that she believed she was the person who called 911. Registered Nurse B stated she did not actually perform the CPR on Resident 1 but was aware of other staff going past with the emergency cart while she was on the phone at the nurses' station. Resident 1's nurse's notes, authored by Registered Nurse B, indicated the following notations, at 6:45 a.m: "Received resident in bed. Unresponsive (no) vital signs present. Skin cold. Resident's (relative) ... called, requested information re: funeral homes ... Phone call placed for (Nurse Practitioner)." Resident 1's nurse notes at 7 a.m. indicated, "Message left for (Nurse Practitioner) to call back. (Physician) notified of resident's condition. He was also made aware that coroner will be notified as resident was a "Full code" status." Furthermore notes at 7:10 a.m. indicated the coroner's office was called and at 7:15 a.m. indicated the police department was notified. Additional nurse's notes at 7:15 a.m. indicated the paramedics arrived and pronounced Resident 1 dead. Resident 1's clinical record did not contain documentation of implementation of CPR as stated by Registered Nurse A and Registered Nurse B.The facility failed to ensure prompt initiation of cardiopulmonary resuscitation pursuant to Resident 1's POLST when Resident 1 was discovered without signs of life. Specifically, at least thirty minutes passed between the time night shift staff discovered Resident 1 was unresponsive at 6:15 a.m. and CPR was initiated at approximately 6:45 a.m. At least forty-five minutes passed before the physician was notified at 7 a.m. These facility failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 110001255 |
Evergreen Lakeport Healthcare |
110012048 |
A |
29-Dec-16 |
8RYX11 |
8597 |
T22 DIV5 CH3 ART3-72311(a)(1)(C) (a)Nursing service shall include, but not be limited to, the following: (1)Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (Refer to 72311(a)(2) tag 166) T22 DIV5 CH3 ART3-72311(a)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to implement Resident 1's fall risk care plan intervention of use of an alarm in wheelchair and bed and failed to review, evaluate and update the patient's care plan by, failure to incorporate Occupational Therapists discharge summary (service dates 10/3/13 to 11/13/13) of patient's decline after room change and planned refocus on cognitive interventions to increase safety. Resident 1 sustained three falls from date of admission xxxxxxx through xxxxxxx. Resident 1 died on xxxxxxx from blunt impact injuries to the head and face and a broken neck, caused by a fall Resident 1 sustained on 11/16/13. Review of Resident 1's clinical record revealed that Resident 1 was a 95 year old male, admitted to the facility on 10/2/2013, with diagnoses that included generalized muscle-weakness, CHF (congestive heart failure), atrial fibrillation, history of open heart surgery, history of alcohol abuse, and no capacity to understand choices and make health care decisions. Review of a Nursing Admission Evaluation, dated 10/2/13, revealed Resident 1 had a history of falls, was dependent and required extensive staff assistance for mobility using a walker and/or a wheelchair. Review of a document entitled, "Fall Evaluation," dated 10/2/13, further revealed Resident 1 had intermittent confusion, a balance problem while walking, required assistive devices, exhibited daily unsafe ambulatory/transfer skills, with a total score of 23. A score of 13 or greater is considered a high potential for falls requiring a fall risk care plan. A Fall Risk Care Plan dated 10/2/13, was reviewed. The care plan indicated that Resident 1 would have an alarm on his bed and wheelchair and to remind Resident 1 frequently to utilize his call light for assistance. A Review of the MDS (Minimum Data Set of CMS Long -Term Care Facility Resident Assessment Instrument, an assessment tool), dated 10/9/13, indicated Resident 1 had a cognitive score of 7 indicating severe impairment (13-15 cognitively intact; 8-12 moderately impaired and 0-7 severe impairment). The MDS further documented that Resident 1 has trouble concentrating on things, needed extensive assist or one person physical assist for transfers, dressing and toileting. The MDS also indicated that Resident 1's balance was not steady and that he was only able to stabilize with assistance. First Fall: Review of the Nurse's Notes dated 10/29/13 revealed Resident 1 had a fall in his room on 10/29/13 at 2:45 p.m. while attempting to ambulate from the wheelchair to reposition cushion in wheelchair. There was no notation about alarms found. Second Fall: A review of Nurse's Notes dated 11/12/13 at 11:45 p.m. was conducted. The notes revealed that Resident 1 sustained a witnessed fall in his room while wearing white socks, slipping to floor, and landing in a sitting position next to his bed on a landing pad. There was no notation about alarms found. Third Fall: A review of Interdisciplinary Progress Notes dated 11/16/13 at 8 p.m., indicated Resident 1 sustained a fall in his room. Resident was found lying face down on the floor, next to his bedside, with hematomas (a localized swelling that is filled with blood) on his left cheek and also on his left forehead. Further, Resident 1's skin was noted to be pulled back on his forehead and Resident 1 also had a right hand laceration. A review of Nurses's Notes, dated late entry for 11/17/13 at 2000 (8 p.m.) indicated, "Based on the position of the resident, the resident got up out of his w/c and was attempting to toilet himself." There was no notation about alarms found. During an interview on 11/25/13, at 3:30 p.m., Unlicensed Staff B stated, "I work full time evening shift, and I was the regular assigned aide to (Resident 1). I never saw an alarm on him or on the bed." Unlicensed Staff B stated that Resident 1 did not have an alarm. During an interview on 11/25/13, at 3:16 p.m., Unlicensed Staff A stated, "I was on duty the evening (Resident 1) fell on 11/16/13 when (Resident 2) informed us by yelling that (Resident 1) had fallen. No, I did not hear the alarm." During an interview on 12/2/13, at 11:27 a.m., Licensed Staff C could not recall that Resident 1 had an alarm for his bed or wheelchair. During an interview on 11/25/13, at 3:57 p.m., Resident 2 stated, "I was just going by in the hallway (on 11/16/13) and heard (Resident 1) hollering, "help, help, help me and I saw that (Resident 1) was on the floor, so I went to tell (Unlicensed Staff B). I heard (Resident 1) hollering, no alarms." A clinical record review of Resident 2's medical chart indicated she was admitted on 8/11/2009 and is her own responsible party. Resident 2's MDS, dated 6/20/2013, indicated adequate hearing and vision and a cognitive score of 13 indicating intact cognition. During a telephone interview on 7/17/14, at 12: 00 p.m., Therapist D stated, "(Resident 1) always wanted to stay in the PT room and go to sleep in his wheelchair after his PT session. He said he felt safe here, he knew we would not allow him to fall. He also said he felt better around with other people. He asked for a restraint like glue to put on his butt so that will make him sit." During an interview on 7/18/14, at 2:25 p.m., Management Staff E stated, "For patients with memory loss, we certainly put in alarms to alert staff of their activity, call light is in place to remind them to use it. For a cognitively impaired resident, he would probably not remember to use the call light and the call light as an effective intervention is hard to tell. It is more of monitoring and constant reminders." During an interview on 7/22/14, at 4:55 p.m., Management Staff F stated she was aware Resident 1 was getting up unassisted but could not advise if Resident 1 was able to use the call light. During a telephone interview on 7/21/14, at 9:07 a.m., Resident 1's Family Member G stated, "The family expected the facility to protect and care for the resident." Family Member G also advised she told just about every staff member in the facility that Resident 1's equilibrium was bad and that Resident 1 needed to be watched because he was forgetful. A review of the telephone order dated 11/16/13 at 8:00 p.m. indicated Resident 1 was transferred to the local acute care hospital on 11/16/13 at 9: 02 p.m., and was discharged on 11/17/13 at 12:35 a.m., to another acute care hospital. Review of the emergency provider notes dated 11/16/13, indicated Resident 1 needed interventions not readily available at the local acute care hospital. A review of the second acute care hospital's discharge summary, dated 11/17/13, indicated Resident 1 was admitted on xxxxxxx with diagnoses of head and neck trauma, subarachnoid and subdural hemorrhage and cervical 2 (neck) fracture. It was noted that Resident 1 died on xxxxxxx at 3:30 p.m. The coroner's report, dated 11/17/13, indicated Resident 1 died on 11/17/13 at 3:30 p.m. from blunt impact injuries to the head and face and a broken neck. The facility failed to implement the use of an alarm on Resident 1's wheelchair and bed, as identified as needed for Resident 1 based on his fall assessment and care plan. Resident 1 sustained three falls between 10/2/13 and 11/16/13, with the third fall resulting in head and neck trauma, subarachnoid and subdural hemorrhage and a cervical 2 (neck) fracture. Resident 1 died on 11/17/13 at 3:30 p.m. Although the facility updated on Resident 1's care plan, after the second fall of 11/12/13 to include intervention for the resident to use non-skid socks as resident allowed, there were no additional interventions such as increased supervision, one on one monitoring added to address the resident's increased risk for falls due to his cognitive decline. 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. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012902 |
A |
28-Feb-17 |
G9FK11 |
32665 |
The citation narrative for this penalty will not fully display due to narrative length limitations. Please send a request toÿCHCQdata@cdph.ca.govÿto obtain a full copy of this citation narrative.ÿ
F353 ?483.35(a)(1)-(4) Sufficient 24-Hr Nursing Staff Per Care Plans 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 and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at ?483.70(e).[As linked to Facility Assessment, ?483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] (a) Sufficient Staff. (a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. (a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. The facility failed to ensure adequate nursing staff to provide quality care, which caused harm to their residents as evidenced by: 1. The facility did not provide adequate supervision and assistance, revise fall risk care plans and implement the care plans, follow fall protocol for post-fall assessment and management to prevent falls and injuries for Residents 1, 2, 3, 4, 5, 6, and 14 when: a. Resident 1 walked to the restroom unassisted, grabbed the rod across the restroom entrance and fell on the floor on 8/28/16. This caused Resident 1 to sustain a left humeral neck (upper arm bone just under the shoulder joint) fracture which required admission to an acute care hospital for treatment. b. Resident 2 had five falls during a one month period from 8/12/16 to 9/14/16. Resident 2 sustained a head injury from the last fall on 9/14/16, which required Resident 2 to be sent to an acute care hospital for evaluation and treatment. After 9/14/16, Resident 2 had three more falls on 10/26/16, 11/5/16, and 11/26/16. c. Staff did not follow their fall protocol for post-fall assessment and notify the physician of a fall when Resident 3 reported having fallen on 10/20/16. This resulted in Resident 3 not being evaluated after the fall until 10/25/16 (five days later). d. Resident 5 had six falls during a six and one-half months period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom which was wet with urine. A fall on 11/23/16, resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose on 11/23/16 at 9:35 p.m. (This was the second fall that day). e. Resident 4 had three falls during a one-month period from 8/16/16 to 9/17/16. Resident 4 sustained a skin tear on the right hand from a fall on 8/16/16, and re-opened a skin tear on the right hand from a fall on 8/21/16. Resident 4 had three more falls during a one-week period from 10/13/16 to 10/17/16, which resulted in a nasal bone (nose) fracture from a fall on 10/13/16. f. Resident 6 had multiple falls in a six-month period from 5/22/16 to 11/25/16. Resident 6 sustained bleeding in the head from the fall on 8/1/16; a laceration (cut) on the left side of the head, which required eight staples from the fall on 10/13/16. Resident 6 sustained a laceration on the right side of the head from the fall on 11/25/16. g. Licensed Staff did not revise Resident 14's (who had one unwitnessed fall on 11/4/16, which resulted in a skin tear to the left elbow and a fractured pelvis), "Fall Care Plan" to indicate Resident 14 was to be on, "one-on-one" with staff at all times starting 11/5/16, per physician's order. This failure to revise Resident 14's, "Fall Care Plan" had the potential for Resident 14 to fall again causing injury or even death. 2. Residents' care needs were not being met when call lights were not answered in a timely manner for Resident 17 and 18, and Resident 17's need of getting out of the bed earlier in the morning was not honored. These failures resulted in Resident 17 staying wet with the urine and feeing bad, and potentially compromised residents' physical and psychosocial well-being. 1a. Resident 1's admission record indicated Resident 1 was admitted to the facility on xxxxxxx 16, with diagnoses including blindness both eyes, difficulty in walking, and generalized muscle weakness. Resident 1's Minimum Data Set (MDS), a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/29/16, revealed a BIMS (Brief Interview for Mental Status) score of 14, which indicated Resident 1 was cognitively intact. The MDS assessment indicated Resident 1 required limited assistance of one person with physical assistance for walking in the corridor and toilet use. The Fall Risk Assessment, dated 7/27/16, indicated Resident 1 was at high risk for falls due to multiple problems, including intermittent confusion, one to two falls in past three months, and being legally blind. Resident 1's care plan for fall risk prevention and management, initiated on 1/22/16 and re-evaluated on 7/16, indicated approaches for fall risk prevention and management including, "Orient resident to environment each time changes are made and provide an environment that supports minimized hazards over which the Facility has control..." The care plan did not specify how the facility would provide supervision to prevent Resident 1 from falling. Resident 1's care plan for visual impairment, initiated on 1/22/16, indicated, "Provide environment with items kept in consistent location, free from obstacles and clutter...uses handrails in hallway..." The care plan for activities of daily living, initiated on 1/22/16 and re-evaluated on 7/16, indicated Resident 1 required assistance for toilet use and personal hygiene. The Nurse's Note, dated 8/28/16, revealed Resident 1 had an unwitnessed fall at 9:10 a.m., when Resident 1 was ambulating to the restroom and walked onto wet floor sign. The IDT (Interdisciplinary Team) Conference Record, dated 8/29/16, indicated on 8/28/16, at 9:10 a.m., Resident 1 walked to the bathroom and stopped at the restroom doorway. Resident 1's hands grabbed the spring rod, which the housekeeper placed in the doorway for cleaning, and simultaneously leaned her weight backward expecting the rod to be stable like a handrail. Resident 1 fell to her left side and had left shoulder pain and left hip discomfort. Resident 1 was sent to an Emergency Department and admitted to an acute care hospital. The CT (Computerized Tomography, combines of X-ray images using computer process to create images) examination result, dated 8/28/16, and the History and Physical Report from the acute care hospital, dated 8/28/16, indicated Resident 1 sustained a non-operable left humeral neck (upper arm bone) fracture and was admitted to the hospital for pain control and evaluation. During an interview on 10/26/16 at 10:02 a.m., regarding Resident 1's fall on 8/28/16, Licensed Staff A stated Resident 1 usually used the handrails in the hallway when Resident 1 was walking. Licensed Staff A stated Resident 1 had visual impairment. Resident 1 liked to grab the handrail and lean backward while talking to staff or other residents. Licensed Staff A stated on the day Resident 1 fell, Resident 1 walked to the restroom in the hallway and grabbed the spring rod, which the housekeeper placed in the doorway for cleaning. Licensed Staff A stated Resident 1 thought the rod was the handrail, so Resident 1 leaned her body backward while grabbing the rod. Licensed Staff A stated Resident 1 fell on the floor because the rod was not stable and fell off the doorway. Licensed Staff A stated no staff walked with Resident 1 because it was Resident 1's routine to walk to the restroom by herself using the handrails. Licensed Staff A stated the biggest mistake was lack of communication. Licensed Staff A stated the housekeeper did not tell her (Licensed Staff A) about placing the rod in the restroom doorway, otherwise she would have educated Resident 1 and let her feel the rod or walked with her. Licensed Staff A stated the rod was a new product, but they should not use it on the floor because it was dangerous. During an interview on 10/26/16, at 11:50 a.m., regarding Resident 1's fall on 8/28/16, Housekeeping Staff P stated she put the rod with a sign across the restroom doorway and two signs on the floor when she was mopping the restroom. Housekeeping Staff P stated she told Resident 1 the restroom was closed. Housekeeping Staff P stated after she cleaned the restroom, she left the rod with a sign across the restroom doorway and went to another hall. Housekeeping Staff P stated she did not tell Resident 1 that the rod was left in the doorway. Housekeeping Staff P stated she did not tell any staff about the rod because they could see it. Housekeeping Staff P stated from the beginning of using this type of rod, she told the Housekeeping Supervisor that the rod was terrible and not good for use because the rod did not have spring and was easy to fall off. She stated the rod was not stable and when people grabbed the rod, the rod fell. During a concurrent observation and interview on 10/26/16, at 11:25 a.m., in the Housekeeping Supervisor's office, Housekeeping Supervisor Q showed a yellow rod with a yellow sign, "CLOSED FOR CLEANING" hanging to the rod. Housekeeping Supervisor Q stated this was the rod with the sign Housekeeping Staff P used when she cleaned the restroom where Resident 1 fell. Housekeeping Supervisor Q stated the housekeeper put the rod across the doorway to indicate the room was being cleaned. Housekeeping Supervisor Q stated the housekeeper should tell the nurse when the rod was placed. Housekeeping Supervisor Q stated the rod was light metal and was not strong. Housekeeping Supervisor Q stated the facility had been using the rod for about six to seven months, but they did not have a policy and procedure regarding the use of the rod. Upon request for the manufacturer's guidelines for the rod, Housekeeping Supervisor Q provided a page documentation titled, "FACILITY MAINTENANCE," undated, under A. Site Safety Hanging Sign, which did not indicate how to use the rod and sign safely. 1b. Resident 2's admission record indicated Resident 2 was re-admitted to the facility on xxxxxxx 16, with diagnoses including Alzheimer's disease (a brain disease causing memory loss, impaired thinking and disorientation), dementia, and neuromuscular (relating to the nerves and muscles) dysfunction of bladder. Resident 2's MDS assessment, dated 8/19/16, indicated Resident 2 was not able to complete the Brief Interview for Mental Status (BIMS). The MDS assessment indicated staff interview for mental status was conducted, and indicated Resident 2's cognitive skills for daily decision making was, "moderately impaired - decisions poor; cues/supervision required." Resident 2's Fall Risk Evaluation, dated 8/12/16, indicated Resident 2 was at high risk for falls due to multiple problems including mental status, history of falls, ambulatory and elimination status, and gait/balance problems. The care plan for fall risk prevention and management, initiated on 8/12/16, with approach started date 8/11/16, indicated approaches including, "Bed in low position, pad alarm (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or the bed) in bed..." The care plan did not specify how the facility would provide supervision to prevent Resident 2 from falling. First Fall: The Nurse's Note, dated 8/12/16 at 12 a.m., revealed Resident 2 had an unwitnessed fall in the his room. Resident 2 sustained a 3 cm X 3 cm skin tear with bruising at left elbow. The care plan for the actual fall on 8/12/16, indicated a goal, "No serious injury from fall [for 7 days]." The approaches included observing and monitoring for 72 hours, mobility alarm, pads at bedside, and visual monitor just for one shift. The IDT (Interdisciplinary Team) Conference Record, dated 8/12/16, regarding Resident 2's fall on 8/12/16 at midnight, did not indicate new approaches to the fall risk care plan to prevent further falls. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Second Fall: The Nurse's Note, dated 8/29/16, at 7 a.m., indicated nursing staff from the last two work shifts reported Resident 2 had a fall at 7:15 a.m., on 8/28/16. However, there was no documentation of Nurses' Notes on 8/28/16, regarding the fall. The IDT Conference Record, dated 8/30/16, indicated Resident 2 had a fall with no injury on 8/28/16. The IDT note indicated to resume Risperdal (an antipsychotic medication, which works by changing the effects of chemicals in the brain), which was discontinued, due to increased agitation, re-emergence of aggressive verbal outbursts, pressured speech, and etc. The care plan for the actual fall on 8/28/16, included to teach the new nurses on fall follow-up process and continue plan of care. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Third Fall: The Nurse's Note, dated 9/5/16, at 4:20 p.m., indicated Resident 2 fell out from the wheelchair when he was watching TV in the TV room with other residents. The IDT Conference Record, dated 9/6/16, regarding Resident 2's fall on 9/5/16, indicated Resident 2 had, "very poor safety awareness." The IDT determined to continue using the alarm with a goal, "no serious injury [with] fall." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/5/16, was to continue plan of care. The fall risk care plan initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fourth Fall: The Nurse's Note, dated 9/10/16, with unknown time of the note, indicated, "Am shift reports fall [with] no injury 10:30 Am..." The Nurse's Note did not describe how Resident 2 fell. The IDT Conference Record, dated 9/12/16, indicated Resident 2 stood up and fell at the Nurse's Station. The IDT note indicated Resident 2 continued having poor safety awareness. The IDT note indicated, "Comfort is goal and [with] regard to falls, minimizing serious injury is goal..." The IDT note indicated, "Will continue use of alarm, encourage wheelchair..." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/10/16, was to continue plan of care. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fifth Fall: The Nurse's Note, dated 9/14/16, at 7:55 p.m., revealed Resident 2 had an unwitnessed fall and sustained a skin tear at his left elbow and injury in the back of Resident 2's head which required Resident 2 to be sent to an Emergency room for evaluation. The IDT Conference Record, dated 9/15/16, indicated on 9/14/16, at 7:55 p.m., Resident 2 was found on the floor next to the bed. The IDT note indicated an alarm was present but was not engaged. The IDT note indicated a fall prevention plan which included care alert posted in Resident 2's room. The IDT note did not specify how the facility would provide supervision to prevent Resident 2 from further falls. The Care Alert, dated 9/15/16, posted in Resident 2's room, indicated, "[Resident 2] is a high fall risk with a recent fall requiring a trip to the ER. Please make sure [Resident 2] has his loud alarm attached at all times! Check frequently as he is able to inadvertently remove the alarm..." The Care Alert did not specify how frequently to check the alarm or Resident 2. During an interview on 11/3/16, at 2:35 p.m., regarding, "Check frequently" for the alarm indicated in the Care Alert, the DON (Director of Nursing) stated she expected the staff check the alarm when staff made rounds every two hours; the Hall Monitor (an employee) walked back and forth in the hall, and when walking to Resident 2's room, the Hall Monitor could look inside the room from the hallway to see if the alarm was intact. When asked if the Hall Monitors were trained on how to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff if anything was out of the ordinary. The DON stated a Hall Monitor was a facility staff member, but was not a caregiver. The DON stated the Hall Monitors did not do hands-on resident care; they could guide the resident and gently hold the resident's hands/elbows. The IDT Conference Record, dated 9/16/16, for safety review related to the fall on 9/14/16, indicated to evaluate Resident 2's room to, "reconfigured room to have bed at a slight angle decreasing the likelihood of striking head during a fall. Mats at both side of bed." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. During a concurrent observation and interview on 10/25/16, at 10 a.m., Resident 2 was in bed and awake. One floor mat was placed on Resident 2's right side, and one mat was up leaning against the wall below the window. When asked about his fall on 9/14/16, Resident 2 stated he did not remember the fall. During an interview on 10/25/16, at 3 p.m., regarding Resident 2's fall on 9/14/16 at 7:55 p.m., Licensed Staff C stated a Hall Monitor found Resident 2 on the floor. Licensed Staff C stated when she arrived at the scene, Resident 2 was laying on the floor mat with the head against the wall on the left side of the bed. Licensed Staff C stated she did not hear the alarm. She stated Resident 2 took the alarm off all the time. When asked about fall prevention, Licensed Staff C stated when Resident 2 was not in bed, Resident 2 sat at the Nurse's Station. When Resident 2 was in bed, staff would listen to the alarm or Resident 2 yelling. Licensed Staff C stated they did not have a set time to check on Resident 2 because Resident 2 was not on an every 15 minute check. During a concurrent observation and interview on 10/25/16, at 3:05 p.m., in Resident 2's room, one floor mat was on the right side of the bed, and one mat was up against the wall. Licensed Staff C stated the floor mat should be on the left side because Resident 2 got out of the bed from his left side. During a concurrent interview and record review of Resident 2's care plans for fall and fall risk on 10/25/16, at 3:13 p.m., Licensed Staff C stated a care plan described what was the best care provided to the resident and communication with the care team. Licensed Staff C stated all nurses should review the care plans. When asked if the care plans specify providing supervision to Resident 2, Licensed Staff C reviewed the care plans, initiated on 8/12/16 and 8/15/16, and stated the supervision was to observe and monitor Resident 2 for 72 hours. When asked what happened after 72 hours, Licensed Staff C stated, "none" and the care plans did not specify supervision. During an interview on 10/25/16, at 4:40 p.m., Unlicensed Staff O stated when Resident 2 was in bed, she would check Resident 2 approximately every five minutes. When asked how she knew about the five minutes, Unlicensed Staff O stated, "from the text book." When asked how she knew the care needed for a resident, Unlicensed Staff O stated she would ask other staff or look at the care plans, which would tell her about the resident. When reviewing Resident 2's care plan, which indicated Resident 2 had four falls from 8/12/16 to 9/10/16, Unlicensed Staff O stated she did not know Resident 2 had so many falls, "like constantly falling." Unlicensed Staff O stated by looking at the falls indicated in the care plan, Resident 2 should not be left alone. Unlicensed Staff O stated the care plan did not specify the frequency of checking Resident 2. During a concurrent interview and record review on 10/26/16, at 2:50 p.m., the DON stated they tried different interventions including alarm, pad, and visual monitor for one shift only. The DON reviewed the fall and fall risk care plans, and stated the care plans did not specify providing supervision to Resident 2 to prevent falls. During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated he did not witness Resident 2's fall. Unlicensed Staff L stated he was not assigned to Resident 2, but he still helped check on Resident 2 and the alarm function at least every hour. Unlicensed Staff L stated when Resident 2 had repeated falls (4 - 5 times in a month), staff should be with Resident 2 all the time. Unlicensed Staff L stated they did not have enough CNAs (Certified Nursing Assistant) in the hall where Resident 2 resided. Unlicensed Staff L stated because of short staffing, they were not able to check residents as frequently as they would, to prevent residents from falling. The Emergency Department Report, dated 9/14/16, indicated Resident 2 sustained a wound 2 cm in length in the head, and the wound was repaired with staples. The Emergency Department report indicated Resident 2 did not receive any imaging or extensive work-up because Resident 2 was on hospice with comfort measures only. Resident 2 had three more falls after 9/14/16, as follows: a. The IDT note, dated 10/26/16, indicated Resident 2 fell from a wheelchair to the floor in the TV room; b. The IDT note, dated 11/7/16, indicated Resident 2 fell on 11/5/16, witnessed by a Hall Monitor; and c. The IDT note, dated 11/28/16, indicated Resident 2 fell on 11/26/16, sliding out of a wheelchair. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to, "us" [Certified Nursing Assistants]. Unlicensed Staff BB stated they just put up signs in the utility room and in the resident's room and, "hoping us to know" what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote, "keep bed low, keep bed at an angle." During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent injuries from falls. The DON stated she educated the staff about the sign but did not have a log to ensure all staff were educated and understood the sign. 1c. During a concurrent observation and interview on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 stated she fell approximately at 3 a.m. four days ago from her bed to the floor. Resident 3 stated she climbed back to bed because no staff were around to assist her. Resident 3 stated she told a nurse about the fall at approximately 5:30 a.m. the day she fell. She stated the nurse just told her to go back to bed. Resident 3's MDS dated 8/9/16, indicated Resident 3's BIMS (Brief Interview for Mental Status) score was 13, which indicated Resident 3 was cognitively intact. Resident 3's Fall Risk Evaluation, dated 8/4/16, indicated Resident 3 was at high risk for falls due to multiple problems including history of falls, ambulatory and elimination status, and gait/balance problem. During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately seven hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head-to-toe assessment. Licensed Staff B stated he documented the assessment. The Nurse's Note, dated 10/20/16 at 10:15 a.m., indicated, "[Resident 3] [up out of bed] in [wheelchair]. Denies any residual pain [secondary to fall]. [Resident 3] in wheelchair, going up and down hallway [without] difficulty. Will continue to monitor." The note did not indicate a head-to-toe assessment. There was no documentation of physician notification. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated there was no specific document for the head-to-toe assessment. Licensed Staff B stated he documented the head-to-toe assessment in the Nurse's Note. When asked about the Nurse's Note, Licensed Staff B stated the Nurse's Note, dated 10/20/16 at 10:15 a.m., was written by him. When asked for the fall protocol, Licensed Staff B stated they filled out the information forms which the night shift nurse should have done and turned it in to the DON. During a concurrent interview and record review on 10/26/16, at 8:35 a.m., the DON reviewed Licensed Staff B's Nurse's Note, dated 10/20/16 at 10:15 a.m., and stated it was not well documented and did not show the head-to-toe assessment. The DON stated the post-fall protocol included completing the incident report, post-fall assessment, post-fall huddle, and neurological check flow sheet for unwitnessed fall. The DON stated staff had not notified her of Resident 3's fall. The DON stated staff did not complete the post-fall protocol procedures for Resident 3's fall on 10/20/16. Review of the Fall Management Program Policy No. FA-01, documented following each fall, the licensed nurse would perform a post-fall assessment, the licensed nurse would notify the Director of Nursing and / or Administrator, and the Licensed Nurse would notify the resident's attending physician and responsible party of the fall incident. 1d. Resident 5's admission record indicated Resident 5 was admitted to the facility on xxxxxxx 16, with diagnoses including difficulty in walking, muscle weakness, dementia with behavioral disturbance. Resident 5's fall risk evaluation, dated 10/10/16, 11/24/16, and 12/6/16, indicated Resident 5 was at high risk for falls due to multiple problems including mental status (disoriented or intermittent confusion), history of falls, gait and balance problems, and medications. Resident 5 was on Risperdal (an antipsychotic medication which works by changing the effects of the chemicals to the brain. Common side effects includes dizziness, drowsiness, and tired feeling) 0.5 mg by mouth every day and Haldol (an antipsychotic medication which may work by blocking some chemical effects in the brain. Major common side effects include loss of balance control, muscle spasms, and shuffling walk) 70 mg intramuscularly every month for dementia with psychosis. Resident 5's MDS, dated 3/17/16 and 9/16/16, indicated Resident 5's cognition was moderately to severely impaired. First fall: The Nurse's Note, dated 5/24/16 at 11 p.m. and the IDT note, dated 5/25/16, indicated Resident 5 had an unwitnessed fall on 5/24/16 at 7:45 p.m. in the bathroom. Resident 5 was found in the bathroom sitting on the floor wet with urine. Resident 5 complained of left shoulder pain and treated with Norco (pain medication). The IDT note indicated Resident 5 received antipsychotic (Haldol injection) prior to the fall. The IDT note indicated the Charge Nurse's plan to increase monitoring for a few hours after the monthly Haldol injection and recommended non-slip shoes for Resident 5. Resident 5's care plan for fall risk prevention and management, initiated on 3/11/16, and re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including, "Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue B-wing for increased supervision. The fall risk care plan did not reflect nor specify how to increase monitoring after the monthly Haldol injection. Second fall: The IDT note, dated 10/3/16, indicated Resident 5 had an unwitnessed fall in his room on 10/3/16 at 1:15 a.m. The IDT note indicated referring for physical and occupational therapy and continue to encourage wearing the hipster (Padded pants that cover the hip to cushion a fall to prevent injuries to the hip) when ambulating. The IDT note did not specify providing supervision to Resident 5. Third fall: The Nurse's Note, dated 10/9/16 at 2:30 a.m. and the IDT note, dated 10/10/16, indicated Resident 5 had an unwitnessed fall in his room on 10/9/16, with unknown time of fall. The IDT note indicated referring for physical and occupational therapy and continue to encourage wearing the hipster when ambulating. The IDT note did not specify providing supervision to Resident 5. Fourth fall: The IDT note, dated 11/24/16, indicated Resident 5 had a fall on 11/23/16 at 12 p.m. The IDT note indicated Resident 5 was walking in the hallway, "but still asleep." The Hall Monitor headed toward Resident 5, "but before she got to him he fell onto his [left] hip and elbow." The IDT note indicated, "will make a referral to PT/OT [Physical Therapy/Occupational Therapy]..." The IDT note did not specify providing supervision to Resident 5. Fifth fall: The Nurse's Note, dated 11/23/16, and the IDT note, dated 11/24/16, indicated Resident 5 had an unwitnessed fall in his room on 11/23/16 at 9:35 p.m. Resident 5 sustained a small skin tear on the top ridge of the nose. The IDT note indicated, "observe and monitor for 72 hours and on 15 [minutes check]." Sixth Fall: The Nurse's Note, dated 12/6/16 at 3 a.m., and the IDT note, dated 12/6/16, indicated Resident 5 was found on the floor in his room. The IDT note indicated every 15 minute checks was initiated after the first hour of neuro checks. Resident 5's care plan for fall risk prevention and management, initiated on 3/11/16, re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including, "Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue B-wing for increased supervision. The fall risk care plan did not reflect the 15 minute checks and who was/how to check Resident 5. During a concurrent interview and record review on 12/8/16, at 8:35 a.m., regarding supervision for Resident 5, Unlicensed Staff CC stated she checked on Resident 5 whenever she saw him. Unlicensed Staff CC stated every staff in the hall was responsible to check on Resident 5. Unlicensed Staff CC stated she also reviewed care plans for resident care. When she reviewed Resident 5's fall risk care plan and asked her what did, "...increase supervision..." mean to her, Unlicensed Staff CC stated, "To me, may need one-to-one..." When asked her if Resident 5 was on one-to-one supervision, Unlicensed Staff CC stated she needed to check the documentation and found Resident 5 was on every 15 minute checks. Unlicensed Staff CC stated all staff were responsible for monitoring and documentation. During a concurrent interview and record review on 12/8/16, at 8:55 a.m., Licensed Staff NN reviewed the fall risk care plan and stated, "...increase supervision..." meant every 15 minute checks. Licensed Staff NN stated the DON or ADON was responsible to review and update the care plans. Licensed Staff NN stated the care plan was used for following-up on residents and making goals for resident care. During an interview on 12/9/16, at 7:20 a.m., Resident 5's fall risk care plan was reviewed with the DON. The DON stated the care plan did not specify supervision for Resident 5, and she understood that staff could have interpreted differently for, "...increase supervision." 1e. Resident 4's admission record and MDS, dated 10/3/16, documented Resident 4 |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012903 |
A |
28-Feb-17 |
G9FK11 |
17424 |
F309 ?483.24, 483.25(k) PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
483.25
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
The facility failed to: 1. adequately assess and treat Resident 3's pain and care plan to taper Norco (a medication for pain), which resulted in harm to Resident 3 who was crying in tears and was having difficulties with moving around due to severe pain in her left leg, secondary to a bone condition and a recent fall; and 2. follow through with a treatment order of Debrox (ear wax removal) for Resident 11, which caused Resident 11's left ear to be plugged up and loss of hearing.
1. Resident 3's admission record indicated Resident 3 was admitted to the facility on XXXXXXX16 with diagnoses including toxic encephalopathy (a nervous system disorder caused by exposure to toxic agents) and personal history of malignant neoplasm (a tumor), and paresthesia (a sensation of tingling, tickling, pricking, or burning) of skin.
Resident 3's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 8/9/16 and 11/8/16, indicated Resident 3's BIMS (brief interview for mental status) score was 13 - 14, which indicated Resident 3 was cognitively intact.
During a concurrent observation and interview that started on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 was sitting in her wheelchair tilted to her right side. Resident 3 stated she had to sit tilted to her right side because she was having pain 9/10 (pain scale 0-10, 0 indicates no pain and 10 indicates most severe pain) in her left hip since early morning. Resident 3 stated that it was difficult for her to move around and it made her irritable due to the pain. Resident 3 stated she already asked for pain medication but, "they said I am a drug addict" and could not give me more medication. Resident 3 stated she fell from her bed to the floor at approximately 3 a.m. four days ago. Resident 3 stated she climbed back to bed because there were no staff around to assist her. Resident 3 stated she told a nurse about the fall and pain at approximately 5:30 a.m. the day she fell. She stated the nurse just told her to go back to bed. Resident 3 stated she had arthritis pain 4-5/10 in her left hip down to the leg, but the pain in the left hip increased to 8-9/10 after the fall. Resident 3 stated she thought she, "hurt something" from the fall. Resident 3 stated she told all of her nurses but nobody checked on her nor did they send her to the hospital. Resident 3 stated one of the nurses, Licensed Staff C, told her (Resident 3) she reported the fall because she wanted more pain medications. Resident 3 stated Licensed Staff C told Resident 3 that eventually all her medications would be taken away. Resident 3 stated she always had to wait for the pain medication for one to two hours after the scheduled time. Resident 3 stated that staff were mad at her and acted like she was, "a drug addict." When asked if she wished to have a staff member to check on her, Resident 3 started crying in tears and stated she was OK with the DON (director of nursing) or another one particular nurse but not the other nurses because they did not check on her and said she was a drug addict and that she was, "tired of it."
During an interview on 10/25/16, at 11:45 a.m., Licensed Staff C stated last night Resident 3 asked for Narcotics (opioid pain relievers). Licensed Staff C stated she explained to Resident 3 that her pain medication was not due and explained to her that her narcotic medication needed to be "tapered". Licensed Staff C stated Resident 3 mentioned about her left hip. Licensed Staff C stated she faxed a request for x-ray to the physician.
During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately 7 hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head to toe assessment and documented the assessment. Licensed Staff B stated no injuries noted related to the fall. Licensed Staff B stated Resident 3 usually complained of pain 8-9/10 in her left lower extremity. Licensed Staff B stated Resident 3 asked for Narcotic medications for pain "no matter what." Licensed Staff B stated Resident 3 had history of drug seeking behaviors and asked for narcotic medications even though she was sleeping in her wheelchair. Once she opened her eyes, she would ask for Narcotic medication. Resident 3 had PRN (as needed) Norco order and it was now changed to regularly scheduled Norco.
A nurse's note dated 10/20/16, at 10:15 a.m., indicated "[Resident 3] [up out of bed] in [wheelchair]. Denies any residual pain [secondary to fall]. [Resident 3] in wheelchair, going up and down hallway [without] difficulty. Will continue to monitor." The note did not indicate a head to toe assessment. The nurse's note dated from 10/20/16 to 10/24/16, did not indicate a complete post fall assessment nor notified the physician of Resident 3's fall.
During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated no specific document was used for the head to toe assessment. Licensed Staff B stated he documented the head to toe assessment in the nurse's notes. When asked about the nurse's notes, Licensed Staff C stated the nurse's note dated 10/20/16 at 10:15 a.m. was written by him. When asked about the facility's fall protocol, Licensed Staff C stated staff would use a form which the night shift nurse should have done and should have turned in to the DON.
During a concurrent interview and record review on 10/26/16, at 8:35 a.m., The DON reviewed Licensed Staff B's nurse note dated 10/20/16 at 10:15 a.m. and stated it was not well documented and did not show the head to toe assessment. The DON stated the post fall protocol included completing the incident report, post fall assessment, post fall huddle (staff meet together to discuss about the fall), and neurological check flow sheet for unwitnessed fall. The DON stated the staff did not complete the post fall protocol procedures for Resident 3's fall on 10/20/16.
During an interview on 11/8/16, at 9:10 a.m., the DON stated the facility's standard practice and her expectation was for the charge nurse to notify the physician on the same work shift the resident fell, either by fax or by calling the physician depending on the severity of injury.
The physician's order dated 10/14/16 indicated: Schedule Norco 5/325 (strength of the Norco) as one tablet by mouth 4 times a day for one week, then one tablet by mouth 3 times a day for one week, then one tablet by mouth 2 times a day for one week, then one tablet by mouth every morning for one week and off (discontinue).
The care plan for pain initiated on 8/4/16 with a goal date 11/16, did not indicate Resident 3 was to have Norco tapered and did not indicate approaches specific to taper the medication.
During a concurrent interview and record review on 10/26/16, at 8:10 a.m., when asked what care plan for tapering the Norco was for Resident 3, Licensed Staff B provided the MAR (medication administration record) with the Norco administration schedule. When asked again for care planning and what would he do when Resident 3 kept asking for Norco, Licensed Staff B stated he would re-direct Resident 3 by telling her that physician ordered for her narcotics to be tapered and she had to wait for the next scheduled dose. Licensed Staff B stated he had not reviewed the chart if the chart contained any care plan for tapering the Narcotics.
During an interview on 10/26/16, at 8:35 a.m., the DON stated she did not care plan the tapering Narcotics for Resident 3 and believed care plan was not in place. The DON reviewed Resident 3's chart and stated there was no care plan and she understood the need to care plan how the facility would help the resident in tapering the Norco besides telling her to wait. The DON stated Resident 3 had drug seeking behaviors, kept asking for Norco and staff had to tell her to wait.
During an interview on 11/1/16, at 9:20 a.m., the DON stated Resident 3's recent x-ray result after the fall on 10/20/16 indicated a condition that required a physician's referral for Resident 3 to have a hip replacement.
Resident 3's x-ray result dated 10/27/16, indicated Resident 3 had, "Severe avascular necrosis of the left hip without evidence of acute fracture." Avascular necrosis is a condition which commonly occurs in the hip when there is loss of blood to the bone and could cause the bone to die and collapse. The symptoms of avascular necrosis include severe pain that interferes with the ability to use the joint when the disease progresses and the bone and joint collapse.
During an interview on 11/3/16, at 2:35 p.m., when asked if the facility evaluated the underlying cause of the pain since Resident 3's admission until the x-ray on 10/27/16, the DON stated she was not aware of an evaluation of the underlying cause of the pain. The DON stated Resident 3 had been treated for chronic pain based on the admission diagnoses. The DON stated Resident 3 was not being sent out for imaging or work ups because Resident 3's insurance did not cover for rehabilitation.
During an interview on 11/8/16, at 10:05 a.m., when asked what was her expectation of being notified of a resident's fall, Physician S stated the facility staff usually notified her the same day or the day after the fall by fax or phone. Physician S stated the staff should have notified her earlier of Resident 3's fall. Physician S stated Resident 3's avascular necrosis was not a result from the fall, but avascular necrosis could cause increasing pain. Physician S stated Resident 3 had chronic hip pain and after the fall, she looked deeper and found Resident 3 had avascular necrosis of the hip. Physician S stated she referred Resident 3 for a hip replacement. Physician S stated she tried to taper Resident 3's Narcotics, but now she could not taper the Narcotics because of Resident 3's left hip avascular necrosis.
During a concurrent observation and interview that started on 12/6/16, at 8:16 a.m., Resident 3 was eating breakfast. Resident 3's face was grimacing. Resident 3 stated she was, "in a lot of pain" and needed medications. Resident 3 put on the call light. Unlicensed Staff AA responded to the call light and told Resident 3 that she would tell the nurse about the pain. Unlicensed Staff AA left the room and came back at 8:21 a.m. and told Resident 3 that the nurse [Licensed Staff B] stated he would give Resident 3 medications when the nurse arrived here [Resident 3's room]. Resident 3 stated Licensed Staff B would go room by room giving residents medications and asked what room Licensed Staff B was at this time. Unlicensed Staff AA stated the nurse was at room 2, which was about four rooms away.
During an interview on 12/6/16, at 12:40 p.m., regarding Resident 3's pain, Licensed Staff B stated Resident 3 had drug seeking behaviors and made up the pain. Licensed Staff B stated after x-ray of the left hip and found avascular necrosis, Resident 3 started complaining of left hip pain. Licensed Staff B stated he saw Resident 3 was in the wheelchair and self-propelled down the hallway this morning, but Resident 3 did not complain of pain. Licensed Staff B stated when he was giving medications including pain medication to Resident 3 at approximately 9 a.m., following his sequence, Resident 3 complained of pain 9/10 but Resident 3 closed her eyes resting. Licensed Staff B stated "If I have 9/10 pain, I will be screaming."
The nurse's note and the MAR (medication administration record) from 12/6/16 to 12/9/16 did not indicate a nursing assessment for Resident 3's complaint of pain on 12/6/16 at 8:16 a.m. to 8:21 a.m.
During an interview on 12/9/16, at 7:20 a.m., the DON stated the nurse should have assessed Resident 3 when the resident complained of pain. The DON stated the nurse should not wait for the sequence to give medication when the resident complained of pain because "you don't know" if it was a new onset of pain.
The facility's policy and procedure titled "Pain Management," date revised November 2015, indicated "A Licensed Nurse will assess residents for pain on admission, quarterly, when there is a new onset of pain, or significant change in condition. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible...The Licensed Nurse will develop a Care Plan for pain management, including non-pharmacological interventions...Nursing Staff will implement timely interventions to reduce the increase in severity of pain...Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain...The Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication...Upon admission, quarterly, and with significant change in condition the IDT will meet to review the resident's Pain Assessment. The IDT will document the following...i. Summary of event causing pain; ii. Root cause analysis; iii. Referrals, as necessary, and iv. Interventions to prevent future pain..."
The facility's policy and procedure titled "Pain Management," revised November 2016, indicated "...Facility Staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible...Licensed Nurse will assess each resident for pain upon admission, quarterly, when there is a new onset of pain, exacerbation of pain..."
2. During an interview on 12/5/16 at 3:40 p.m. and 12/7/16 at 11:20 a.m., Resident 11 complained of her left ear feeling plugged. Resident 11 stated she had informed her nurse (could not recall nurse's name) about her left ear feeling plugged and has been waiting for some type of treatment. Resident 11 stated she was having difficulties hearing out of the left ear now due to it being plugged.
During a concurrent interview and clinical record review on 12/7/16 at 11:25 a.m., Licensed Staff TT was asked if Resident 11 had received any ear treatment for her left ear. Licensed Staff TT checked to see if an order had been written regarding treatment for Resident 11's left ear. Licensed Staff TT stated an order was written for Debrox (earwax removal and treatment) to be started, but it did not look like it was ever started. Review of the "Physician Telephone Orders" written at 11/30/16 at 5:00 a.m. indicated Debrox 2 drops was to be inserted into left ear and then irrigate with warm water every evening for three days. Review of Resident 11's "Routine Medication Administration Record" (MAR) for November indicated the Debrox treatment was to be started 11/30/16 at bedtime and to be continued for the next two days, but there was no nurse's signature indicating it was ever started. Review of Resident 11's Routine MAR for December indicated Debrox treatment should have been given on 12/1/16 and 12/2/16, but there was no signature indicating the Debrox treatment was ever performed.
Review of the facility's policy titled, "Physician Orders" revised 1/1/12, did not indicate how a licensed nurse would carry out the physician's order once the order was transcribed on to the resident's Routine MAR.
Review of the facility's admission pack (given to all residents upon their admission), titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" dated 5/11, indicated all residents who are admitted to the facility have "a right to prompt medical care and treatment."
The facility's policy and procedure titled "Resident Rights - Quality of Life," revised 1/1/12, indicated "Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality."
Therefore, the facility failed to 1. adequately assess and treat Resident 3's pain and care plan to taper Norco (a medication for pain), which resulted in harm to Resident 3 who was crying in tears and was having difficulties with moving around due to severe pain in her left leg, secondary to a bone condition and a recent fall; and 2. follow through with a treatment order of Debrox (ear wax removal) for Resident 11, which caused Resident 11's left ear to be plugged up and loss of hearing.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012904 |
A |
28-Feb-17 |
G9FK11 |
5677 |
F-323 ?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 maintain an accident hazard free environment, provide adequate supervision and assistance and implement Resident 6's care plan when: Resident 6 had multiple falls in a six-month period from 5/22/16 to 11/25/16. Resident 6 sustained bleeding in the head from the fall on 8/1/16; a laceration (cut) on the left side of the head which required eight staples from the fall on 10/13/16. Resident 6 sustained a laceration on the right side of the head from the fall on 11/25/16.
Resident 6's admission record indicated Resident 6 was admitted to the facility on XXXXXXX16, with diagnoses including Alzheimer's disease (a brain disease causing a memory loss and disorientation), epilepsy (seizure) and depressive disorder.
The Admission Minimum Data Set, dated 4/1/16, and the most recent quarterly MDS, dated 9/29/16, indicated Resident 6 had a short-term and long-term memory loss and had severely impaired cognition.
The CAA (CAA, a tool used to identify concerns and develop an individualized care plan), dated 4/1/16, indicated Resident 6 was a risk for falls, Alzheimer's type dementia, and was on Psychotropic drugs.
During a record review on 12/7/16, a Nurse's Note, dated 11/25/16 at 2:45 a.m.,
while ambulating on B Hallway, Resident 6 tripped on a pedal of another resident's wheelchair; thus causing a fall. Resident 6 had a laceration on the right side of her head. Resident 6 had a hipster on. The Nurse's Note also indicated, "prior to the fall, Resident 6 per report from the Night shift nurse, was agitated, combative and in constant motion. Resident 6's behavior escalated to screaming, hitting staff and kicking other residents. PRN (as needed medication) was given, but no avail." Staff was planning to notify Resident 6's husband to help calm her prior to the fall.
During observation and interview on 12/7/16 at 8:45 a.m., Resident 6 was walking down the hallway back and forth multiple times without being accompanied by anyone. When asked why Resident 6 was walking alone, Licensed Staff NN stated she did not know why the Hall Monitors were not walking with her. Licensed Staff NN also stated Resident 6 did not like Hall Monitors getting closer to her, and if they did, Resident 6 started pushing and yelling at them and got agitated and combative, so they had to walk behind Resident 6. When asked how was that going to prevent Resident 6 from falling, Licensed Staff NN stated she did not know what to do.
During record review on 12/7/16, a care plan dated 11/25/16, documented an intervention for Resident 6 to have 1:1 supervision upon return from the ED.
During an interview on 12/9/16 at 8:20 a.m., Licensed Staff D stated she witnessed the fall on 11/25/16 at 8:45 a.m. Resident 6 was walking the hallway and tripped on the pedal of another resident's wheelchair and fell. Licensed Staff D stated she assessed Resident 6 and noted Resident 6 had a laceration to her right forehead. Licensed Staff D stated she called the treatment nurse who came, cleaned and put pressure on the wound. Licensed Staff D then called an ambulance that came and took Resident 6 to the hospital for evaluation and treatment.
During record review, on 12/7/16, IDT (interdisciplinary team) Notes indicated Resident 6 had multiple falls from the date of admission (3/25/16) to date of the survey (12/5/16). Three of these falls caused injuries to Resident 6's head, which required her to be sent to an acute care hospital for evaluation and treatments.
During a record review on 12/7/16, an IDT Note, dated 8/2/16, indicated on 8/1/16, Resident 6 was ambulating all morning as Resident 6 usually was, unable to sit still. Resident 6 was noted to be irritable and poking staff as they walked by. At one point Resident 6 grabbed the neck of one staff who was attempting to pick up Resident 6's Teddy Bear. Resident 6's gait was shuffling as was usual, she was leaning back as Resident 6 stood. Suddenly, Resident 6 witnessed to be standing and fell backward bumping her right elbow and back of her head. Resident 6 had some bleeding in her head, pressure was applied and 911 called for transport to the ED for evaluation and treatment. The physician was faxed regarding reducing meds.
During a record review on 12/7/16, an IDT note, dated 10/26/16, indicated on 10/13/16, Resident 6 had a fall and sustained a laceration to the left side of her head, requiring eight staples. The physician ordered increased Depakote (anti-seizure medication) for seizures, and Resident 6 continued to be risk for falls. Resident 6's gait was steady and Hall Monitors were available in B wing, according to IDT notes.
Therefore, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance and implement Resident 6's care plans when:
Resident 6 had multiple falls in a six-month period from 5/22/16 to 11/25/16. Resident 6 sustained bleeding in the head from the fall on 8/1/16; a laceration (cut) on the left side of the head, which required eight staples from the fall on 10/13/16. Resident 6 sustained a laceration on the right side of the head from the fall on 11/25/16.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012905 |
A |
28-Feb-17 |
G9FK11 |
32677 |
The citation narrative for this penalty will not fully display due to narrative length limitations. Please send a request toÿCHCQdata@cdph.ca.govÿto obtain a full copy of this citation narrative.ÿ
F-520 ?483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS (g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (g)(2) The quality assessment and assurance committee must: (i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. The facility's quality assessment and assurance committee (QAA) failed to: 1. Develop formal corrective action plans or implement the action plans to prevent falls, which caused harm to residents as evidenced by: The facility did not provide adequate supervision and assistance, revise fall risk care plans and implement the care plans, follow fall protocol for post-fall assessment and management to prevent falls and injuries for Residents 1, 2, 3, 4, 5, 6, and 14 when: a. Resident 1 walked to the restroom unassisted, grabbed the rod across the restroom entrance and fell on the floor on 8/28/16. This caused Resident 1 to sustain a left humeral neck (upper arm bone just under the shoulder joint) fracture which required admission to an acute care hospital for treatment. b. Resident 2 had five falls during a one month period from 8/12/16 to 9/14/16. Resident 2 sustained a head injury from the last fall on 9/14/16, which required Resident 2 to be sent to an acute care hospital for evaluation and treatment. After 9/14/16, Resident 2 had three more falls on 10/26/16, 11/5/16, and 11/26/16. c. Staff did not follow their fall protocol for post-fall assessment and notify the physician of a fall when Resident 3 reported having fallen on 10/20/16. This resulted in Resident 3 not being evaluated after the fall until 10/25/16 (five days later). d. Resident 5 had six falls during a six and one-half months period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom which was wet with urine. A fall on 11/23/16, resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose on 11/23/16 at 9:35 p.m. (This was the second fall that day). e. Resident 4 had three falls during a one-month period from 8/16/16 to 9/17/16. Resident 4 sustained a skin tear on the right hand from a fall on 8/16/16, and re-opened a skin tear on the right hand from a fall on 8/21/16. Resident 4 had three more falls during a one-week period from 10/13/16 to 10/17/16, which resulted in a nasal bone (nose) fracture from a fall on 10/13/16. f. Resident 6 had multiple falls in a six-month period from 5/22/16 to 11/25/16. Resident 6 sustained bleeding in the head from the fall on 8/1/16; a laceration (cut) on the left side of the head, which required eight staples from the fall on 10/13/16. Resident 6 sustained a laceration on the right side of the head from the fall on 11/25/16. g. Licensed Staff did not revise Resident 14's (who had one unwitnessed fall on 11/4/16, which resulted in a skin tear to the left elbow and a fractured pelvis), "Fall Care Plan" to indicate Resident 14 was to be on, "one-on-one" with staff at all times starting 11/5/16, per physician's order. This failure to revise Resident 14's, "Fall Care Plan" had the potential for Resident 14 to fall again causing injury or even death. 2. Identify staffing issues and ensure sufficient nursing staff to provide quality resident care, which caused harm to their residents, as evidenced by resident falls and injuries (refer to 1a - 1g) and residents' care needs were not being met when call lights were not answered in a timely manner for Resident 17 and 18, and Resident 17's need of getting out of the bed earlier in the morning was not honored. These failures resulted in Resident 17 staying wet with the urine and feeing bad, and potentially compromised residents' physical and psychosocial well-being. 3. Communicate QAA minutes to the staff. These failures also prevented the QAA committee from implementing and evaluating action plans to correct quality deficiencies and therefore was not able to determine effectiveness of changes to be implemented. 1a. Resident 1's admission record indicated Resident 1 was admitted to the facility on xxxxxxx 16, with diagnoses including blindness both eyes, difficulty in walking, and generalized muscle weakness. Resident 1's minimum data set (MDS, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/29/16, revealed a BIMS (Brief Interview for Mental Status) score of 14, which indicated Resident 1 was cognitively intact. The MDS assessment indicated Resident 1 required limited assistance of one person with physical assistance for walking in the corridor and toilet use. The Fall Risk Assessment, dated 7/27/16, indicated Resident 1 was at high risk for falls due to multiple problems, including intermittent confusion, one to two falls in past three months, and being legally blind. Resident 1's care plan for fall risk prevention and management, initiated on 1/22/16 and re-evaluated on 7/16, indicated approaches for fall risk prevention and management including, "Orient resident to environment each time changes are made and provide an environment that supports minimized hazards over which the Facility has control..." The care plan did not specify how the facility would provide supervision to prevent Resident 1 from falling. Resident 1's care plan for visual impairment, initiated on 1/22/16, indicated, "Provide environment with items kept in consistent location, free from obstacles and clutter...uses handrails in hallway..." The care plan for activities of daily living, initiated on 1/22/16 and re-evaluated on 7/16, indicated Resident 1 required assistance for toilet use and personal hygiene. The Nurse's Note, dated 8/28/16, revealed Resident 1 had an unwitnessed fall at 9:10 a.m., when Resident 1 was ambulating to the restroom and walked onto wet floor sign. The IDT (Interdisciplinary Team) Conference Record, dated 8/29/16, indicated on 8/28/16, at 9:10 a.m., Resident 1 walked to the bathroom and stopped at the restroom doorway. Resident 1's hands grabbed the spring rod, which the housekeeper placed in the doorway for cleaning, and simultaneously leaned her weight backward expecting the rod to be stable like a handrail. Resident 1 fell to her left side and had left shoulder pain and left hip discomfort. Resident 1 was sent to an Emergency Department and admitted to an acute care hospital. The CT (Computerized Tomography, combines of X-ray images using computer process to create images) examination result, dated 8/28/16, and the History and Physical Report from the acute care hospital, dated 8/28/16, indicated Resident 1 sustained a non-operable left humeral neck (upper arm bone) fracture and was admitted to the hospital for pain control and evaluation. During an interview on 10/26/16 at 10:02 a.m., regarding Resident 1's fall on 8/28/16, Licensed Staff A stated Resident 1 usually used the handrails in the hallway when Resident 1 was walking. Licensed Staff A stated Resident 1 had visual impairment. Resident 1 liked to grab the handrail and lean backward while talking to staff or other residents. Licensed Staff A stated on the day Resident 1 fell, Resident 1 walked to the restroom in the hallway and grabbed the spring rod, which the housekeeper placed in the doorway for cleaning. Licensed Staff A stated Resident 1 thought the rod was the handrail, so Resident 1 leaned her body backward while grabbing the rod. Licensed Staff A stated Resident 1 fell on the floor because the rod was not stable and fell off the doorway. Licensed Staff A stated no staff walked with Resident 1 because it was Resident 1's routine to walk to the restroom by herself using the handrails. Licensed Staff A stated the biggest mistake was lack of communication. Licensed Staff A stated the housekeeper did not tell her (Licensed Staff A) about placing the rod in the restroom doorway, otherwise she would have educated Resident 1 and let her feel the rod or walked with her. Licensed Staff A stated the rod was a new product, but they should not use it on the floor because it was dangerous. During an interview on 10/26/16, at 11:50 a.m., regarding Resident 1's fall on 8/28/16, Housekeeping Staff P stated she put the rod with a sign across the restroom doorway and two signs on the floor when she was mopping the restroom. Housekeeping Staff P stated she told Resident 1 the restroom was closed. Housekeeping Staff P stated after she cleaned the restroom, she left the rod with a sign across the restroom doorway and went to another hall. Housekeeping Staff P stated she did not tell Resident 1 that the rod was left in the doorway. Housekeeping Staff P stated she did not tell any staff about the rod because they could see it. Housekeeping Staff P stated from the beginning of using this type of rod, she told the Housekeeping Supervisor that the rod was terrible and not good for use because the rod did not have spring and was easy to fall off. She stated the rod was not stable and when people grabbed the rod, the rod fell. During a concurrent observation and interview on 10/26/16, at 11:25 a.m., in the Housekeeping Supervisor's office, Housekeeping Supervisor Q showed a yellow rod with a yellow sign, "CLOSED FOR CLEANING" hanging to the rod. Housekeeping Supervisor Q stated this was the rod with the sign Housekeeping Staff P used when she cleaned the restroom where Resident 1 fell. Housekeeping Supervisor Q stated the housekeeper put the rod across the doorway to indicate the room was being cleaned. Housekeeping Supervisor Q stated the housekeeper should tell the nurse when the rod was placed. Housekeeping Supervisor Q stated the rod was light metal and was not strong. Housekeeping Supervisor Q stated the facility had been using the rod for about six to seven months, but they did not have a policy and procedure regarding the use of the rod. Upon request for the manufacturer's guidelines for the rod, Housekeeping Supervisor Q provided a page documentation titled, "FACILITY MAINTENANCE," undated, under A. Site Safety Hanging Sign, which did not indicate how to use the rod and sign safely. 1b. Resident 2's admission record indicated Resident 2 was re-admitted to the facility on xxxxxxx 16, with diagnoses including Alzheimer's disease (a brain disease causing memory loss, impaired thinking and disorientation), dementia, and neuromuscular (relating to the nerves and muscles) dysfunction of bladder. Resident 2's MDS assessment, dated 8/19/16, indicated Resident 2 was not able to complete the Brief Interview for Mental Status (BIMS). The MDS assessment indicated staff interview for mental status was conducted, and indicated Resident 2's cognitive skills for daily decision making was, "moderately impaired - decisions poor; cues/supervision required." Resident 2's Fall Risk Evaluation, dated 8/12/16, indicated Resident 2 was at high risk for falls due to multiple problems including mental status, history of falls, ambulatory and elimination status, and gait/balance problems. The care plan for fall risk prevention and management, initiated on 8/12/16, with approach started date 8/11/16, indicated approaches including, "Bed in low position, pad alarm (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or the bed) in bed..." The care plan did not specify how the facility would provide supervision to prevent Resident 2 from falling. First Fall: The Nurse's Note, dated 8/12/16 at 12 a.m., revealed Resident 2 had an unwitnessed fall in the his room. Resident 2 sustained a 3 cm X 3 cm skin tear with bruising at left elbow. The care plan for the actual fall on 8/12/16, indicated a goal, "No serious injury from fall [for 7 days]." The approaches included observing and monitoring for 72 hours, mobility alarm, pads at bedside, and visual monitor just for one shift. The IDT (Interdisciplinary Team) Conference Record, dated 8/12/16, regarding Resident 2's fall on 8/12/16 at midnight, did not indicate new approaches to the fall risk care plan to prevent further falls. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Second Fall: The Nurse's Note, dated 8/29/16, at 7 a.m., indicated nursing staff from the last two work shifts reported Resident 2 had a fall at 7:15 a.m., on 8/28/16. However, there were no documentation of Nurses' Notes on 8/28/16, regarding the fall. The IDT Conference Record, dated 8/30/16, indicated Resident 2 had a fall with no injury on 8/28/16. The IDT note indicated to resume Risperdal (an antipsychotic medication, which works by changing the effects of chemicals in the brain), which was discontinued, due to increased agitation, re-emergence of aggressive verbal outbursts, pressured speech, and etc. The care plan for the actual fall on 8/28/16, included to teach the new nurses on fall follow-up process and continue plan of care. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Third Fall: The Nurse's Note, dated 9/5/16, at 4:20 p.m., indicated Resident 2 fell out from the wheelchair when he was watching TV in the TV room with other residents. The IDT Conference Record, dated 9/6/16, regarding Resident 2's fall on 9/5/16, indicated Resident 2 had, "very poor safety awareness." The IDT determined to continue using the alarm with a goal, "no serious injury [with] fall." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/5/16, was to continue plan of care. The fall risk care plan initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fourth Fall: The Nurse's Note, dated 9/10/16, with unknown time of the note, indicated, "Am shift reports fall [with] no injury 10:30 Am..." The Nurse's Note did not describe how Resident 2 fell. The IDT Conference Record, dated 9/12/16, indicated Resident 2 stood up and fell at the Nurse's Station. The IDT note indicated Resident 2 continued having poor safety awareness. The IDT note indicated, "Comfort is goal and [with] regard to falls, minimizing serious injury is goal..." The IDT note indicated, "Will continue use of alarm, encourage wheelchair..." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/10/16, was to continue plan of care. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fifth Fall: The Nurse's Note, dated 9/14/16, at 7:55 p.m., revealed Resident 2 had an unwitnessed fall and sustained a skin tear at his left elbow and injury in the back of Resident 2's head which required Resident 2 to be sent to an Emergency room for evaluation. The IDT Conference Record, dated 9/15/16, indicated on 9/14/16, at 7:55 p.m., Resident 2 was found on the floor next to the bed. The IDT note indicated an alarm was present but was not engaged. The IDT note indicated a fall prevention plan which included care alert posted in Resident 2's room. The IDT note did not specify how the facility would provide supervision to prevent Resident 2 from further falls. The Care Alert, dated 9/15/16, posted in Resident 2's room, indicated, "[Resident 2] is a high fall risk with a recent fall requiring a trip to the ER. Please make sure [Resident 2] has his loud alarm attached at all times! Check frequently as he is able to inadvertently remove the alarm..." The Care Alert did not specify how frequently to check the alarm or Resident 2. During an interview on 11/3/16, at 2:35 p.m., regarding, "Check frequently" for the alarm indicated in the Care Alert, the DON (Director of Nursing) stated she expected the staff check the alarm when staff made rounds every two hours; the Hall Monitor (an employee) walked back and forth in the hall, and when walking to Resident 2's room, the Hall Monitor could look inside the room from the hallway to see if the alarm was intact. When asked if the Hall Monitors were trained on how to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff if anything was out of the ordinary. The DON stated a Hall Monitor was a facility staff member, but was not a caregiver. The DON stated the Hall Monitors did not do hands-on resident care; they could guide the resident and gently hold the resident's hands/elbows. The IDT Conference Record, dated 9/16/16, for safety review related to the fall on 9/14/16, indicated to evaluate Resident 2's room to, "reconfigured room to have bed at a slight angle decreasing the likelihood of striking head during a fall. Mats at both side of bed." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. During a concurrent observation and interview on 10/25/16, at 10 a.m., Resident 2 was in bed and awake. One floor mat was placed on Resident 2's right side, and one mat was up leaning against the wall below the window. When asked about his fall on 9/14/16, Resident 2 stated he did not remember the fall. During an interview on 10/25/16, at 3 p.m., regarding Resident 2's fall on 9/14/16 at 7:55 p.m., Licensed Staff C stated a Hall Monitor found Resident 2 on the floor. Licensed Staff C stated when she arrived at the scene, Resident 2 was laying on the floor mat with the head against the wall on the left side of the bed. Licensed Staff C stated she did not hear the alarm. She stated Resident 2 took the alarm off all the time. When asked about fall prevention, Licensed Staff C stated when Resident 2 was not in bed, Resident 2 sat at the Nurse's Station. When Resident 2 was in bed, staff would listen to the alarm or Resident 2 yelling. Licensed Staff C stated they did not have a set time to check on Resident 2 because Resident 2 was not on an every 15 minute check. During a concurrent observation and interview on 10/25/16, at 3:05 p.m., in Resident 2's room, one floor mat was on the right side of the bed, and one mat was up against the wall. Licensed Staff C stated the floor mat should be on the left side because Resident 2 got out of the bed from his left side. During a concurrent interview and record review of Resident 2's care plans for fall and fall risk on 10/25/16, at 3:13 p.m., Licensed Staff C stated a care plan described what was the best care provided to the resident and communication with the care team. Licensed Staff C stated all nurses should review the care plans. When asked if the care plans specify providing supervision to Resident 2, Licensed Staff C reviewed the care plans, initiated on 8/12/16 and 8/15/16, and stated the supervision was to observe and monitor Resident 2 for 72 hours. When asked what happened after 72 hours, Licensed Staff C stated, "none" and the care plans did not specify supervision. During an interview on 10/25/16, at 4:40 p.m., Unlicensed Staff O stated when Resident 2 was in bed, she would check Resident 2 approximately every five minutes. When asked how she knew about the five minutes, Unlicensed Staff O stated, "from the text book." When asked how she knew the care needed for a resident, Unlicensed Staff O stated she would ask other staff or look at the care plans, which would tell her about the resident. When reviewing Resident 2's care plan, which indicated Resident 2 had four falls from 8/12/16 to 9/10/16, Unlicensed Staff O stated she did not know Resident 2 had so many falls, "like constantly falling." Unlicensed Staff O stated by looking at the falls indicated in the care plan, Resident 2 should not be left alone. Unlicensed Staff O stated the care plan did not specify the frequency of checking Resident 2. During a concurrent interview and record review on 10/26/16, at 2:50 p.m., the DON stated they tried different interventions including alarm, pad, and visual monitor for one shift only. The DON reviewed the fall and fall risk care plans, and stated the care plans did not specify providing supervision to Resident 2 to prevent falls. During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated he did not witness Resident 2's fall. Unlicensed Staff L stated he was not assigned to Resident 2, but he still helped check on Resident 2 and the alarm function at least every hour. Unlicensed Staff L stated when Resident 2 had repeated falls (4 - 5 times in a month), staff should be with Resident 2 all the time. Unlicensed Staff L stated they did not have enough CNAs (Certified Nursing Assistant) in the hall where Resident 2 resided. Unlicensed Staff L stated because of short staffing, they were not able to check residents as frequently as they would, to prevent residents from falling. The Emergency Department Report, dated 9/14/16, indicated Resident 2 sustained a wound 2 cm in length in the head, and the wound was repaired with staples. The Emergency Department report indicated Resident 2 did not receive any imaging or extensive work-up because Resident 2 was on hospice with comfort measures only. Resident 2 had three more falls after 9/14/16, as follows: a. The IDT note, dated 10/26/16, indicated Resident 2 fell from a wheelchair to the floor in the TV room; b. The IDT note, dated 11/7/16, indicated Resident 2 fell on 11/5/16, witnessed by a Hall Monitor; and c. The IDT note, dated 11/28/16, indicated Resident 2 fell on 11/26/16, sliding out of a wheelchair. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to, "us" [Certified Nursing Assistants]. Unlicensed Staff BB stated they just put up signs in the utility room and in the resident's room and, "hoping us to know" what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote, "keep bed low, keep bed at an angle." During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent injuries from falls. The DON stated she educated the staff about the sign but did not have a log to ensure all staff were educated and understood the sign. 1c. During a concurrent observation and interview on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 stated she fell approximately at 3 a.m. four days ago from her bed to the floor. Resident 3 stated she climbed back to bed because no staff were around to assist her. Resident 3 stated she told a nurse about the fall at approximately 5:30 a.m. the day she fell. She stated the nurse just told her to go back to bed. Resident 3's MDS dated 8/9/16, indicated Resident 3's BIMS (Brief Interview for Mental Status) score was 13, which indicated Resident 3 was cognitively intact. Resident 3's Fall Risk Evaluation, dated 8/4/16, indicated Resident 3 was at high risk for falls due to multiple problems including history of falls, ambulatory and elimination status, and gait/balance problem. During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately seven hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head-to-toe assessment. Licensed Staff B stated he documented the assessment. The Nurse's Note, dated 10/20/16 at 10:15 a.m., indicated, "[Resident 3] [up out of bed] in [wheelchair]. Denies any residual pain [secondary to fall]. [Resident 3] in wheelchair, going up and down hallway [without] difficulty. Will continue to monitor." The note did not indicate a head-to-toe assessment. There was no documentation of physician notification. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated there was no specific document for the head-to-toe assessment. Licensed Staff B stated he documented the head-to-toe assessment in the Nurse's Note. When asked about the Nurse's Note, Licensed Staff B stated the Nurse's Note, dated 10/20/16 at 10:15 a.m., was written by him. When asked for the fall protocol, Licensed Staff B stated they filled out the information forms which the night shift nurse should have done and turned it in to the DON. During a concurrent interview and record review on 10/26/16, at 8:35 a.m., the DON reviewed Licensed Staff B's Nurse's Note, dated 10/20/16 at 10:15 a.m., and stated it was not well documented and did not show the head-to-toe assessment. The DON stated the post-fall protocol included completing the incident report, post-fall assessment, post-fall huddle, and neurological check flow sheet for unwitnessed fall. The DON stated staff had not notified her of Resident 3's fall. The DON stated staff did not complete the post-fall protocol procedures for Resident 3's fall on 10/20/16. Review of the Fall Management Program Policy No. FA-01, documented following each fall, the licensed nurse would perform a post-fall assessment, the licensed nurse would notify the Director of Nursing and / or Administrator, and the Licensed Nurse would notify the resident's attending physician and responsible party of the fall incident. 1d. Resident 5's admission record indicated Resident 5 was admitted to the facility on xxxxxxx 16, with diagnoses including difficulty in walking, muscle weakness, dementia with behavioral disturbance. Resident 5's fall risk evaluation, dated 10/10/16, 11/24/16, and 12/6/16, indicated Resident 5 was at high risk for falls due to multiple problems including mental status (disoriented or intermittent confusion), history of falls, gait and balance problems, and medications. Resident 5 was on Risperdal (an antipsychotic medication which works by changing the effects of the chemicals to the brain. Common side effects includes dizziness, drowsiness, and tired feeling) 0.5 mg by mouth every day and Haldol (an antipsychotic medication which may work by blocking some chemical effects in the brain. Major common side effects include loss of balance control, muscle spasms, and shuffling walk) 70 mg intramuscularly every month for dementia with psychosis. Resident 5's MDS, dated 3/17/16 and 9/16/16, indicated Resident 5's cognition was moderately to severely impaired. First fall: The Nurse's Note, dated 5/24/16 at 11 p.m. and the IDT note, dated 5/25/16, indicated Resident 5 had an unwitnessed fall on 5/24/16 at 7:45 p.m. in the bathroom. Resident 5 was found in the bathroom sitting on the floor wet with urine. Resident 5 complained of left shoulder pain and treated with Norco (pain medication). The IDT note indicated Resident 5 received antipsychotic (Haldol injection) prior to the fall. The IDT note indicated the Charge Nurse's plan to increase monitoring for a few hours after the monthly Haldol injection and recommended non-slip shoes for Resident 5. Resident 5's care plan for fall risk prevention and management, initiated on 3/11/16, and re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including, "Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue B-wing for increased supervision. The fall risk care plan did not reflect nor specify how to increase monitoring after the monthly Haldol injection. Second fall: The IDT note, dated 10/3/16, indicated Resident 5 had an unwitnessed fall in his room on 10/3/16 at 1:15 a.m. The IDT note indicated referring for physical and occupational therapy and continue to encourage wearing the hipster (Padded pants that cover the hip to cushion a fall to prevent injuries to the hip) when ambulating. The IDT note did not specify providing supervision to Resident 5. Third fall: The Nurse's Note, dated 10/9/16 at 2:30 a.m. and the IDT note, dated 10/10/16, indicated Resident 5 had an unwitnessed fall in his room on 10/9/16, with unknown time of fall. The IDT note indicated referring for physical and occupational therapy and continue to encourage wearing the hipster when ambulating. The IDT note did not specify providing supervision to Resident 5. Fourth fall: The IDT note, dated 11/24/16, indicated Resident 5 had a fall on 11/23/16 at 12 p.m. The IDT note indicated Resident 5 was walking in the hallway, "but still asleep." The Hall Monitor headed toward Resident 5, "but before she got to him he fell onto his [left] hip and elbow." The IDT note indicated, "will make a referral to PT/OT [Physical Therapy/Occupational Therapy]..." The IDT note did not specify providing supervision to Resident 5. Fifth fall: The Nurse's Note, dated 11/23/16, and the IDT note, dated 11/24/16, indicated Resident 5 had an unwitnessed fall in his room on 11/23/16 at 9:35 p.m. Resident 5 sustained a small skin tear on the top ridge of the nose. The IDT note indicated, "observe and monitor for 72 hours and on 15 [minutes check]." Sixth Fall: The Nurse's Note, dated 12/6/16 at 3 a.m., and the IDT note, dated 12/6/16, indicated Resident 5 was found on the floor in his room. The IDT note indicated every 15 minute checks was initiated after the first hour of neuro checks. Resident 5's care plan for fall risk prevention and management, initiated on 3/11/16, re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including, "Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue B-wing for increased supervision. The fall risk care plan did not reflect the 15 minute checks and who was/how to check Resident 5. During a concurrent interview and record review on 12/8/16, at 8:35 a.m., regarding supervision for Resident 5, Unlicensed Staff CC stated she checked on Resident 5 whenever she saw him. Unlicensed Staff CC stated every staff in the hall was responsible to check on Resident 5. Unlicensed Staff CC stated she also reviewed care plans for resident care. When she reviewed Resident 5's fall risk care plan and asked her what did, "...increase supervision..." mean to her, Unlicensed Staff CC stated, "To me, may need one-to-one..." When asked her if Resident 5 was on one-to-one supervision, Unlicensed Staff CC stated she needed to check the documentation and found Resident 5 was on every 15 minute checks. Unlicensed Staff CC stated all staff were responsible for monitoring and documentation. During a concurrent interview and record review on 12/8/16, at 8:55 a.m., Licensed Staff NN reviewed the fall risk care plan and stated, "...increase supervision..." meant every 15 minute checks. Licensed Staff NN stated the DON or ADON was responsible to review and update the care plans. Licensed Staff NN stated the care plan was used for following-up on residents and making goals for resident care. During an interview on 12/9/16, at 7:20 a.m., Resident 5's fall risk care plan was reviewed with the DON. The DON stated the care plan did not specify supervision for Resident 5, and she understood that staff could have interpreted |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012936 |
B |
14-Mar-17 |
G9FK11 |
4075 |
Health & Safety Code 1418.91(a) and 1418.91(b)
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The facility failed to report an incident of resident-to-resident abuse to the Department of Public Health within 24 hours when Licensed Staff J did not report a witnessed event involving one Sampled Resident (Resident 7) and three Unsampled Residents (Resident 28, 33, and 34). This resulted in lack of a facility investigation and the Department's ability to ensure a complete investigation was initiated timely and ensure interventions were initiated to protect other residents, as well as those residents involved, preventing a reoccurrence of abusive behaviors.
During concurrent record review and interview on 12/7/16 at 8:40 a.m., the "24 Hour Report" flow sheet, dated 9/2/16, relevant to the residents on C Wing and the "Nurse's Notes," indicated Resident 7 was abusive, both verbally and physically on 9/2/16 at 12:00 a.m. Resident 7 was sitting in her wheelchair and blocking the entrance of her room, refusing to allow her roommates (Resident 28, 33, and 34) out of their room. Resident 7 started yelling at Resident 28, 33, 34 and staff, "I am going to kill you fucken bitch," and then Resident 7 threw a trash can down. Resident 7's abusive behavior caused Resident 28 and 33 to be fearful of Resident 7. The Director of Nursing (DON) was asked if Resident 7's abusive behavior should have been reported to: 1. her and/or the administrator; and 2. the State licensing/certification agency, police, and ombudsman. The DON stated Resident 7's aggressive behavior was documented on the, "24 Hour Report" flow sheet, which was filled out by the nurse each shift documenting relevant resident information, and the information was then passed on to the nurse on the following shift. The DON stated the, "24 Hour Report" went to the facility's daily Stand-Up Meeting, which included all department heads. The DON stated she did not see the incident on the, "24 Hour Report" due to she had been working nights and had not attended the Stand-Up Meeting on 9/2/16. The DON stated Resident 7's abusive behavior should have been reported to her and to the administrator in order for the resident-to-resident altercation to have been investigated and reported to the appropriate authorities.
During an interview on 12/8/16 at 5:32 a.m., when Licensed Staff J was asked why she did not report Resident 7's abusive behavior to the DON and/or administrator, which took place during her shift (9/2/16 at 12 a.m.), Licensed Staff J stated she did not feel it was at the level of abuse to report the incident even though Resident 7 was: 1) sitting in her wheelchair and blocking the entrance of her room, refusing to allow her roommates (Resident 28, 33, and 34) out of their room, and 2) throwing hair brushes at staff. Licensed Staff J stated she documented Resident 7's abusive behavior on the, "24 Hour Report," which should have gone to the Stand-Up Meeting, which the DON attended; The DON would have been aware of Resident 7's abusive behavior by way of the, "24 Hour Report."
Review of the facility policy and procedure titled, "Abuse - Reporting & Investigation," revised date 11/18/15, indicated the facility needed to report the suspected incident of resident abuse to the administrator or designee in order for he or she to have: 1. Started an investigation; 2. Provided a safe environment for the residents involved; and 3. Reported the allegation of resident-to-resident abuse to law enforcement by telephone, and a written report (SOC 341) needed to be sent to the Ombudsman and to the California Department of Public Health Licensing and Certification within 24 hours of the alleged abuse.
Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse, resulting in an automatic B violation. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012991 |
A |
28-Feb-17 |
G9FK11 |
7338 |
F-323 ?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 maintain an accident hazard free environment and provide adequate supervision and assistance for Resident 1 when: Resident 1 walked to the restroom unassisted, grabbed the rod across the restroom entrance and fell on the floor on 8/28/16. This caused Resident 1 to sustain a left humeral neck (upper arm bone just under the shoulder joint) fracture, which required admission to an acute care hospital for treatment.
Resident 1's admission record indicated Resident 1 was admitted to the facility on XXXXXXX16, with diagnoses including blindness in both eyes, difficulty in walking, and generalized muscle weakness.
Resident 1's minimum data set (MDS, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/29/16, revealed a BIMS (brief interview for mental status) score of 14, which indicated Resident 1 was cognitively intact. The MDS assessment indicated Resident 1 required limited assistance of one person with physical assistance for walking in the corridor and toilet use.
The fall risk assessment, dated 7/27/16, indicated Resident 1 was at high risk for fall due to multiple problems including intermittent confusion, one to two falls in the past three months, and being legally blind.
Resident 1's care plan for fall risk prevention and management, initiated on 1/22/16, and re-evaluated on 7/16, indicated approaches for fall risk prevention and management including, "Orient resident to environment each time changes are made and provide an environment that supports minimized hazards over which the Facility has control..." The care plan did not specify how the facility would provide supervision to prevent the resident from falling.
Resident 1's care plan for visual impairment, initiated on 1/22/16, indicated, "Provide environment with items kept in consistent location, free from obstacles and clutter...uses handrails in hallway..." The care plan for activities of daily living initiated on 1/22/16, indicated Resident 1 required assistance for toilet use.
The Nurse's Note, dated 8/28/16, revealed Resident 1 had an unwitnessed fall at 9:10 a.m., when Resident 1 was ambulating to the restroom and walked onto a wet floor sign.
The IDT (interdisciplinary team) Conference Record, dated 8/29/16, indicated on 8/28/16, at 9:10 a.m., Resident 1 walked to the bathroom and stopped at the restroom doorway. Resident 1's hands grabbed the spring rod, which the housekeeper placed in the doorway for cleaning, and simultaneously leaned her weight backward expecting the rod to be stable like a hand rail. Resident 1 fell to her left side and had left shoulder pain and left hip discomfort. Resident 1 was sent to an Emergency Department and was admitted to an acute care hospital.
The CT (computerized tomography, combines of X-ray images using computer process to create images) examination result, dated 8/28/16, and the History and Physical Report from the acute care hospital, dated 8/28/16, indicated Resident 1 sustained a non-operable left humeral neck (upper arm bone) fracture and was admitted to the hospital for pain control and evaluation.
During an interview on 10/26/16 at 10:02 a.m., regarding Resident 1's fall on 8/28/16, Licensed Staff A stated Resident 1 usually used the handrails in the hallway when Resident 1 was walking. Licensed Staff A stated Resident 1 had visual impairment. Resident 1 liked to grab the handrail and leaned backward while talking to the staff or other residents. Licensed Staff A stated, on the day Resident 1 fell, Resident 1 walked to the restroom in the hallway and grabbed the spring rod, which the housekeeper placed in the doorway for cleaning. Licensed Staff A stated Resident 1 thought the rod was the handrail, so Resident 1 leaned her body backward while grabbing the rod. Licensed Staff A stated Resident 1 fell on the floor because the rod was not stable and fell off the doorway. Licensed Staff A stated no staff walked with Resident 1 because it was Resident 1's routine to walk to the restroom by herself using the handrails. Licensed Staff A stated the biggest mistake was lack of communication. Licensed Staff A stated the housekeeper did not tell her (Licensed Staff A) about placing the rod in the restroom doorway, otherwise she would have educated Resident 1 and let her feel the rod or walked with her. Licensed Staff A stated the rod was a new product, but they should not use it on the floor because it was dangerous.
During an interview on 10/26/16 at 11:50 a.m., regarding Resident 1's fall on 8/28/16, Housekeeping Staff P stated after she cleaned the restroom, she left the rod with a sign across the restroom doorway and went to another hall. Housekeeping Staff P stated she did not tell Resident 1 that the rod was left in the doorway. Housekeeping Staff P stated she did not tell any staff about the rod because they could see it. Housekeeping Staff P stated from the beginning of using this type of rod, she told the housekeeping supervisor that the rod was terrible and not good for use because the rod did not have a spring and was easy to fall off. She stated the rod was not stable and when people grabbed the rod, the rod fell.
During a concurrent observation and interview on 10/26/16, at 11:25 a.m., in the Housekeeping Supervisor's office, Housekeeping Supervisor Q showed a yellow rod with a yellow sign, "CLOSED FOR CLEANING" hanging to the rod. Housekeeping Supervisor Q stated this was the rod with the sign Housekeeping Staff P used when she cleaned the restroom where Resident 1 fell. Housekeeping Supervisor Q stated the housekeeper put the rod across the doorway to indicate the room was being cleaned. Housekeeping Supervisor Q stated the housekeeper should tell the nurse when the rod was placed. Housekeeping Supervisor Q stated the rod was light metal and was not strong. Housekeeping Supervisor Q stated the facility had been using the rod for about six to seven months, but they did not have a policy and procedure regarding the use of the rod.
Upon request for the manufacturer's guidelines for the rod, Housekeeping Supervisor Q provided a page documentation titled, "FACILITY MAINTENANCE," undated, indicated under, "A. Site Safety Hanging Sign," which did not indicate how to use the rod and sign safely.
Therefore, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance for Resident 1 when:
Resident 1 walked to the restroom unassisted, grabbed the rod across the restroom entrance and fell on the floor on 8/28/16. This caused Resident 1 to sustain a left humeral neck (upper arm bone just under the shoulder joint) fracture which required admission to an acute care hospital for treatment.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012997 |
A |
28-Feb-17 |
G9FK11 |
14272 |
F-323 ?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 maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plan for Resident 2 when: Resident 2 had five falls during a one month period from 8/12/16 to 9/14/16. Resident 2 sustained a head injury from the last fall on 9/14/16, which required Resident 2 to be sent to an acute care hospital for evaluation and treatment. After 9/14/16, Resident 2 had three more falls on 10/26/16, 11/5/16, and 11/26/16.
Resident 2's admission record indicated Resident 2 was re-admitted to the facility on XXXXXXX16, with diagnoses including Alzheimer's disease (a brain disease causing memory loss, impaired thinking and disorientation), dementia, and neuromuscular (relating to the nerves and muscles) dysfunction of bladder.
Resident 2's MDS assessment, dated 8/19/16, indicated Resident 2 was not able to complete the brief interview for mental status (BIMS). The MDS assessment indicated staff interview for mental status was conducted, and indicated Resident 2's cognitive skills for daily decision making was, "moderately impaired - decisions poor; cues/supervision required."
Resident 2's fall risk evaluation, dated 8/12/16, indicated Resident 2 was at high risk for fall due to multiple problems including mental status, history of falls, ambulatory and elimination status, and gait/balance problems.
The care plan for fall risk prevention and management, initiated on 8/12/16, with approach started date 8/11/16, indicated approaches including, "Bed in low position, pad alarm (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or the bed) in bed..." The care plan did not specify how the facility would provide supervision to prevent Resident 2 from falling.
First Fall:
The Nurse's Note, dated 8/12/16 at 12 a.m., revealed Resident 2 had an unwitnessed fall in his room. Resident 2 sustained a 3 cm X 3 cm skin tear, with bruising, at left elbow.
The care plan for the actual fall on 8/12/16, indicated a goal, "No serious injury from fall [for 7 days]." The approaches included observing and monitoring for 72 hours, mobility alarm, pads at bedside, and visual monitor just for one shift.
The IDT (Interdisciplinary Team) Conference Record, dated 8/12/16, regarding Resident 2's fall on 8/12/16, at midnight, did not indicate new approaches to the fall risk care plan to prevent further falls. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls.
Second Fall:
The Nurse's Note, dated 8/29/16, at 7 a.m., indicated nursing staff from the last two work shifts reported Resident 2 had a fall at 7:15 a.m., on 8/28/16. However, there were no documentation of Nurses' Notes on 8/28/16, regarding the fall.
The IDT Conference Record, dated 8/30/16, indicated Resident 2 had a fall with no injury on 8/28/16. The IDT note indicated to resume Risperdal (an antipsychotic medication, which works by changing the effects of chemicals in the brain), which was discontinued, due to increased agitation, re-emergence of aggressive verbal outbursts, pressured speech, and etc.
The care plan for the actual fall on 8/28/16, included to teach the new nurses on fall follow-up process and continue plan of care. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls.
Third Fall:
The nurse's note dated 9/5/16, at 4:20 p.m., indicated Resident 2 fell out from the wheelchair when Resident 2 was watching TV in the TV room with other residents.
The IDT Conference Record, dated 9/6/16, regarding Resident 2's fall on 9/5/16, indicated the Resident 2 had, "very poor safety awareness." The IDT determined to continue using the alarm with a goal, "no serious injury [with] fall." The IDT note did not specify providing supervision to Resident 2 to prevent further falls.
The care plan for the actual fall on 9/5/16, was to continue plan of care. The fall risk care plan, initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls.
Fourth Fall:
The Nurse's Note dated 9/10/16, with unknown time of the note indicated "Am shift reports fall [with] no injury 10:30 Am..." The Nurse's Note did not describe how Resident 2 fell.
The IDT Conference Record, dated 9/12/16, indicated Resident 2 stood up and fell at the nurse's station. The IDT note indicated Resident 2 to continue having poor safety awareness. The IDT note indicated, "Comfort is goal and [with] regard to falls, minimizing serious injury is goal..." The IDT note indicated, "Will continue use of alarm, encourage wheelchair..." The IDT note did not specify providing supervision to Resident 2 to prevent further falls.
The care plan for the actual fall on 9/10/16, was to continue plan of care. The fall risk care plan initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls.
Fifth Fall:
The Nurse's Note, dated 9/14/16, at 7:55 p.m., revealed Resident 2 had an unwitnessed fall and sustained a skin tear at his left elbow and injury in Resident 2's back of the head which required Resident 2 to be sent to an Emergency Room for evaluation.
The IDT Conference Record, dated 9/15/16, indicated on 9/14/16, at 7:55 p.m., Resident 2 was found on the floor next to the bed. The IDT note indicated alarm was presented but was not engaged. The IDT note indicated a fall prevention plan which included care alert posted in Resident 2's room. The IDT note did not specify how the facility would provide supervision to prevent Resident 2 from further falls.
The Care Alert, dated 9/15/16, posted in Resident 2's room indicated, "[Resident 2] is a high fall risk with a recent fall requiring a trip to the ER. Please make sure [Resident 2] has his loud alarm attached at all times! Check frequently as he is able to inadvertently remove the alarm..." The Care Alert did not specify how frequently to check the alarm or Resident 2.
During an interview on 11/3/16, at 2:35 p.m., regarding, "Check frequently" for the alarm indicated in the Care Alert, the DON (Director of Nursing) stated she expected that staff checked the alarm when staff made rounds every two hours; the Hall Monitor (an employee) walked back and forth in the hall and when the Hall Monitor walked to Resident 2's room, the Hall Monitor could look inside the room, from the hallway, to see if the alarm was intact. When asked if the Hall Monitors were trained on how to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff if anything was out of the ordinary. The DON stated a Hall Monitor was a staff, but was not a care giver. The DON stated the Hall Monitors did not do hands-on resident care; they could guide the resident and gently hold the resident's hands/elbows.
The IDT Conference Record, dated 9/16/16, for safety review related to the fall on 9/14/16, indicated an evaluation Resident 2's room to reconfigured room to have bed at a slight angle decreasing the likelihood of striking head during a fall. Mats at both side of bed. The IDT note did not specify providing supervision to Resident 2 to prevent further falls.
The fall risk care plan initiated on 8/12/16, did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls.
During a concurrent observation and interview on 10/25/16, at 10 a.m., Resident 2 was in bed and awake. One floor mat was placed on Resident 2's right side and one mat was up leaning against the wall below the window. When asked about his fall on 9/14/16, Resident 2 stated he did not remember the fall.
During an interview on 10/25/16, at 3 p.m., regarding Resident 2's fall on 9/14/16 at 7:55 p.m., Licensed Staff C stated a Hall Monitor found Resident 2 on the floor. Licensed Staff C stated when she arrived at the scene, Resident 2 was laying on the floor mat, with his head against the wall, on the left side of the bed. Licensed Staff C stated she did not hear the alarm. She stated Resident 2 took the alarm off all the time. When asked about fall prevention, Licensed Staff C stated when Resident 2 was not in bed, they sat Resident 2 at the nurse station. When Resident 2 was in bed, staff would listen to the alarm or Resident 2 yelling. Licensed Staff C stated they did not have a set time to check on Resident 2 because Resident 2 was not in an every 15 minutes check.
During a concurrent observation and interview on 10/25/16, at 3:05 p.m., in Resident 2's room, one floor mat was on the right side of the bed and one mat was up against the wall. Licensed Staff C stated the floor mat should be on the left side because Resident 2 got out of the bed from his left side.
During a concurrent interview and record review of Resident 2's care plans for fall and fall risk, on 10/25/16, at 3:13 p.m., Licensed Staff C stated a care plan described the best care provided to the resident and communication with the care team. Licensed Staff C stated all nurses should review the care plans. When asked if the care plans specify providing supervision to Resident 2, Licensed Staff C reviewed the care plans, initiated on 8/12/16 and 8/15/16, and stated the supervision was to observe and monitor Resident 2 for 72 hours. When asked what happened after 72 hours, Licensed Staff C stated, "none," and the care plans did not specify supervision.
During an interview on 10/25/16, at 4:40 p.m., Unlicensed Staff O stated when Resident 2 was in bed, she would check Resident 2 approximately every five minutes. When asked how she knew about the five minutes, Unlicensed Staff O stated, "from the text book." When asked how she knew the care needed for a resident, Unlicensed Staff O stated she would ask other staff or look at the care plans, which would tell her about the resident. When reviewing Resident 2's care plan, which indicated Resident 2 had four falls from 8/12/16 to 9/10/16, Unlicensed Staff O stated she did not know Resident 2 had so many falls, "like constantly falling." Unlicensed Staff O stated by looking at the falls indicated in the care plan, Resident 2 should not be left alone. Unlicensed Staff O stated the care plan did not specify the frequency of checking Resident 2.
During a concurrent interview and record review on 10/26/16, at 2:50 p.m., the DON stated they tried different interventions including alarm, pad, and visual monitor for one shift only. The DON reviewed the fall and fall risk care plans and stated the care plans did not specify providing supervision to Resident 2 to prevent falls.
During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated he did not witness Resident 2's fall. Unlicensed Staff L stated he was not assigned to Resident 2, but he still helped check on Resident 2 and the alarm function at least every hour. Unlicensed Staff L stated when Resident 2 had repeated falls (4 - 5 times in a month), staff should be with Resident 2 all the times. Unlicensed Staff L stated they did not have enough CNA's (Certified Nursing Assistants) in the hall where Resident 2 resided. Unlicensed Staff L stated because of short staffing, they were not able to check residents as frequently as they could to prevent residents from falling.
The Emergency Department Report, dated 9/14/16, indicated Resident 2 sustained a wound 2 cm in length in the head, and the wound was repaired with staples. The Emergency Department report indicated Resident 2 did not receive any imaging or extensive work-up because Resident 2 was on hospice with comfort measures only.
Resident 2 had three more falls after 9/14/16 as follows:
a. The IDT note dated 10/26/16, indicated Resident 2 fell from a wheelchair to the floor in the TV room;
b. The IDT note, dated 11/7/16, indicated Resident 2 fell on 11/5/16 witnessed by a Hall Monitor; and
c. The IDT note, dated 11/28/16, indicated Resident 2 fell on 11/26/16, sliding out of a wheelchair.
During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to, "us" [Certified Nursing Assistants]. Unlicensed Staff BB stated they just put up signs in the utility room and in the residents' room and hoping us to know what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote, "keep bed low, keep bed at an angle."
During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent Resident 2 from injuries from falls. The DON stated she educated the staff about the sign, but did not have a log to ensure all staff were educated and understood the sign.
Therefore, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plans for Resident 2 when:
Resident 2 had five falls during a one-month period from 8/12/16 to 9/14/16. Resident 2 sustained a head injury from the last fall on 9/14/16, which required Resident 2 to be sent to an acute care hospital for evaluation and treatment. After 9/14/16, Resident 2 had three more falls on 10/26/16, 11/5/16, and 11/26/16.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012998 |
A |
28-Feb-17 |
G9FK11 |
13774 |
F-323 ?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 maintain an accident hazard free environment, provide adequate supervision and assistance, and revise fall risk care plans for Resident 4 when: Resident 4 had three falls during a one-month period from 8/16/16 to 9/17/16. Resident 4 sustained a skin tear on the right hand from a fall on 8/16/16, and reopened a skin tear on the right hand from a fall on 8/21/16. Resident 4 had three more falls during a one-week period from 10/13/16 to 10/17/16, which resulted in a nasal bone (nose) fracture from a fall on 10/13/16.
Resident 4's admission record and MDS, dated 10/3/16, documented Resident 4 was admitted on 4/1/10. Resident 4's diagnoses included Chronic Obstructive Pulmonary Disease, Hypertension (high blood pressure), Cardiac Arrhythmia (problem with the rate or rhythm of the heartbeat), schizophrenia (a mental illness in which someone cannot think or behave normally and often experiences delusions), and muscle weakness (general).
Resident 4's MDS, dated 10/03/16, revealed the BIMS (brief interview for mental status) score was 3, which indicated Resident 4 was severely cognitively impaired. The MDS assessment indicated Resident 4 required supervision with one person physical assist with transfers and walking in his room. The MDS assessment indicated Resident 4 required one person physical assist for walking in the corridor and toilet use.
Resident 4's care plan for fall risk prevention and management, initiated on 10/04/16, indicated fall risk prevention and management approaches included, "Orient resident to environment each time changes are made, remove hazards from environment, maintain bed in low position and continue alarms in place on bed..." The care plan did not specify providing supervision to prevent resident from falling.
The short-term care plan (written care plan done for the actual fall), initiated on 10/14/16, indicated fall risk prevention and management approaches including, "hipsters" (padded type pants that cover the hips to cushion a fall), continue alarms... "replace when resident removes."
A short-term care plan re-evaluated on 10/18/16, indicated fall risk prevention and management approaches including video monitor of Resident 4's bed area, continue frequent observation, per discretion of nurse, every 15 minute mini-checks, and all other monitoring as needed.
During an interview on 11/09/16 at 9:15 a.m., Licensed Staff B was asked what every fifteen minute mini-checks and all other monitoring would mean to him. Licensed Staff B stated it would mean different things depending on what the issue was. When asked about falls in relationship to every fifteen mini-checks and all other monitoring, he stated that would mean neuro checks for the licensed personnel and for the CNA (Certified Nursing Assistant) it would mean vital signs. Regarding all other monitoring he stated it would mean wanderguards, tag alarms, and alarms for bed and wheelchair.
During an interview on 11/9/16 at 3:55 p.m., Unlicensed Staff R was asked about, "mini-checks" and what that meant to him. Unlicensed Staff R stated it would mean the nurse would do neuro checks, and he would do vital signs every 15 minutes times 2 hours, then every 30 minutes for 2 hours, then every hour for 4 hours. When asked about, "all other monitoring," he stated he would watch for pain, level of consciousness and safety. When asked regarding safety, he stated it could be done with alarms, like bed and chair alarms and a 1:1 (one staff to one resident supervision), if possible.
During an interview on 11/9/16 at 4:05 p.m., Unlicensed Staff K was asked about, "mini-checks" and what that meant to her. Unlicensed Staff K stated it would mean vital signs (not sure how frequently) and checking them [the residents] to see how alert they were. When Unlicensed Staff K was asked what, "all other monitoring" meant to her, she stated alarms could be used, "sometimes a 1:1."
First Fall:
The Nurse's Note, dated 8/15/16, no time, indicated Resident 4 was found on the floor by his bed. Resident 4 had open abrasions to his knuckles that were cleaned and bandaged. He was placed in geri-chair in front of the Nurse's Station on A-wing. A bed alarm, bed lowered, floor mat and alarm placed on resident were ordered.
The Interdisciplinary Team Conference Record, dated 8/16/16, regarding Resident 4's fall on 8/15/16 at 5:45 p.m., indicated Resident 4 had attempted a self-transfer and fell at the side of the bed. It indicated, "alarm" was on and hipsters were in place. The IDT Conference Record indicated to continue hipsters and alarms and care plans updated. There was no short-term care plan found.
Second Fall:
There was no documentation in the Nurse's Note for Resident 4's fall on 8/21/16.
The IDT Conference Record, dated 8/22/16, indicated Resident 4, at 1:30 p.m., was up in a chair and he attempted to reposition himself and he slid down to the floor. Resident 4 slightly reopened his right hand skin tears, and they were re-bandaged. The IDT Conference Record indicated to continue alarm and hipsters. The IDT Conference Record indicated care plans were updated. There was no short-term care plan found.
Third Fall:
The Nurse's Note, dated 9/20/16, no time, indicated a, "Late Entry" for 9/17/16 at 9:55 a.m. Resident 4 was sitting in bed and leaned forward. The Nurse's Note indicated Resident 4 went to the floor. There were no visible injuries and no complaint of pain, per the Nurse's Note.
The IDT Conference Record, dated 9/19/16, no time noted, indicated Resident 4's fall was not witnessed. The record indicated Resident 4 was sitting up in his chair and leaned forward and fell forward on his knees. The record indicated Resident 4 was at risk for falls related to his end-stage chronic obstructive pulmonary disease
(lung disease that makes it hard to breath), and he had poor safety awareness and often tried to transfer himself. The record indicated Resident 4 was to have a wheelchair and bed alarm in place. The IDT note did not specify providing supervision to Resident 4 to prevent further falls.
Resident 4's fall risk care plan, dated 10/4/16, indicated Resident 4 had an actual fall 9/20/16, and alarms were in place on the bed. No other changes were indicated.
Fourth Fall:
There was no documentation of a Nurse's Note found for the fall that occurred on 10/13/16.
A Physician's Progress Note, dated 10/14/16, indicated, "Pt. (patient) had another fall trying to get up soon [sic] feel strong enough. Poor balance....Medically stable, physically and mentally failing. Very high risk to fall."
Within the Nurse's Note, dated 10/17/16 at 2:30 p.m., written by RT (respiratory therapist), it was indicated Resident 4 sustained a fall which included bruising around the nose.
The IDT (Interdisciplinary Team) Conference Record, dated 10/14/16, indicated he [Resident 4], "had been safe in bed with hipsters on and alarm in place per care team, when he unexpectedly got up, took his own alarm and hipsters off but had his boots on and ambulated to the closet area near a lift, falling to the floor..." Physician had requested trial of mattress on the floor. Per PT (Physical Therapy) it was indicated the mattress on floor would increase risk, so would use low bed, mats at bedside. The record indicated care plans were updated.
The fall risk care plan, dated 10/04/16, did not indicate any changes were made.
During an interview on 10/26/16 at 11:05 a.m., Licensed Staff F stated she found him [Resident 4] in his room but nearer the wall by the door on his hands and knees trying to get up. Licensed Staff F did not witness the fall. She stated Resident 4 had a bloody nose. She called code STAT (immediately) for a fall and had help immediately. Licensed Staff F stated the resident went to the emergency room. Licensed Staff F stated Resident 4 had a 1:1 after he returned from the Emergency Room, but it did not occur too often, due to staffing issues, and stated there were not enough staff to cover for current residents and not able to find someone to come in to stay with residents.
Fifth Fall:
There was no documentation of Nurses Notes for the fall that occurred on 10/15/16.
During an interview on 10/26/16, at 12:01 p.m., Unlicensed Staff M stated she was aware (she stated she was in the shower room on 10/15/16, when Resident 4 fell) that Resident 4, "tripped over a hoyer lift (a mechanical lift) that someone forgot to take out." Unlicensed Staff M stated she came over (the hoyer lift was still in the room), but there were staff already helping him. She was aware Resident 4 went to the Emergency Room. Unlicensed Staff M stated with the 1:1 for Resident 4, it was much better. Unlicensed Staff M stated, "Especially on PM's there is not enough staff to watch everyone, so a 1:1 for the resident really helps."
During an interview on 12/9/16 at 7:20 a.m., regarding Resident 4's fall on 10/15/16, with a hoyer lift in Resident 4's room, the DON stated two CNAs were getting ready to assist Resident 4's roommate with a hoyer lift. The DON stated the two CNAs heard a code, "STAT" [immediately] from another room. The two CNAs left Resident 4's room to attend to the code, "STAT." The two CNAs left the hoyer lift in Resident 4's room. After the two CNAs left the room, Resident 4 might have gotten up from his bed and fell. Resident 4's face might have hit the base of the hoyer lift because the base of the hoyer lift had blood. The DON stated the two CNAs should have removed the hoyer lift from Resident 4's room prior to attending to the code, "STAT" and should not put one resident in danger in order to help another resident.
The IDT (Interdisciplinary Team) Conference Record, dated 10/17/216, indicated he [Resident 4] was found in a seated position in room next to nightstand on 10/15/16. "Resident is on 15 minute checks due to prior fall.....Resident will be observed and monitored for 72 hours." The IDT Conference Record indicated to continue with hipsters and a mat at the bedside. The Conference Record indicated Resident 4 had a, "history of falls" related to forgetting to use his call light/waiting for assistance, taking off bed/chair alarms and could not stand or ambulate with staff assistance.
The fall risk care plan, dated 10/04/16, did not indicate any changes, such as increased supervision, were made.
Sixth Fall:
There was no documentation of Nurse's Notes for the fall that occurred on 10/17/16.
The IDT (Interdisciplinary Team) Conference Record, dated 10/18/16, indicated on 10/17/16, Resident 4 had an unwitnessed, non-injury fall while attempting to get of of bed. Resident 4 had been at the Nurses Station with a nurse before this fall and had requested to go back to bed.
The Nurse's Note, dated 10/24/16, indicated he [Resident 4] continued to attempt to ambulate and self transfer. "High fall risk.... Resident turning off alarm and picking it up and walking with it. Poor Safety awareness."
The Care Alert, dated 8/22/16, and updated/reviewed on 10/17/16, and posted in Resident 4's room noted, "[Resident 4] is at high risk of fall with injury due to his restlessness and frailty. Please make sure he is offered assistance with a urinal/toileting at least every 2 hours. Please make sure he has an alarm on at all times, keep a mat on the floor next to his bed; if he is out of bed, assist him to wear hipsters and appropriate non-slip foot wear. [Resident 4] may enjoy being up in a Geri-Chair for relaxation. If he does not choose to utilize a Geri-Chair, offer him his regular wheelchair. If he does use the Geri-Chair, please supervise him closely and assist him to safely get up when he wants to get up." The Care Alert did not specify timeframe for, "supervise him closely."
During a concurrent observation and interview with Resident 4, on 10/25/16, at 10 a.m., Resident 4 was in the activity room, currently painting alone at a table. Resident 4 stated he enjoyed painting. Resident 4 stated he did not remember the fall. He hurts, "all the time." When asked about pain, Resident 4 stated he had arthritis. He stated they gave him pain medication and it helped. The Activity Assistant was helping two other residents at another table with art work. There were no other personnel in Activity Room.
During an interview with Licensed Staff B on 10/26/16, at 10:15 a.m., when asked about Resident 4, he stated Resident 4 had days when he was, "hyperactive" (moving around, cannot keep still) and other days when he was, "hypoactive" (slept most of the day-only waking for meals). He stated the 1:1 made a difference, but due to staffing it did not always happen.
Therefore, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans for Resident 4 when:
Resident 4 had three falls during a one-month period from 8/16/16 to 9/17/16. Resident 4 sustained a skin tear on the right hand from a fall on 8/16/16, and reopened a skin tear on the right hand from a fall on 8/21/16. Resident 4 had three more falls during a one-week period from 10/13/16 to 10/17/16, which resulted in a nasal bone (nose) fracture from a fall on 10/13/16.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000078 |
Eureka Rehab & Wellness Center, LP |
110012999 |
A |
28-Feb-17 |
G9FK11 |
17315 |
F-323 ?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 maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plan, follow fall protocol for post-fall assessment and management to prevent accidents for Residents 3, 5, and 14 when:
1. Staff did not follow their fall protocol for post-fall assessment and notify the physician of a fall, when Resident 3 reported having fallen on 10/20/16. This resulted in Resident 3 not being evaluated after the fall until 10/25/16 (five days after the fall).
2. Resident 5 had six falls during a six and one-half month period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom, which was wet with urine. A fall on 11/23/16 at 9:35 p.m., resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose (This was the second fall on
the same day, 11/23/16).
3. Licensed Staff did not revise Resident 14's (who had one unwitnessed fall on 11/4/16, which resulted in a skin tear to the left elbow and a fractured pelvis), "Fall Care Plan" to indicate Resident 14 was to be on, "one on one" with staff at all times starting 11/5/16, per physician's order. This failure to revise Resident 14's, "Fall Care Plan" had the potential for Resident 14 to fall again causing injury or even death.
1. During a concurrent observation and interview on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 stated she fell approximately at 3 a.m. four days ago, from her bed to the floor. Resident 3 stated she climbed back to bed because no staffs were around to assist her. Resident 3 stated she told a nurse about the fall at approximately 5:30 a.m. the day she fell. She stated the nurse just told her to go back to bed.
Resident 3's MDS, dated 8/9/16, indicated Resident 3's BIMS (brief interview for mental status) score was 13, which indicated Resident 3 was cognitively intact.
Resident 3's Fall Risk Evaluation, dated 8/4/16, indicated Resident 3 was at high risk for fall due to multiple problems including history of falls, ambulatory and elimination status, and gait/balance problem.
During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately seven hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head-to-toe assessment. Licensed Staff B stated he documented the assessment.
The Nurse's Note dated 10/20/16 at 10:15 a.m., indicated, "[Resident 3] [up out of bed] in [wheelchair]. Denies any residual pain [secondary to fall]. [Resident 3] in wheelchair, going up and down hallway [without] difficulty. Will continue to monitor." The note did not indicate a head-to-toe assessment. There was no documentation of physician notification.
During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated there was no specific document for the head-to-toe assessment. Licensed Staff B stated he documented the head-to-toe assessment in the Nurse's Note. When asked about the Nurse's Note, Licensed Staff B stated the Nurse's Note, dated 10/20/16 at 10:15 a.m., was written by him. When asked for the fall protocol, Licensed Staff B stated they filled out the information forms which the night shift nurse should have done and turned it in to the DON.
During a concurrent interview and record review on 10/26/16, at 8:35 a.m. The DON reviewed Licensed Staff B's Nurse Note, dated 10/20/16 at 10:15 a.m., and stated it was not well documented and did not show the head-to-toe assessment. The DON stated the post-fall protocol included completing the incident report, post-fall assessment, post-fall huddle, and neurological check flow sheet for unwitnessed fall. The DON stated staff had not notified her of Resident 3's fall. The DON stated staff did not complete the post-fall protocol procedures for Resident 3's fall on 10/20/16.
Review of the Fall Management Program Policy No. FA-01, documented following each fall, the licensed nurse would perform a post-fall assessment, the licensed nurse would notify the Director of Nursing and / or Administrator, and the Licensed Nurse would notify the resident's attending physician and responsible party of the fall incident.
2. Resident 5 had six falls during a six and one-half month period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom, which was wet with urine. A fall on 11/23/16, resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose on 11/23/16 at 9:35 p.m. (This was the second fall on the same day, 11/23/16).
Resident 5's admission record indicated Resident 5 was admitted to the facility on XXXXXXX16, with diagnoses including difficulty in walking, muscle weakness, dementia with behavioral disturbance.
Resident 5's Fall Risk Evaluation, dated 10/10/16, 11/24/16, and 12/6/16, indicated Resident 5 was at high risk for falls due to multiple problems including mental status (disoriented or intermittent confusion), history of falls, gait and balance problems, and medications. Resident 5 was on Risperdal (an antipsychotic medication which works by changing the effects of the chemicals to the brain. Common side effects include dizziness, drowsiness, and tired feeling) 0.5 mg by mouth every day and Haldol (an antipsychotic medication which may work by blocking some chemical effects in the brain. Major common side effects include loss of balance control, muscle spasms, and shuffling walk) 70 mg intramuscularly every month for dementia with psychosis.
Resident 5's MDS, dated 3/17/16 and 9/16/16, indicated Resident 5's cognition was moderately to severely impaired.
First fall:
The Nurse's Note, dated 5/24/16 at 11 p.m., and the IDT Note, dated 5/25/16, indicated Resident 5 had an unwitnessed fall on 5/24/16 at 7:45 p.m., in the bathroom. Resident 5 was found in the bathroom sitting on the floor wet with urine. Resident 5 complained of left shoulder pain and was treated with Norco (pain medication). The IDT note indicated Resident 5 received antipsychotic (Haldol injection) prior to the fall. The IDT note indicated the charge nurse's plan to increase monitoring for a few hours after the monthly Haldol injection and recommended non-slip shoes for Resident 5.
Resident 5's care plan for fall risk prevention and management, initiated on 3/11/16, and had been re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including, "Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue B-wing for increase supervision. The fall risk care plan did not reflect nor specified how to increase monitoring after the monthly Haldol injection.
Second fall:
The IDT Note, dated 10/3/16, indicated Resident 5 had an unwitnessed fall in the his room at 1:15 a.m. The IDT note indicated referring for physical and occupational therapy and continued to encourage wearing the hipster (Padded pants that cover the hip to cushion a fall to prevent injuries of the hip) when ambulating. The IDT note did not specify providing supervision to Resident 5.
Third fall:
The Nurse's Note, dated 10/9/16 at 2:30 a.m., and the IDT Note, dated 10/10/16, indicated Resident 5 had an unwitnessed fall in his room on 10/9/16, with unknown time of fall. The IDT note indicated referring for physical and occupational therapy and continued to encourage wearing the hipster when ambulating. The IDT note did not specify providing supervision to Resident 5.
Fourth fall:
The IDT Note, dated 11/24/16, indicated Resident 5 had a fall on 11/23/16 at 12 p.m. The IDT Note indicated Resident 5 was walking in the hallway, "but still asleep." The Hall Monitor headed toward Resident 5, "but before she got to him he fell onto his [left] hip and elbow." The IDT note indicated "will make a referral to PT/OT [Physical Therapy/Occupational Therapy]..." The IDT note did not specify providing supervision to Resident 5.
Fifth fall:
The Nurse's Note, dated 11/23/16, and the IDT Note, dated 11/24/16, indicated Resident 5 had an unwitnessed fall in his room on 11/23/16 at 9:35 p.m. Resident 5 sustained a small skin tear on the top ridge of his nose. The IDT note indicated, "observe and monitor for 72 hours and, "on 15 [minutes check]."
Sixth Fall:
The Nurse's Note, dated 12/6/16 at 3 a.m., and the IDT Note, dated 12/6/16, indicated Resident 5 was found on the floor in the room. The IDT note indicated every 15 minutes check was initiated after the first hour of neuro checks.
Resident 5's care plan for fall risk prevention and management, initiated on 3/11/16, and had been re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including, "Call light within reach, remind resident to use call light - unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue B-wing for increase supervision. The fall risk care plan did not reflect the 15 minutes check and how/who to check Resident 5.
During a concurrent interview and record review, on 12/8/16, at 8:35 a.m., regarding Resident 5's supervision, Unlicensed Staff CC stated she checked on Resident 5 whenever she saw him. Unlicensed Staff CC stated every staff in the hall was responsible to check on Resident 5. Unlicensed Staff CC stated she also reviewed care plans for resident care. When she reviewed Resident 5's fall risk care plan and asked her what did "...increase supervision..." mean to her, Unlicensed Staff CC stated, "To me, may need one-to-one..." When asked if Resident 5 was on one-to-one supervision, Unlicensed Staff CC stated she needed to check the documentation and found Resident 5 was on every 15 minutes check. Unlicensed Staff CC stated all staff were responsible for monitoring and documentation.
During a concurrent interview and record review on 12/8/16, at 8:55 a.m., Licensed Staff NN reviewed the fall risk care plan and stated, "...increase supervision..." meant every 15 minutes check. Licensed Staff NN stated the DON or ADON was responsible to review and update the care plans. Licensed Staff NN stated the care plan was used for following-up on residents and making goals for resident care.
During an interview on 12/9/16, at 7:20 a.m., Resident 5's fall risk care plan was reviewed with the DON. The DON stated the care plan did not specify supervision for Resident 5, and she understood that staff could have interpreted differently for, "...increase supervision."
Therefore, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plans, follow the fall protocol for post-fall assessment and management to prevent accidents for Resident 5, when:
Resident 5 had six falls during a six and one-half months period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom, which was wet with urine. A fall on 11/23/16, resulted in Resident 5 sustaining a small skin tear on the top ridge of his nose on 11/23/16 at 9:35 p.m. (This was the second fall on the same day, 11/23/16).
3. Review of Resident 14's admitting History and Physical, indicated Resident 14 had severe dementia and was admitted to the facility on 7/6/16, after increasingly falling.
The, "Fall Risk Assessment," dated 7/6/16, indicated Resident 14 was at high risk for falls due to multiple problems, including disorientation and poor vision. Resident 14's, "Fall Risk Assessment" dated 11/7/16, indicated he was high risk for falls due to one to two falls in the past three months.
Review of Resident 14's Post-Fall Assessments, Nursing Notes, and IDT Conference Record, indicated Resident 14 had a witnessed non-injury fall on 8/19/16 and 8/12/16, and an unwitnessed fall, with injury, on 11/5/16. The IDT Conference Record, dated 11/5/16, indicated a Certified Nursing Assistant (CNA) found Resident 14 on the floor next to his bed on 11/4/16, at 9:15 p.m., laying on his left elbow, and he had a skin tear at his left elbow. Resident 14's Nurse's Notes, dated 11/5/16, indicated: 1. CNA notified nurse Resident 14 was not able to bear weight on his left leg and was complaining of pain, 2. The nursing assessment indicated Resident 14's left leg had a slight external rotation, and 3. Resident 14 was sent to the Emergency Department (ED) per physician's order. The IDT Conference Record indicated the ED nurse contacted the facility's charge nurse who reported Resident 14 had a pelvic fracture.
Review of, "Physician Orders, dated for December, indicated, starting on 11/5/16, Resident 14 was to be, "one on one with staff at all times."
Review of, "Resident Care Plan Fall Risk Prevention and Management," revised and re-written on 11/8/16, indicate Resident 14: 1. Was at high risk for falls; 2. Had severe dementia; and 3. Had a significant change in condition, whereby Resident 14 had a pelvic fracture, which occurred on 11/4/16; there was no indication for Resident 14 to be, "one on one with staff at all times."
Review of Resident 14's Care Plan Short Term, start date 12/5/16, indicated the approach to fall problems was for staff to notify the Charge Nurse immediately of any changes in behavior for reassessment of supervision needed. There was no indication for Resident 14 to be "one on one with staff at all times."
The facility's policy and procedure titled, "Fall Management Program," date revised 3/1/16 and 11/7/16, indicated, "The Facility will implement a Fall Management Program that supports providing an environment free from the hazards...The IDT will initiate, review, and update resident fall risks and Plan of Care at the following intervals: admission, quarterly, annually, upon significant change of condition identification, and post fall as needed...Post-Fall Response A. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment utilizing FA-01-Form A-Post Fall Assessment, and update, initiate or revise a Plan of Care. B. The Licensed Nurse will complete the FA-01-Form B-Neurological Flow Sheet for an un-witnessed fall, or witnessed fall with suspected or known head injury for seventy-two (72) hours following the fall incident. The Attending Physician will be informed if there is a deviation from the resident's normal status for further instruction...D. The Licensed Nurse will notify the resident's Attending Physician and responsible party of the fall incident...Post Fall Huddle A. Within 15-20 minutes after a fall the Licensed Nurse will initiate a post fall huddle utilizing the Post fall Huddle form...Fall Investigation/Reporting and Documentation A. Following a resident incident of fall, the Licensed Nurse who has the most knowledge about the incident will complete AP-31-Form A-Incident and Accident Report Forms...E. The IDT will summarize conclusions after their review of the fall and circumstances surrounding the fall on an IDT note. The plan of care will also be reviewed and the care plan will be revised as necessary in an effort to prevent further falls with major injury...Recurrent Falls...These residents may require more frequent observation of activities and whereabouts..."
Therefore, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plans, follow the fall protocol for post-fall assessment and management to prevent accidents for Residents 3, 5, and 14 when:
1. Staff did not follow their fall protocol for post-fall assessment and notify the physician of a fall, when Resident 3 reported having fallen on 10/20/16. This resulted in Resident 3 not being evaluated after the fall until 10/25/16 (five days after the fall).
2. Resident 5 had six falls during a six and one-half month period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom, which was wet with urine. A fall on 11/23/16 at 9:35 p.m., resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose (This was the second fall on the same day, 11/23/16).
3. Licensed Staff did not revise Resident 14's (who had one unwitnessed fall on 11/4/16, which resulted in a skin tear to the left elbow and a fractured pelvis), "Fall Care Plan" to indicate Resident 14 was to be on, "one-on-one" with staff at all times starting 11/5/16, per physician's order. This failure to revise Resident 14's, "Fall Care Plan" had the potential for Resident 14 to fall again, causing injury or even death.
The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000028 |
EmpRes Post Acute Rehabilitation |
110013447 |
B |
29-Aug-17 |
FHER11 |
11683 |
B 825 T22 DIV5 CH3 ART3-72311(a)(1)(C) Nursing Services General
(a) Nursing service shall include, but not be limited to, the following:
(1) Planning of patient care, which shall include at least the following:
(C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.
The facility violated the regulation by failing to ensure that Resident 1, who was at risk for falls and known attempts at exit seeking from the facility, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Resident 1 had seven falls in a three month period from 11/13/15 to 1/21/16, with no effective interventions considered preventing further falls. These failures contributed to injuries to Resident 1; which included, swollen and purple knees, a large green blue discoloration to the left side of her face, right knee pain, pain in the cervical area of her neck, and right hip pain.
Findings:
Resident 1, an 81 year old female, was admitted to the facility on XXXXXXX 14, with diagnoses including wandering and history of falling, which included a fall at home that resulted in a subdural hematoma and hospitalization prior to admission to the facility.
Resident 1's nursing fall care plan dated 8/13/14 indicated that Resident 1 had intermittent confusion; a history of 1-2 falls prior to admission had subdural hematoma after a fall. Resident 1 had problems standing, walking, and decreased coordination. The fall interventions were as follows: 1) Complete Resident 1's fall risk assessment every quarter and as necessary; 2) Provide Resident 1 with well lit, clutter free environment; 3) Encourage Resident 1 to wear non slip safety shoes; 4) Keep resident clean and dry; 5) Refer to therapy for screening with physical therapy and occupational therapy; 6) Evaluate blood pressure at time of any fall and initiate orthostatic blood pressures; 7) Initiate neuro checks at time of fall; 8) Provide Resident 1 with training in self-care to prevent falls, injuries, and promote her own safety; 9) Ask for help when needed; 10) Rise slowly; 11) Stay active; and 12) Additional interventions bed against wall on the right side. There were no goals with measurable time tables checked on the nursing plan of care for Resident 1.
The Minimum Data Set for Resident 1(an assessment tool) dated 10/8/15 indicated: Cognition/Severely Impaired, Delirium/Disorganized thinking, Balance/Not Steady; yet the transfer, walk in room, and walk in corridor all were coded supervision with set-up help.
There were no revisions to Resident 1's fall risk care plan after the 10/8/15 assessment.
First Fall:
The IDT (inter-disciplinary team) Fall Review, dated 11/13/15, indicated: Resident 1 stepped outside the front entrance door and alarms went off. Resident 1 was found on her knees. The intervention to prevent future falls was listed as: Continue to monitor exit seeking behaviors. The IDT conclusions were listed as continue with Wander guard, Request PT/OT evaluation. Resident 1's fall risk nursing plan of care was not updated with newly identified interventions that were specific and effective to prevent further falls and to keep Resident 1 safe.
Second Fall:
The IDT Fall Review, dated 11/24/15, indicated: Resident 1 was found sitting on the floor. There was no indication of where in the facility the resident was found on the floor. Resident 1 complained of pain in her right hip at the time of the incident. The IDT Conclusion was to redirect Resident 1 when staff observed her attempting to sit on the floor, and to continue to monitor for pain. The nursing care plan had no newly identified interventions listed for the date of the fall. There were no specific effective interventions considered to prevent Resident 1 from further falls.
Third fall:
The Nursing Progress Note dated 12/11/15, indicated Resident 1 was found with both knees swollen and right knee had purple discoloration. Resident 1's nursing plan of care had no newly identified interventions that were resident specific and effective to prevent Resident 1 from further falls.
During interview on 8/3/17 at 6:20 p.m., Administrator stated the facility did x-rays as the intervention for that incident. Administrator stated this was not a fall, but a change of condition.
During an interview on 8/4/17 at 1:00 p.m., Administrator stated there was no investigation for injury of unknown origin, so maybe it was a fall and she missed some steps.
Fourth Fall:
The IDT Fall Review, dated 12/15/15, indicated Resident 1 stumbled while ambulating in the hallway and fell on her right side. The IDT Conclusion was to attempt to assist Resident 1 to sit down or lie down for a nap when her gait appears tired or faltering. The nursing care plan listed the intervention as assist to lie down when tired. There was no indication as to how Resident 1 would indicate when she was tired, since she spoke primarily Spanish, and was confused. The nursing care plan lacked specificity of how Resident 1 would ask for help when she had disorganized thinking and her cognition was impaired per the MDS assessment conducted on 10/8/15. There were no newly identified interventions that were resident specific and effective to prevent Resident 1 from further falls.
Fifth Fall:
The Minimum Data Set for Resident 1 dated 1/2/16 indicated: Cognition/Severely Impaired, Delirium/Disorganized thinking, Balance/Not Steady; yet the transfer, walk in room, and walk in corridor all were coded as supervision with set-up help. The report for this time period remained the same despite two falls in November and two falls in December.
The IDT Fall Review, dated 1/3/16, indicated: Resident 1 was ambulating and tripped over the weight scale. The Fall risk assessment date 1/3/16 at 9:30 a.m., revealed Resident 1 complained of right knee pain and pain in the cervical area of her neck. The IDT intervention to prevent further falls was to do head to toe evaluation and initiate neuro checks. Resident 1's fall nursing care plan intervention was to move the scale. Staff were to maintain resident in a safe clutter free environment and obtain therapy evaluation (These were not new interventions and were already on the initial fall risk nursing plan of care on 8/14/15). A new intervention was to encourage Resident 1 to call for assistance as needed.
During an interview on 8/3/17 at 2:34 p.m. CNA G stated that Resident 1 could not use the call light because she would be instructed and forget how to use it.
During an interview on 8/3/17 at 2:48 p.m., CNA H stated that Resident 1 could not use the call light; it is protocol for her to have it. We have to read her needs, if she gets agitated she has to go to the bathroom.
During an interview on 8/3/17 at 3:36 p.m., Licensed Nurse I stated that Resident 1 could not use the call light. They check on her every 15 minutes. It is a requirement to have it (call light) there.
During interview on 8/3/17 at 6:26 p.m., the Administrator was asked if there was any other intervention and she stated. "You can't use all of your interventions for one fall." There were no resident specific interventions that effectively met the needs of Resident 1 to prevent further falls.
Sixth Fall:
Review of fall event investigation report dated 1/6/16, indicated Resident 1 was found on the floor on her right side in the dining area. A visitor stated the resident fell slowly. Resident 1 was not able to stand alone and Resident 1 was weaker on the right upper extremity than on the left upper extremity. The IDT Fall Review, dated 1/7/16, indicated: It was felt that the physician should assess the medications and recommend a reduction as he sees fit. Resident 1's fall nursing care plan intervention was that Resident 1?s medication would be reduced as the physician ordered, Physical Therapy (PT), Occupation Therapy (OT) evaluation, and treat. (This was not a new intervention PT and OT evaluation, this intervention was on the initial fall resident nursing plan of care 8/14/15 and on 1/2/15.) There were no other newly identified interventions that were resident specific and effective interventions to prevent Resident 1 from further falls.
Seventh Fall:
Resident 1's fall assessment dated 1/21/16 at 1:00 p.m., indicated Resident 1 was ambulating in the hall and tripped and fell, hitting her head which resulted in Resident 1's left forehead and left cheek bone were swollen. The doctor ordered x-rays.
Resident 1's Fall Risk Care Plan dated 1/21/16 showed that staff should conduct a neuro evaluation (This was not a new intervention, see initial fall nursing care plan 8/14/15) and Resident 1 was not to use assistive devices. The facility did not specify what assistive device. The Fall Risk Care Plan indicated Resident 1 was having medication titration. There were no newly identified interventions that were resident specific and effective to prevent Resident 1 from further falls.
The IDT Fall Review dated 1/22/16, indicated that Resident 1 tripped and fell hitting her head. The IDT Fall Review indicated that Resident 1 could not utilize assistive devices secondary to dementia. The IDT note did not indicate what assistive device.
During an observation on 1/28/16 at 10:35 a.m., Resident 1 had a large green blue bruise to the left side of the face.
Review of the facility's policy and procedure titled "Fall Evaluation and Management? dated 1/2014, indicated: "...Evaluation: The nurse completes the Fall Evaluation Form at admission, quarterly, and with significant change... If the total score is 13 or greater, the resident is considered as having a High Potential for falls... Residents, who are disoriented, confused, or who have fallen in the past 3 months are also considered High Potential for falls...The Center utilizes the Fall Scene Investigation Report to assist with post-fall evaluations. Management: Staff notifies the licensed nurse, who will...Complete a neurological evaluation, if the resident hit his or her head, or if the fall is not witnessed....Post-Fall Documentation: ...the licensed nurse: Completes the interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, ...the residents condition. Updates the Care Plan with newly identified interventions ...Residents are monitored for 72 hours post fall." The facility's policy and procedure did not indicate how the facility was going to provide adequate supervision to prevent further falls.
Therefore, The facility violated the regulations by failing to ensure that Resident 1, who was at risk for falls and known attempts at exit seeking from the facility, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Resident 1 had seven falls in a three month period from 11/13/15 to 1/21/16, with no effective interventions considered preventing further falls. These failures contributed to injuries to Resident 1; which included, swollen and purple knees, large green blue discoloration the left side of face, right knee pain, pain in the cervical area of her neck, and right hip pain.
The violation of the regulation had direct or immediate relationship to the health, safety, or security of patients. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120009136 |
B |
13-Jun-12 |
FKOV11 |
2519 |
Health and Safety Code 1418.91(a)(b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.On 10/4//11 at 8:50 AM, an unannounced visit was made to the facility to investigate an entity reported alleged resident to resident altercation.Based on interview and record review, the facility failed to report an allegation of resident to resident altercation to the Department of Public Health within 24 hours.Resident A was a 76 year old non interviewable female with the diagnosis of senile dementia, depressive disorder, mood disorder, anxiety state, and delusional disorder. She was ambulatory without assistance. Her Care Plans indicated inability to follow directions, aggressive behavior towards staff and residents, and indication of multiple altercations with other residents. Resident B was a 56 year old female with the diagnosis of depressive disorder, falls, stroke, diabetes, and used a wheel chair. She was alert and oriented and had difficulty being understood when she communicated. During an interview with Resident B, on 10/4/11, at 10:50 AM, she stated she remember the event but was not injured. During an interview with Certified Nursing Assistant 1 (CNA 1), on 10/4/11 at 10:40 AM, she stated she had been on one to one (CNA is assigned to that one resident only) with Resident A and they were in the lobby. Resident A grabbed Resident B's wheelchair and proceeded to push it outside. Resident B said no, and Resident A grabbed her hair and started pulling it.During an interview with the Administrator on 10/4/11, at 11:00 AM, he stated he called in the incident the same day at approximately 2 PM.He was unable to provide documented evidence of the phone call, and the Department had no record of the phone call. However, CDPH had received a faxed report of the incident on 9/28/11 at 6:09 PM (5 days after the incident had occurred). On 10/7/11 at 3:41 PM, the Department sent a faxed request to the facility requesting any documented evidence of the facility reporting the incident prior to the faxed report of 9/26/11. No further documentation was made available to the Department. Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours.In accordance with Health and Safety Code Section 1418.91, this violation is a class B violation. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120009137 |
B |
13-Jun-12 |
FKOV11 |
2916 |
Health and Safety Code 1418.91(a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.On 10/4/11 at 9 AM, an unannounced visit was made to the facility to investigate an entity reported alleged resident to resident altercation.Based on interview and record review, the facility failed to report an allegation of resident to resident altercation to the California Department of Public Health (CDPH) within 24 hours.Resident A was a 77 year old non interviewable female patient with the diagnosis of dementia without behaviors, depressive disorder and anxiety. She was ambulatory without assistance. Her Care Plan for "Dementia/Alzheimer's" indicated altered thought process, impaired verbal communication related to deteriorated cognition, and inability to follow direction. Her Care Plan for "Patient to Patient Altercation" indicated she had multiple encounters with other residents and staff. Resident A had been placed on every 15 minutes checks due to her aggressive behaviors and was now on one to one monitoring (staff person assigned to that resident only). Resident B was a 76 year old non interviewable female with the diagnosis of senile dementia, depressive disorder, mood disorder, anxiety state, and delusional disorder. She was ambulatory without assistance. Her Care Plans indicated inability to follow directions, aggressive behavior towards staff and residents, and a history of multiple altercations with other residents.During an interview with Certified Nursing Assistant 1 (CNA 1), on 10/4/11 at 1 PM, she stated on 9/23/11 in the AM, she was standing at the nurses' station with Resident B when Resident A approached them. Resident A grabbed Resident B's wrist and said come with me, Resident B said "No, no, no." CNA1 said she attempted to get Resident A to release Resident B's wrist but she would not let go. Other staff came to assist but had a hard time getting her to release the wrist.During an interview with Administrator on 10/4/11 at 10 AM he stated he did call this event to the Department on 9/23/11 at 2:40 PM. No record of the phone call was found at the Department. However, there was a faxed report of the incident. The fax had been sent to the Department on 9/28/11 at 6:02 PM (5 days after the incident). On 10/7/11 at 3:41 PM, the Department sent a faxed request to the facility requesting any documented evidence of the facility reporting the incident prior to the faxed report of 9/28/11. No further documentation was made available to the Department. Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours.In accordance with Health and Safety Code Section 1418.91, this violation is a class B violation. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120009141 |
B |
13-Jun-12 |
FKOV11 |
2648 |
Health and Safety Code 1418.91(a)(b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.On 10/3/11 at 8:30 AM, an unannounced visit was made to the facility to investigate an entity reported alleged resident to resident altercation.Based on interview and record review, the facility failed to report an allegation of resident to resident altercation to the California Department of Public Health (CDPH) within 24 hours.Resident A was a 77 year old non interviewable female with the diagnosis of dementia without behaviors, depressive disorder and anxiety. She was ambulatory without assistance. Her Care Plan for "Dementia/Alzheimer's" indicated altered thought process, impaired verbal communication related to deteriorated cognition, and inability to follow direction. Her Care Plan for "Patient to Patient Altercation" indicated two altercations with Resident B (spouse). Due to the altercations Resident A had been on every 15 minutes checks. At the time of the incident, Resident A was on a one to one monitoring (staff person is assigned to the one resident only).Resident B was a 79 year old male with the diagnosis of Alzheimer's disease, and Senile Dementia. He was ambulatory without assistance. His Care Plan for "Cognitive Pattern" indicated an altered thought process related to dementia, with sort and long term memory loss. His Care Plan for "Patient to Patient Altercation" documented three separate altercations with spouse who was also his roommate.During an interview with Medical Records staff, on 10/4/11 at 1:10 PM, she stated she saw Resident A and B outside the dining room and Resident A shoved Resident B. They were separated but managed to get back together again and began hitting each other. They were separated again and taken to separate rooms.During an interview with Administrator, on 10/4/11 at 10 AM, he stated he had called CDPH on 9/24/11 to report the event. No record of the phone call was found at the office of CDPH. However, CDPH did receive a faxed report of the incident. The information on the faxed report indicated Resident A had shoved Resident B (her Husband) on 9/24/11 at 10:40 AM. CDPH received this faxed report on 9/29/11 at 5:38 PM (two days after the incident had occurred). Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours.In accordance with Health and Safety Code Section 1418.91, this violation is a class B violation. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120009142 |
B |
13-Jun-12 |
FKOV11 |
3258 |
Health and Safety Code 1418.91(a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.On 9/27/11 at 8:30 AM, an unannounced visit was made to the facility to investigate an entity reported alleged resident to resident altercation.Based on interview and record review, the facility failed to report an allegation of resident to resident altercation to the California Department of Public Health within 24 hours.Resident A was a 76 year old non interviewable female with the diagnosis of senile dementia, depressive disorder, mood disorder, anxiety state, and delusional disorder. She was ambulatory without assistance. Her Care Plans indicated inability to follow directions, aggressive behavior towards staff and residents, and indication of multiple altercations with other residents. Resident A was on a one to one monitoring with staff (one staff person is assigned to care for only that resident). Resident B was a 77 year old female with the diagnosis of dementia without behaviors, depressive disorder and anxiety. She was ambulatory without assistance. Her Care Plan for "Dementia/Alzheimer's" indicated altered thought process, impaired verbal communication related to deteriorated cognition, and inability to follow direction. Her Care Plan for "Patient to Patient Altercation" indicated she had multiple encounters with other residents and staff, had been on every 15 minutes checks and currently on one to one monitoring because of her aggressive behaviors. On 9/26/11 at 7:59 AM, the facility reported an allegation of Resident A to Resident B abuse via fax. The incident had occurred on 9/18/11 at 7:30 PM (8 days prior to their reporting). During an interview with Certified Nursing Assistant 1 (CNA 1), on 10/4/11 at 1 PM, she stated she had been on one to one with both Resident A and B but at different times. She stated on 9/18/11 at 7:30 PM, Resident B was in the lobby near the door. CNA 1 was on one to one with Resident A, who was walking towards Resident B. CNA 1 stated she was trying to get Resident B to move away from the door when Resident B grabbed the pen CNA 1 had in her hand. Resident A then slapped Resident B's hand. Other staff came immediately and the residents were separated and redirected.The clinical record of Resident A was reviewed on 9/27/11. The Nursing Notes, dated 9/18/11, at 8:10 PM, indicated Resident A hit Resident B when Resident B attempted to grab a CNA's pen. The nurse further documented that she had made the family and physician aware of the incident, but there was no documented evidence that the Department had been notified. On 10/7/11 at 3:41 PM, the Department sent a faxed request to the facility requesting any documented evidence of the facility reporting the incident prior to the faxed report of 9/26/11. No further documentation was made available to the Department. Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours.In accordance with Health and Safety Code Section 1418.91, this violation is a class B violation. |
| 120000379 |
EVERGREEN BAKERSFIELD POST ACUTE CARE |
120010393 |
B |
23-Jan-14 |
NQ1E11 |
3114 |
Health and Safety Code 1418.91(a)(b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/1/12, an unannounced visit was made to the facility to investigate a complaint claim that the facility was not reporting allegations of staff to patient abuse. Based on interview and record review, the facility failed to report allegations of staff to patient abuse for three of three patients (Patient A, B, C) within 24 hours to the Department.Patient A was a 90-year-old man admitted to the facility on 12/3/10 with moderately impaired cognition. Patient B was a 97-year-old woman admitted to the facility on 12/15/09 with severe cognitive impairment. Patient C was a 97-year-old woman admitted to the facility on 8/26/09 with altered mental status. On 4/30/12, a complaint was received regarding alleged abuse of patients. The complainant stated a former staff (FS 2) had witnessed a certified nursing attendant (CNA 3), on three occasions, roughly handled three patients during routine care.During an interview with FS 2 on 5/1/12, at 10:38 AM, she stated that on 4/25/12 she gave the Admission Coordinator (AC) a written statement alleging CNA 3 had abused two patients (Patient A and B). FS 2 stated AC told her "I would be contacted in a few days and said not to contact the State (Licensing and Certification) because (the name of the Director of Nursing) would. No one talked to me about it."On 5/1/12, at 1:10 PM, the interim Administrator and the Director of Nursing was interviewed at the facility. The interim Administrator stated he did not remember hearing of any allegation of abuse from FS 2. The DON stated she also had not heard of such allegation or received any written statement. At 1:15 PM, the AC was interviewed regarding the written statement. AC stated she gave the statement to the Director of Nursing immediately and denied that she instructed FS 2 not to report the abuse allegation to the Department. At 1:20 PM, Director of Nursing located the written statement and handed it to the interim Administrator.At this time, FS 2's written statement was reviewed. On the third page, she wrote, "I have witnessed a CNA lifting a resident (Patient A) and putting him in a chair against his will & he became very combative & upset...I found this CNA to have not given residents back their call lights after laying them down."On page two, she wrote, "I have witnessed the screams of some residents (Patient B and C) because they were not informed on (sic) what the CNA (CNA 3) was gonna (sic) do and were just moved around without their knowledge."During an interview with the DON on 5/1/12, at 1:35 PM, she stated, "I didn't consider it an allegation of abuse until now. (FS 2) was angry."Therefore the facility failed to report allegations of abuse of residents within 24 hours. The above violation has a direct relationship to the health, safety or security of residents. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120010413 |
B |
29-Jan-14 |
JEWX11 |
2370 |
Health and Safety Code 1418.91(a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.On 9/27//11 at 10:30 AM, an unannounced visit was made to the facility to investigate the above entity reported incident.Based on interview and record review, the facility failed to notify the California Department of Public Health (CDPH) of an allegation of patient-to-patient (Patient 1 to Patient 2) altercation within 24 hours. This had violated the regulatory requirement of reporting mandate.Findings: On 9/27/11, entered the facility to investigate an allegation of patient-to-patient altercation the facility had reported to the Department on 9/21/11 at 7:52 AM. The incident occurred on 9/18/11, the report was not made to the Department until 9/21/11, two days after the incident. On 9/27/11, at 10:39 AM, Patient 1's clinical record was reviewed. He was described in the medical record as having short and long term memory problem. A Social Service notes dated 9/20/11, not timed, read, "(Patient 1) picked up (Patient 2's) banana from the table, when (Patient 2) became upset and both residents began to argue, (they) proceeded to stand up, when (Patient 1) punched (Patient 2) in the face. Both residents were separated..." When Social Service Director interviewed Patient 1, Patient 1 was unable to answer appropriately or recall event.The clinical record for Patient 2 was reviewed on 9/27/11. He was alert and able to make simple decisions; but he also had episodes of verbal outburst. Interdisciplinary Progress notes, dated 9/20/11, indicated Patient 2 sustained red nose but he did not complain of pain.During an interview with Certified Nursing Assistant (CNA 1), on 9/27/11, at 5:04 PM, She stated she was present in the dining room and observed the patient-to-patient altercation that occurred on 9/18/11, at 5 PM. Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours. In accordance with Health and Safety code section 1418.91, this violation is a class "B" violation. Failure to comply with the requirement had direct or immediate relationship to the health, safety, or security of patients. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120010424 |
B |
06-Feb-14 |
U7YY11 |
2784 |
72315 (b). Nursing Service - Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Based on Interview and record review the facility failed to protect one Patient (1) from physical abuse when a staff member hit the patient's leg with a closed fist while providing care. This had the potential for injury to the patient's leg and emotional distress. Findings: During an interview with Licensed Vocation Nurse (LVN 1) on 7/12/13, at 2:15 PM, she stated Certified Nursing Assistant (CNA 1) was assisting her with Patient 1's wound care. LVN 1 described they had finished changing him and CNA 1 was applying skin protection cream to his scrotal area. Patient 1 struck out at the CNA 1 and she stepped back and let him calm down. CNA 1 again attempted to apply the cream and Patient 1 struck out hitting the assistant again. LVN 1 stated, "She (CNA 1) struck back with a closed fist hitting Patient 1's thigh. There was a verbal confrontation between the patient and the CNA using the "F" word, and I immediately said 'No stop that'." During an interview with Patient 1 on 7/12/13, at 3:45 PM, using pencil and paper, due to his hard of hearing; he denied any verbal or physical encounters with staff.During an interview with the Administrator, on 7/12/13,at 2 PM, he described, during his investigation, it was determined CNA 1 did strike Patient 1 with her fist, Patient 1 struck her several times and was witnessed by LVN 1. CNA 1 was terminated immediately after the incident. The surveyor attempted to phone the attendant several times without success. During a review of the clinical record on 7/12/13, Patient 1 was admitted with multiple medical issues including dementia. The "Interdisciplinary Progress Notes" (IDT) dated 6/27/13, states "...today during treatment pt (patient) became agitated and was swinging at CNA and cursing at her. Pt turned and hit CNA...the CNA hit rt (right) back on his thigh...CNA and pt altercation witnessed by treatment nurse..." The facility policy and procedure titled "Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy" dated October 2010; read "each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Nursing Center implements policies and process so that residents are not subjected to abuse by staff..."These violations resulted in Patient 1 being physically abused by staff and possibly creating distrust between Patient and care givers, leading to needs not being met, and possible emotional trauma. This had caused under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120010512 |
A |
12-Mar-14 |
RZKZ11 |
7873 |
F223-483.13(b), 483.13(b)(1)(i) - Free From Abuse/Involuntary Seclusion The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.The investigation was initiated on 5/29/13 after receiving a family complaint that her mother, a resident residing at the facility had a deep vaginal tear that was highly suspicious of sexual assault.Based on interview and record review, the facility failed to follow its "Event Reporting and Investigation" policy and procedure to investigate an allegation of a staff (certified nursing attendant, CNA 1) to a resident (Resident A) sexual assault immediately. Such failure had allowed CNA 1 to continue to have contact with vulnerable residents and sexually assaulted another resident (Resident B) causing her to have a deep vaginal tear. The injury was so severe that Resident B had to have a surgery to repair the laceration.Vaginal tear is a laceration of the wall of the vagina may be superficial or deep. The most common cause of vaginal laceration is intercourse. Superficial tears do not require surgery and heal with minimal treatment. Deep tears are serious because they can cause a lot of bleeding. These must be repaired with surgery. Findings: 1. During an interview with the Family Member B (FM B) on 5/26/13, at 9:39 PM, she stated her mother (Resident B) was sent to an acute hospital due to vaginal bleeding. FM B stated she was informed by the staff at the acute hospital her mother's vaginal bleeding was caused by a tear in her vaginal wall and it was deep enough that a surgical repair was necessary to repair the tear. FM B stated the Administrator told her that her mother's vaginal bleed was the result of a self-inflicted injury.During a review of the Operation Report from the acute hospital, dated 5/27/13, it was documented that Resident B, a 93-year-old lady had a surgical repair of a four to five centimeters (a unit of measure) laceration to the right vaginal sidewall. Another social services note, dated 5/28/13, indicated a hospital staff was concerned "regarding how the pt. (patient) suffered a vaginal laceration at a skilled nursing facility." The note further stated the Surgeon who performed the surgery told FM B "it was her opinion that (Resident B) may have been violated resulting in the injury." During an interview with the Surgeon, on 7/3/13, at 9:18 AM, she stated, "The vaginal laceration started 2 centimeters in from the vaginal opening and went back four to five centimeters. There is no way she (Resident B) could have inflicted the injury on herself as she would be unable to reach that far in." The laceration went almost to the deepest portion of the vagina. During an interview with the Administrator and the Director of Nursing (DON), on 5/29/13, at 2:51 PM, both stated Resident B was sent out to an acute care hospital for vaginal bleeding on 5/26/13 after another certified nursing assistant had noticed the bleeding at approximately 5 AM. The Administrator stated, "The hospital did not notify us of any findings, we only found out when the grand-daughter (FM B) called us on 5/28/13 and told us she (Resident B) had surgery to repair a tear in her vagina.The police were notified and an officer came on 5/28/13 around 6 PM.The officer checked the facility and the window screens. They (police) said there was no way anyone could've gotten in through any windows." During a review of the clinical record for Resident B, the Nursing Notes, dated 5/26/13, at 5:35 AM, indicated Resident B was noted to have a moderate amount of vaginal bleeding with clots. The physician was notified of the bleeding and the resident was sent to an acute care hospital for evaluation.2. On 6/3/13, the Department received an entity reported incident from the facility regarding another allegation of sexual assault of Resident A that occurred on 5/21/13. This report was faxed to the Department on 5/31/13, at 7:13 PM. During an interview with Resident A on 6/3/2013, at 2 PM, through a licensed vocational nurse's (LVN 1) translation, Resident A stated in Spanish, "I am afraid of someone that works here, a man, an African American nurse that works here at night. I am afraid that he will come and hurt me again." He then looked away and didn't speak any further. Further attempts to interview Resident A were unsuccessful, as he would not answer any more questions.On 6/3/13, during a review of the "Nurses Notes" for Resident A, dated 5/21/13, entered at 10:30 PM, it read; "Res (Resident A) and daughters are in the facility to visit. Just before they were leaving, resident's wife informed our charge nurse that, per the res, there is an African American male CNA (later identified as certified nursing attendant, CNA 1) whom touched his (Resident A's) private parts when he was being showered." Resident A's family members stated he was uncomfortable and afraid. The family requested the facility not to assign CNA 1 to care for him anymore. The nurse also wrote, on the same notes, "I called out Administrator and informed him of the situation and the families wishes." On 6/4/13, at 1:30 PM, during a review of staffing assignments for the month of May, 2013 with the Administrator, it was noted CNA 1 had been assigned to take care of Resident A and B on several evening shifts and had given a shower to Resident A on 5/4/13. The staffing assignment for 5/24/13 and 5/25/13 were also reviewed. CNA 1 was also assigned to take care of Resident B on both evening shifts which was four days after the Administrator was informed of the sexual abuse allegation filed by Resident A. During an interview with the Administrator on 6/4/13, at 2:21 PM, when questioned the Administrator what actions he took when nursing staff reported to him an allegation of sexual assault. The Administrator could not elaborate he had taken any necessary actions to protect the residents in the community. He stated he reported the allegation to the Department on 5/21/13 and was still in the process of investigating the issue. On 6/4/13, the survey team phoned the Department to verify the Administrator's statement. The Department had not received any report of sexual assault from the facility regarding Resident A's allegation of sexual abuse on or the day after 5/21/13.The facility policy and procedure titled "Investigation of Alleged Sexual Abuse," revised 2/07, read: "6. If evidence determines that an actual or potential sexual assault may have occurred: a. Notify the local law enforcement agency (give brief account and request that an officer be sent to the facility). B. ...If the alleged perpetrator is a staff member, remove him or her from resident care area; assign another staff member to stay with the alleged perpetrator while local law enforcement agency is contacted and in route to the facility. The Executive Director or Director of Nursing Services should place the employee on immediate suspension pending further investigation after the local law enforcement has had an opportunity to complete the interview of the perpetrator. This employee is not allowed to return to the resident care area." The facility Administrator failed to follow this policy and procedure. The inaction of the Administrator had allowed CNA 1 to continue working with vulnerable residents had placed all residents, such as Resident B, at the great risk to sexual assault. Resident B was discharged to live with her daughter and deceased shortly after that. Therefore, the facility failed to protect Resident B from sexual assault by a staff member that constitutes a class "A" citation. The above violation presented imminent danger that serious harm would result or a substantial probability that death would result. |
| 120000379 |
EVERGREEN BAKERSFIELD POST ACUTE CARE |
120011625 |
B |
21-Jul-15 |
4CY311 |
3663 |
(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 6/9/15, at 3:53 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding alleged family to resident abuse. Based on observation, interview, and record review, the facility failed to report an alleged abuse incident within 24 hours for one of one sampled resident (1) when the incident was not reported to the California Department of Public Health for 17 days. This had the potential for abuse incidents to go unreported to the Department.During a review of the facility report dated 6/2/15, indicated in part "...Occurrence date 5/16/15.During an observation on 6/9/15, at 12:20 PM, in the dining room 400, Resident 1 was sitting in her wheelchair. Certified Nursing Assistant (CNA 1) was assisting her with lunch. Resident 1 was observed eating very slow, pocketing food in her mouth, not chewing, and closing her eyes. When Resident 1 was asked how she was doing, Resident 1 did not respond. During a review of the clinical record for Resident 1, the "Nurse's Notes" dated 6/2/15, indicated a late entry for 5/16/15, read "Two CNA [CNAs 2 and 3] assigned in the dining room reported that they did not like the way [Resident 1] was being fed by daughter (slapping her face to get her to wake up and eat). This report was received after dinner. ...Per interview with these two CNAs, they just feel like 'slapping mother's face' was not the correct way to get her to eat. Administrator made aware of this incident." During an interview with the Director of Nursing (DON), on 6/9/15, at 12:50 PM, when asked if the incident was reported to the California Department of Public Health timely, she stated it was not because they did not think abuse happened.During an interview with CNA 1, on 6/9/15, at 1:23 PM, she stated, "She [Resident 1] ate 40% at breakfast. It is normal for resident [1] to eat very slowly and sometimes pocketing food in her mouth. Resident [1] is 92 years old." During an interview with the Registered Nurse Supervisor (RNS), on 6/9/15, at 2:33 PM, she stated, she reported the incident to the Administrator [Abuse Coordinator], the same day the incident happened [5/16/15]. During an interview with the Administrator, on 6/9/15, at 3 PM, when asked about the 5/16/15 incident which was not reported to the California Department of Public Health until 6/2/15, she stated, "We did not think abuse happened. There was no injury. The result of our investigation was unsubstantiated (not proven)." No additional evidence was provided that the facility reported the 5/16/15 incident until 6/2/15 which was 17 days after the date of occurrence. During an interview with CNA 2, on 6/11/15, at 4:56 PM, she stated, "I heard a slapping sound and looked over. I saw [daughter] slapping [Resident's 1] face." When asked what she did when she witnessed the incident, CNA 2 stated, "I reported to the [RNS name] after dinner time at 6:20 PM (on 5/16/15)" The facility policy and procedure titled, "Abuse prohibition Manual", updated 11/13, read "The Center reports allegations and substantiated occurrences of abuse, neglect, misappropriation of property or injuries of unknown source to the state survey and certification agency and appropriate state agency and law enforcement officials in accordance with the state regulation." Therefore, the facility failed to report an allegation of abuse to the Department within 24 hours. |
| 120000379 |
EVERGREEN BAKERSFIELD POST ACUTE CARE |
120011662 |
B |
14-Sep-15 |
O90P11 |
5010 |
F246-42 CFR 483.15(e)(1) Reasonable Accommodation of Needs A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. On July 16, 2015, at 9:15 AM, an unannounced visit was made to the facility to investigate a complaint concerning quality of life. The facility failed to ensure call lights were answered in a timely manner for 4 of 4 sampled residents (Residents 1, 2, 3, 4). This failure resulted in mental anguish for three residents (1, 3, 4) and a fall for one resident (2). Resident 1 was an 88 year old woman who was admitted to the facility on 7/2/13. Resident 1 had a history of arthropathy (disease of a joint), dizziness, osteoarthritis (the most common form of arthritis. It causes pain, swelling, and reduced motion of the joints), joint pain, muscle weakness, and syncope (temporary loss of consciousness and posture, described as "fainting" or "passing out."). Resident 1 was totally dependent on staff and required two-person assistance for toilet use. Resident 2 was a 94 year old woman who was admitted to the facility on 6/24/15. Resident 2 had a history of abnormality of gait, debility (state of being weak, feeble, or infirm), generalized pain, difficulty walking, muscle weakness and neurogenic bladder (problem in which a person lacks bladder control). Resident 2 was dependent on staff for weight bearing support by two people.Resident 3 was a 94 year old woman who was admitted to the facility on 4/9/14. Resident 3 had a history of muscle weakness, osteoarthritis, and difficulty walking. She required extensive assistance with one staff person for toilet use. Resident 4 was a 92 year old woman who was admitted to the facility on 3/16/11. Resident 4 had a history of cerebral palsy (group of permanent movement disorders that appear in early childhood), lack of coordination, abnormality of gait, osteoarthritis, and muscle weakness. She required extensive assistance from two staff for toilet use. During an interview with a Confidential Staff Member, on 7/15/15, at 1:14 PM, she stated she was often too busy to answer call lights or even take a lunch break; assignments were often 13 residents per one Certified Nursing Assistant (CNA) and it was "...just too much". During an interview with Resident 1, on 7/16/15, at 9:15 AM, she stated when she has to use the bathroom; she activates her call light and sometimes has to wait an hour for staff to answer the call light. Resident 1 stated, "When they come, it's too late...I hate it when it happens and they have to clean me up...I hate wearing diapers, but what can I do?" Resident 1 began to cry and stated "I felt so embarrassed."During an interview with Resident 2, on 7/16/15, at 9:50 AM, she stated she usually has to wait a long time for staff to answer her activated call light, sometimes an hour or more. Resident 2 stated on 7/8/15, she needed to use the bathroom; she activated her call light, but no one answered the call light. She stated, "I tried to get out of bed by myself (to go to the bathroom) and fell...I got up and fell again...the call light was still on...I had to yell for help...I was screaming...They had to send me to the hospital...I felt neglected and forgotten...I'm still very sore and beaten up." During a review of the clinical record for Resident 2, the "Patient Transfer Form", dated 7/9/15, indicated Resident 2 was transferred to the hospital for evaluation after a fall. The "Discharge Summary" from the acute care hospital, dated 7/9/15, indicated Resident 2 sustained a closed head injury, lower back pain and a skin tear to her elbow from the fall During an interview with Resident 3, on 7/16/15, at 10:15 AM, she stated when she uses the call light, she frequently has to wait 45 minutes to an hour to get help to the bathroom; sometimes she has to go to the bathroom by herself...and "I pee my pants" when she can't make it to the bathroom in time. Resident 3 stated, "Sometimes they forget about me, they say they are busy..." During an interview with Resident 4 on 7/16/15, at 10:15 AM, she stated call lights (response times) are a problem on the night shift..."I almost always have to wait at least 30 minutes for someone to come help me."During an interview with the Executive Director (ED), on 7/21/15, at 11:40 AM, she stated the expectation for call light response time, is three minutes for an emergency bathroom call light, and 15 minutes for a regular call light. The ED verified the facility did not have a policy related to call lights. Therefore, the facility failed to ensure call lights were answered in a timely manner for 4 of 4 sampled residents (Residents 1, 2, 3, and 4) which resulted in mental anguish for three residents when Resident 1, 3,4 soiled themselves and a fall with injury for Resident 2.This violation had a direct relationship to the health, safety or security of residents. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120011683 |
A |
14-Sep-15 |
HNG611 |
6680 |
F309-42 CFR 483.25Provide Care/Services for Highest Wellbeing 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 July 15, 2015, at 1:32 PM, an unannounced visit was made to the facility to investigate an entity reported incident of a fall with injury. The facility failed to: 1. Monitor and document pain management for one of one sampled resident (1) when facility had no evidence of pain management for Resident 1 with a fractured pelvis for 11 days.2. Administer routine pain medication for one of one sampled resident (1) when Resident 1 did not receive his routinely ordered pain medication for 12 hours.3. Notify the doctor for one of one sampled resident's (1) unrelieved pain.These failures resulted in Resident 1 suffering from unrelieved pain due to a fractured pelvis.Resident 1 was a 59 year old man who was admitted to the facility on 6/4/15. Resident 1 had a history of general muscle weakness, diabetes (group of metabolic diseases in which the person has high blood glucose), heart failure, generalized pain, and a fractured pelvis. 1. During a concurrent observation and interview with Resident 1, on 7/15/15, at 1:40 PM, in Resident 1's room, Resident 1 was lying in his bed. A forward wheeled walker was at bedside. Resident 1 stated, "I have hard time getting in and out of the bed." When asked how his fall happened, he stated, "After I used the bathroom, I tried to reach for the door knob to hold on to but the door opened wide and I missed the knob so I fell down to the floor, landed on my right side. My hip cracked." When asked if he called for assistance before going to the bathroom, he stated, "No, I did not ask for help. It's my fault." When asked if he had concerns with the care he was receiving from the facility, he stated, "I think I don't have enough pain medicine. My pain medication is not working." When asked if he reported to the nursing staff, he stated, "Yes, I did several times but they said, I am already taking Norco [strong narcotic pain medication] every 4 hours."During a review of the clinical record for Resident 1, the "SBAR (Situation, Background, Assessment and Request) Communication Form", dated 7/4/15, indicated, "Resident [1] fell to right side complaining of increased pain to right hip." "Transfer to the hospital" was check marked. The hospital "Patient Visit Information", dated 7/4/15, indicated, "Pelvic fracture".During an interview with the Director of Nursing (DON), on 7/15/15, at 2:52 PM, she reviewed the clinical record and was unable to find documentation of pain management from 7/4/15 to 7/15/15 [for 11 days]. She stated, "I can't find any. It is not done."The facility policy and procedure titled, "Pain Management", dated 7/2014, read "The Pain Management Flowsheet is initiated. The LN [Licensed Nurse] documents the pain evaluation for their shift on the Flowsheet until appropriate pain management has been achieved."2. During a review of the clinical record for Resident 1, the "July 2015 Medications", dated 7/2015, indicated, "Norco 10/325 mg (milligram) tab [tablet] PO [by mouth] q [every] 4 hours (for pain). On 7/14/15, Licensed Nurses' initials were circled at 4 AM, 8 AM, 12 PM and 4 PM. The "PRN (as needed) Notes", dated 7/14/15, indicated, "Norco unavailable pharmacy awaiting." The DON confirmed the finding and stated those were four missed doses of Norco because the pharmacy did not refill.During an interview with the Licensed Vocational Nurse, on 7/15/15, at 3:26 PM, he stated he was the afternoon shift and he received a report from morning shift that resident's [1] Norco ran out. He stated, "Resident [1] missed 4 doses of Norco. Resident [1] complained of pain so I gave the PRN [if needed] Tylenol [medication for mild pain]."During an interview with Resident 1, on 7/15/15, at 4:12 PM, when asked if he remembered he did not receive Norco for 12 hours yesterday (7/14/15), he stated, "Yes, I was in pain yesterday and I refused to do my therapy." When asked about his pain level [10 will be the worst], he stated, "9 out of 10. They said I ran out of pills."During an interview with the Registered Nurse, on 7/20/15, at 10:54 AM, she stated, "Resident [1] had no supply of Norco so he [Resident 1] did not receive a dose for 8 AM and 12 PM [in her shift]." When asked if she notified the doctor, she stated, "I called the doctor, no new order. I told the Therapist and resident [1] to call me if he [Resident 1] needed a pain medication." When asked if she went to reassess Resident 1's pain, she stated, "The Therapist and Resident [1] did not let me know."The facility policy and procedure titled, "Pain Management", dated 7/2014, indicated "When there is a change in pain level, or if there is newly identified pain, the LN [Licensed Nurse] contacts the physician for appropriate treatment orders."3. During a review of the clinical record for Resident 1, the "Nurse's Notes", dated 7/8/15, at 2:45 AM, indicated, "Resident c/o [complained of] pain 6/10 scale [10 is worst pain]. Resident taking Norco." The "Nurse's Notes", dated 7/9/15, at 1:20 AM, indicated in part ..."Continue to experience pain due to fracture of R [right] hip on routine Norco." There was no indication the nurse notified the treating physician of Resident 1's continued pain. The DON verified the findings.During an interview with the DON, on 7/15/15, at 2:52 PM, when asked what were the interventions done for the unrelieved pain, she stated, "I totally agree, there should be non-pharmacological interventions [things done to relieve pain other than giving medication]."The facility policy and procedure titled "Pain Management" dated 7/2014, read "The information on the Pain Evaluation Record is used in conjunction with the Center's other evaluation and data collection tools to develop an individualized care plan, including non-pharmacological interventions, if appropriate."Therefore, the facility failed to 1. Monitor and document pain management for one of one sampled resident (1) when facility had no evidence of pain management for Resident 1 with a fractured pelvis for 11 days.2. Administer routine pain medication for one of one sampled resident (1) when Resident 1 did not receive his routinely ordered pain medication for 12 hours.3. Notify the doctor for one of one sampled resident's (1) unrelieved pain.These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000379 |
EVERGREEN BAKERSFIELD POST ACUTE CARE |
120011795 |
B |
16-Nov-15 |
W1T511 |
3819 |
Health and Safety Code Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of the section shall be a class "B" violation.On October 7, 2015, at 3:12 PM, an unannounced visit was made to the facility to investigate an allegation of resident abuse. Based on observation, interview, and record review, the facility failed to report allegation of abuse and neglect for one of one sampled resident (1) to the California Department of Public Health (CDPH). This had the potential for abuse allegations to go unreported to the Department and uninvestigated. Resident 1 was a 92 year old female with a history of dementia (a gradual and progressive decline in multiple areas of cognitive processing eventually leading to significant inability to maintain performance in activities of daily living), generalized pain, chronic kidney disease (gradual loss of kidney function), and anemia (a lower-than-normal number of red blood cells). During a review of the Police Report, the "Initial Offense Report", dated 10/3/15, indicated, "On 10/3/15 at about 1:45 AM, [Police] was dispatched to [General Acute Care Hospital] at [Hospital address] regarding a report of elder abuse. Family Member [FM 1] said her 92 year old mother; [Resident 1] had possibly been the victim of elder abuse at her live in elder facility. During an interview with Family Member (FM 1), on 10/7/15, at 3:12 PM, she stated, "I don't believe my Mom [Resident 1] fell off from the bed by herself. They might have dropped her while turning her." When asked what happened, she stated, "My Mom cannot move, how could she fall?" When asked whom she reported the incident, she stated, "I reported to the hospital."During an observation on 10/8/15, at 1:30 PM, in Resident 1's room, Resident 1 was sleeping.Resident 1 had a band aid on her left forehead with a bruise.During a review of the clinical record for Resident 1, the "Nurse's Notes", dated 10/5/15, indicated, "...BPD [Bakersfield Police Department] came in as per [General Acute Hospital] called them for possible abuse." During an interview with the Director of Staff Development (DSD), on 10/8/15, at 3:36 PM, when asked if she conducted abuse in-services, she stated, "Yes. 100% staff attended." When asked what she was teaching the staff about reporting, she stated, "All allegations of abuse should be reported to the Ombudsman and State." When asked if DSD was aware of the police visit because of the abuse allegation about Resident 1, she stated, "I'm not aware of that. That should be reported right away. It's not my fault if staff does not follow what was in-serviced." During an interview with the Administrator, on 10/8/15, at 4:25 PM, when asked if the abuse allegation and the police visit were reported to CDPH, she stated, "I did not report because it wasn't abuse." Administrator stated, "The hospital already reported, the police came and investigated there was no abuse, why should I report again?"The facility policy and procedure titled, "Abuse prohibition Manual", updated 11/13, indicated, "Reasonable Cause to Believe: A mandated reporter thinks it is probable that an incident of abuse, abandonment, neglect, or financial exploitation happened, Probable means that based on information or evidence readily obtained from various sources, it is likely the incident occurred. 7. Reporting and Response: b. The Center reports allegations and substantiated occurrences of abuse, neglect, misappropriation of property or injuries of unknown source to the state survey and certification agency and appropriate state agency and law enforcement officials in accordance with the state regulation." |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120012023 |
B |
29-Feb-16 |
JP5U11 |
2416 |
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. The facility failed to report an abuse incident timely for 2 of 2 sampled residents (1 and 2), when the facility did not report the abuse incident for 9 days to the California Department of Public Health (CDPH).On December 9, 2015, at 1 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an incident of alleged resident abuse. During a review of the clinical record for Resident 1 was reviewed. The "Nurse's Notes", dated 11/28/15, at 5:30 AM, read "[Resident 1] stated in Spanish that he was trying to go to the restroom but [Resident 2] kept on getting mad at [Resident 1] that it's his house. So [Resident 1] got mad and hit [Resident 2] with [Resident 1's] wooden cane on [Resident 2's] head. ...DNS [Director of Nursing Services] and Administrator made aware. SOC 341 [Report of Suspected Dependent Adult/Elder Abuse] completed and faxed to law enforcement." The Brief Interview for Mental Status (BIMS- provides a baseline for the level of cognition) indicated Resident 1 had a score of 14 points out of a possible 15 points, which indicated he was cognitively intact. During an interview with the Administrator, on 12/9/15, at 2 PM, when asked about the abuse incident that happened on 11/28/15 but was not reported until 12/7/15 [after 9 days], he stated he did not know about the incident right away and he reported the incident after the investigation was completed. When asked what was the facility's policy and procedure on resident to resident altercation, he stated, "I believe we do not have a policy on resident to resident altercation." The facility policy and procedure titled "Abuse, Neglect, and Misappropriation of Resident Property Prohibition" updated 11/13, read "The Center reports allegations and substantiated occurrences of abuse, neglect, misappropriation of property or injuries of unknown source to the state survey and certification agency and appropriate state agency and law enforcement officials in accordance with state regulation." Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours. |
| 120000373 |
EVERGREEN ARVIN HEALTHCARE |
120012035 |
A |
29-Feb-16 |
7J0E11 |
8187 |
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. Based on interview and record review, the facility failed to take necessary actions for one of one sampled resident (1), who verbalized suicidal ideation (thoughts). This resulted in Resident 1 attempting suicide and then emergently transferred to an acute hospital. An unannounced visit was made to the facility on 1/13/16 at 11:44 AM to investigate an attempted suicide by Resident 1. Resident 1 was a 57 year old male with a history of major depressive disorder (a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem, and by a loss of interest or pleasure in normally enjoyable activities), anxiety state (a chronic condition characterized by an excessive and persistent sense of apprehension, with physical symptoms), hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), pain, and diabetes (abnormal blood sugar).The clinical record for Resident 1 was reviewed. The "QUALITY OF LIFE INITIAL ASSESSMENT" dated 9/4/15, indicated under Significant Life Accomplishments: "Son passed away 18 years ago." The "Interdisciplinary (IDT-group of people organized to do a task together) Progress Notes" dated 9/11/15, indicated "Resident is also on Zoloft (anti-depressant) 25 mg (milligrams) at bedtime for feeling sad. IDT agrees to clarify medication to manifested by crying secondary to resident exhibiting behaviors of crying since admission...the loss of his son triggers crying behavior..." A physician order, dated 11/23/15, indicated Lexapro (anti-depressant) 10 mg by mouth daily at 1830 (6:30 PM) for depressive disorder manifested by crying." The Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/10/15, indicated under Brief Interview for Mental Status (BIMS) a score of 15 (cognitively intact). The Resident Mood Interview indicated under "B. Feeling down, depressed, or hopeless" a score of 1/1 (meaning the symptoms were present and with 2-6 days frequency in the last two weeks look back period). The "BEHAVIOR MONITORING FLOWSHEET" dated January 2016, indicated under "Crying" Resident 1 had two episodes of crying on 1/10/16. On 1/11/16, Resident 1 had one episode of crying and also one episode of crying on 1/12/16. The "NURSE'S NOTES" dated 1/12/16, at 9:20 AM, indicated "...Resident did not eat breakfast today. When asked why you aren't eating he said "I'm not hungry." CNA (Certified Nursing Assistant) left the tray in his room just in case resident changed his mind. Dietary Supervisor went and spoke with the resident and asked him why he wasn't eating. Resident said, "I don't like this place, I don't want to be here, Go to Hell." At 1820 (6:20 PM) "Resident sister found the resident with a tied plastic bag over his head."During an interview with the Administrator, on 1/13/16, at 12:01 PM, he stated the incident happened on 1/12/16, at approximately 6 PM, when the resident's sister came in, she saw the resident with a trash can plastic bag on the resident's head and tied on his neck. The sister tried to remove the plastic bag and called for help. CNA 1 came and ripped open the plastic bag. The Administrator also stated the resident said, "He doesn't wanna live, he doesn't like this place, he wanted to die and will find a way." The resident's physician ordered to send the resident to the hospital for psychiatric evaluation.During an interview with CNA 1, on 1/13/16, at 12:28 PM, she stated yesterday (1/12/15), at approximately 5 PM, she had a meal tray to pass and she saw the resident's sister by the door of Resident 1's room saying the resident had a plastic bag on his head. She immediately put the meal tray down and ran to the resident. The resident had a plastic bag over his head and tied on his neck. CNA 1 ripped the plastic bag between the resident's mouth and nose so the resident could breathe. When CNA 1 was asked if the resident was verbalizing suicidal ideation before this incident happened (1/12/15) she stated, "Oh yes, two weeks ago the resident stated he would get a gun and shoot his head off." CNA 1 stated they (CNA's) told the CEO (Chief Executive Officer) and the afternoon shift nurse about the resident verbalizing suicidal ideation but they (nurses) did not do anything. CNA 1 also stated the resident was very depressed. He was just crying and upset most of the time. He was upset with the Administrator because the resident was saying the Administrator took away his therapy (physical therapy), they (staff) were trying to explain to the resident "Maybe it's the insurance." During an interview with CNA 2, on 1/13/16, at 1:40 PM, he stated the resident would always say "Please and thank you." But because of "I guess insurance, he's not getting therapy anymore." When the therapy was stopped, he started to refuse to get out of bed and work with RNA (Restorative Nursing Assistant) program. The resident was always saying "I'm done." CNA 2 also stated, two weeks ago he knew the resident had an increased depression because he started saying he would get a gun and shoot his head. CNA 2 stated the resident was refusing to eat, "12 hours without food just milk." Resident 1 started to refuse using urinal and just wet his bed. CNA 2 also stated he told Licensed Vocational Nurse (LVN) 1 about it but did not know if the nurse (LVN 1) did the documentation. During an interview with LVN 1, on 1/14/16, at 8:25 AM, she stated on 1/11/16, a CNA told her Resident 1 had refused his meal tray, and the resident repeatedly saying; "I don't care" and some profanity words. During a review of the clinical record for Resident 1, there was no documented evidence found in the nurses notes regarding the resident's verbalizing suicidal ideation. The care plan was also reviewed and found no plan and interventions regarding the resident's suicidal ideation. There was also no IDT review regarding the resident's suicidal ideation. During an interview with the Social Services Director (SSD), on 1/13/16, at 1:58 PM, she was informed regarding CNA 1 and CNA 2's statement on Resident 1's verbalizing suicidal ideation. SSD stated she was not informed the resident had suicidal ideation. SSD was also informed there was no documented evidence in the clinical record regarding the resident's verbalizing suicidal ideation. SSD reviewed the clinical record and again stated, she was not informed of the resident's suicidal ideation. During an interview with the Administrator, on 1/13/16, at 3:08 PM, he stated the facility had no policy and procedures on Suicidal Ideation. The Administrator provided a document dated 7/31/15. The document indicated under "Suicidal Ideation- When a resident states they want to die or complete self-harm, regardless if they have a plan or not, you must treat this as real and planned attempt. The following occurs: The resident becomes 1:1 with another staff member watching them at all times. Their assignment is to only be with this resident. We do not do 15 minute.... checks at any time. MD/family are notified immediately. Preferably a psych (psychiatry) eval (evaluation) is ordered to rollout psychoses. The resident is put on alert charting Q (every) shift for a minimum of 24 hours. Social Service counsels the resident and a care plan is develop. The IDT meets, at a minimum, 24 hours later and determines, as a team, whether precautions should continue. All documentation is documented in the NN (Nurses Notes)/IDT notes and is read at daily in the clinical meeting. It is imperative staff take these comment seriously, whether this is a common occurrence or not. It only takes one time for the resident to follow through." The facility did not take any of the above actions to prevent Resident 1 from harming himself. 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. |
| 120000379 |
EVERGREEN BAKERSFIELD POST ACUTE CARE |
120012740 |
A |
21-Nov-16 |
THX511 |
8450 |
F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Based on observation, interview, and record review, the facility failed to protect one of three sampled Residents (Resident 2) from sexual abuse when another Resident (Resident 1), who had a history of inappropriate sexual behavior, sexually assaulted Resident 2. This resulted in violating Resident 2's right to be free from sexual abuse, and caused abrasions to her genital area and her new fear of being touched by caregivers. Resident 1 was a 72 year old male with a history of diabetes ((condition characterized by high blood sugar levels caused by either a lack of insulin or the body's inability to use insulin efficiently), amputation of left great toe, heart failure (heart failure occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , and schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real). Resident 2 was a 57 year old female with a history of altered mental status (General term indicating that someone is failing to interact with environmental stimuli in a normal manner), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition such as viral infection or toxins in the blood), end-stage renal disease (the last stage of chronic kidney disease when the kidneys no longer function), dysphagia (difficulty swallowing), muscle weakness, cognitive communication deficit (a broad term that's used to describe a wide range of specific communication problems that can result from damage to regions of the brain that control the ability to think. This damage can impair the ability to transform thoughts into meaningful speech, writing, or gestures), diabetes, and epilepsy (a brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions). The clinical record for Resident 1 was reviewed. The "Nurses' Notes", dated 9/26/16, at 1:20 AM, indicated Resident 1 was found next to Resident 2's bed with his left hand touching her vagina. The History and Physical Record for Resident 1, dated 5/29/16, indicated, Resident 1 had the capacity to understand and make his own decisions. The "Minimum Data Set (MDS-a comprehensive assessment tool)" for cognitive function, dated 8/4/16, indicated Resident 1 received a score of 14 (score of 13-15 means cognitively intact). The Functional Status section of the MDS indicated Resident 1 could independently perform dressing, transfer, walking, and moving between locations. Resident 1 also had history of inappropriate behaviors such as making inappropriate sexual comments to staff, sitting outside his room naked in his wheelchair, and going outside the facility naked. A care plan, titled "The Behavioral Disturbance Care Plan", was initiated for Resident 1 on 6/26/16. The interventions the facility had planned to address Resident 1's inappropriate behaviors included psychiatric evaluation, encourage wearing clothes at all times especially around others, and "ensuring safety of other Resident, if necessary removing them to another area." The clinical record of Resident 2 was reviewed. The MDS for Resident 2, dated 9/2/16, indicated she received a score of 3 [score of 0-7 means severe cognitive impairment]. The Functional Status section of this MDS indicated Resident 2 was dependent on staff to perform activities of daily living, such as dressing, transfer, and changing position in bed. The "History and Physical Record", dated 9/1/16, indicated, Resident 2 did not have capacity to understand and make her own decisions. The "Cognitive Pattern(s) Care Plan" for Resident 2, dated 9/21/16, was reviewed. The concern the facility had was "Resident (2) removes clothes." The approaches the facility planned to address the behavior included: "Provide Resident (2) with privacy in room" and "Close curtains of room if Resident (2) removes clothes in room." The "SBAR (Situation, Background, Assessment and Recommendation) Communication Form", dated 9/26/16, at 4 AM, indicated "Resident (2) was possibly abused, (Resident 1) was found with his fingers in (Resident 2's) vagina." This SBAR indicated Resident 2 had redness and a scratch to the skin outside her vagina, upon assessment following the incident. During an observation on 9/26/16, at 2:02 PM, in Resident 2's room, Resident 2 was in bed crying with grimacing face. Certified Nursing Assistant (CNA) 1 asked Resident 2 why she was crying. Resident 2 stated, "Please don't touch me." During a concurrent observation and interview with Resident 1, on 9/26/16, at 2:45 PM, he recalled the incident and stated, "I am tired of the same questions over and over. I can't talk right now." Resident 1 stood up from his wheelchair, transferred himself to the bed, laid down, and closed his eyes. During an interview with Licensed Vocational Nurse (LVN) 1, on 9/28/16, at 8:32 AM, she stated, "(CNA 2) reported to me, she saw (Resident 1) in (Resident 2's) room inappropriately touching (Resident 2)'s vagina and (Resident 1) had his pants down. (Resident 1) was masturbating and his middle finger was in her (Resident 2) vagina." LVN 1 stated, "(Resident 2) had scratch marks and little bumps in different places on her body and redness, scratches, and marks on the left side of her labia (the fleshy area outside the vagina)." LVN 1 stated when she made her rounds at the beginning of her shift, Resident 2 was wearing a diaper. After the incident, when she assessed Resident 2, she was "on her left side naked with a sheet over her." During an interview with CNA 2, on 9/28/16, at 9:21 AM, she stated she was making her rounds when she saw Resident 1 in Resident 2's room leaning over his chair with his left fingers inside Resident 2's vagina. CNA 2 was asked if prior to the incident, Resident 2's curtain was pulled or her door was closed, she stated, "No, the curtain was open." During an interview with LVN 2, on 9/28/16, at 10:13 AM, she stated she saw Resident 1 come out of his room at around 12 midnight and LVN 2 walked passed Resident 1 while giving medications to another Resident prior to the abuse incident. After the abuse incident, LVN 2 stated she asked Resident 1 what he was doing in Resident 2's room, Resident 1 responded, "She (Resident 2) was showing me something." The facility policy and procedure titled, "Policy: Abuse, Neglect, and Misappropriation of Resident Property Prohibition", dated 11/2003, indicated, "Policy Statement: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. Sexual Abuse: Any form of non-consensual contact, including but not limited to, unwanted or inappropriate touching, rape, sodomy, sexual coercion, sexually explicit photographing, and sexual harassment. Remember that sexual contact may also include interactions that do NOT involve touching. In instances of abuse of resident who is unable to express or demonstrate physical harm, pain or mental anguish, the abuse is presumed to cause physical harm, pain, or mental anguish. Prevention: Center supervisors immediately intervene and correct reported or identified situations which abuse, neglect or misappropriation of resident property is at risk for occurring." The facility staff on duty at the time of the sexual assault failed to monitor Resident 1 to "ensure safety of other Residents" while he was seen in the hallway at 1:20 AM and failed to close Resident 2's curtains or door per her care plan. These failures provided the opportunity for Resident 1 to sexually assault Resident 2. 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. |
| 250000051 |
EXTENDED CARE HOSPITAL OF RIVERSIDE |
250010489 |
B |
27-Feb-14 |
2Q8Q11 |
5854 |
Class B Citation 72527. Patients' Rights.(a) Patients have the rights enumerated in this section and the facility shallensure that these rights are not violated. The facility shall establish andimplement written policies and procedures which include these rights and shallmake a copy of these policies available to the patient and to any representativeof 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. On September 8, 2010, an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged patient abuse.Based on interview and record review, the facility failed to protect Patient A from sexual abuse (a type of abuse). Patient B, who had a history of being sexually inappropriate, was found in Patient A's room. Patient B touched Patient A in an inappropriate manner. Patient A, a 32-year-old female, was admitted to the facility on August 17, 2010. Her diagnoses included congestive heart failure, end stage renal disease, diabetes, high blood pressure, chronic pain, anxiety, and blindness. The Nurse's Admission Record, dated August 17, 2010, indicated Patient A was alert, oriented, and able to understand.Patient B, an 87-year-old male, was admitted to the facility on July 30, 2010. His diagnoses included depressive disorder (depression), organic brain syndrome (decrease in mental function), and schizophrenia (a mental disorder). The admission Minimum Data Set (MDS, an assessment tool), dated August 6, 2010, indicated cognitive skills for daily decision making was moderately impaired, as well as short term and long term memory problems. The MDS also indicated Patient B experienced socially inappropriate/disruptive behavior that was not easily altered.A review of the Nurses Notes and facility Investigation Report, indicated that on August 18, 2010, at 8:15 p.m., Certified Nurse Assistant (CNA) 1 observed Patient B in Patient A's room, leaning over her wheelchair. Patient A (a blind female) was interviewed and initially stated her roommate (another female patient) touched her private area, on her breasts (under her shirt) and on the inside of her thighs. Patient A also stated this person took her hands and pulled them toward the front of their own body. Patient A's roommate was interviewed on August 18, 2010, and stated, the man in their room (Patient B), was the one who touched Patient A. The Interdisciplinary Team (IDT) concluded Patient B touched Patient A in a sexually inappropriate manner. A police report was made. Patient B was placed on 1:1 monitoring and transferred out of facility. Patient A was monitored for any changes resulting from the incident. On September 8, 2010, at 9:30 a.m., the Director of Nurses (DON) was interviewed. The DON stated Patient A was legally blind and could not see who was touching her. The DON stated Patient B was admitted from a psychiatric facility with a history of inappropriate sexual behavior, but was told his behaviors were now controlled with medication. On September 8, 2010 the record for Patient B was reviewed. The record indicated Patient B was admitted from a General Acute Care Hospital (GACH), geropsych unit (a unit in the hospital where psychiatric conditions in the elderly are treated) on July 30, 2010. The H&P, dated July 8, 2010, and the Psychological Evaluation, dated July 10, 2010, from the GACH was reviewed. The History and Physical (H&P) indicated Patient B had a history of aggressive behavior and made inappropriate sexual advances towards other patients. Patient B's Psychiatric Evaluation, dated July 10, 2010, indicated, "Patient has a long history of psychiatric illness and has previously been diagnosed with schizoaffective disorder... Patient currently does have breakthrough thoughts of wanting to hurt people. The patient also has hypersexual problems respecting boundaries. The patient is responding to both auditory and visual hallucinations... Symptoms are confusion, disorientation, auditory and visual hallucination, labile moods, labile mood, impulsive and aggressive behavior towards other clients, sexually inappropriate behavior towards other clients, requiring monitoring and inpatient level of care." The facility admission orders included, Depakote ER 250 mg, for schizoaffective disorder, manifested by mood swings. The Nurses Notes(NN), Occupational Therapy (OT) Notes, Medication Record (MAR), 24-Hour Behavior Log, and the Social Service (SS) Assessment and Progress Notes were reviewed. The SS Assessment, dated August 2, 2010, indicated Patient B had presented with several episodes of inappropriate behavior with staff. The NN indicated, on August 3, 2010, Patient B was observed going into another patient room. On August 1, 2, and 8, 2010, Patient B was observed ambulating in the hallway with no pants on, and refusing to put them on. The MAR, dated August 8, 2010, indicated 12 occasions of sexually inappropriate behavior were observed. The OT notes, dated August 9, 2010, indicated Patient B was grabbing at the OT therapist in an inappropriate manner multiple times, at which time the charge nurse was notified. The NN, MAR, and 24-Hour Behavior Log, indicated Patient B had sexually inappropriate behavior with staff on every day he was in the facility from the first day after admission (August 1, 2010) through the day of the incident (August 18, 2010). There was no documentation if the physician was notified of the frequency of these behaviors. Therefore, the facility failed to protect Patient A's right to be free from mental and physical abuse when Patient B entered Patient A's room and sexually abused her.These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 250000119 |
EVERGREEN ESTATES |
250013426 |
A |
29-Aug-17 |
8MWN11 |
12038 |
W 127 483.420 (a)(5) Abuse and Neglect
The facility must ensure that clients are not subjected to physical, verbal, sexual, or psychological abuse or punishment.
W 331 483.460 (c) Nursing Services
The facility must provide clients with nursing services in accordance with their needs.
The facility failed to provide Client 12 with nursing assessments and health care when:
1. An oncologist's (cancer specialist) order dated April 15, 2015, for a PET (special diagnostic X-ray) scan, to determine cancer spread, was not completed for two months. This delayed health care decisions regarding hospice and pain control;
2. There was no pain assessment to develop an individualized pain management plan for Client 12's metastatic (spreading) cancer and decubitus ulcer (pressure sore); and,
3. There was a lack of nursing assessments and follow up for a six month ongoing vaginal discharge, documented by Direct Training Staff (DTS), from January 2015 to June 2015.
On June 19, 2015, at 9:15 a.m. an investigation was initiated for an entity reported incident (ERI) CA00447367. Client 12's record was reviewed. Client 12 was admitted on XXXXXXX 1981, with diagnoses including profound mental retardation and osteoporosis (thinning and painful bones). A left breast mastectomy was performed in 2005.
1. On June 19, 2015, at 10:15 a.m., the "Nursing Notes," were reviewed regarding Client 12's breast cancer and included the following:
March 26, 2015, "...Client 12 had a mammogram done March 24, 2015, the results were abnormal... Physician ordered a breast biopsy." On April 15, 2015, a CT/PET scan (special diagnostic X-ray), was ordered to determine if cancer had spread. On May 15, 2015, a CT (Computerized Tomography X-ray) scan indicated the cancer had spread to the bones, lungs, and possibly the urinary bladder.
In a concurrent interview, the Registered Nurse (RN) acknowledged the PET scan was not followed up with and scheduled until June 17, 2016, a two month delay (The PET scan would determine the cancer spread, prognosis (likely outcome), and pain location). The results would indicate if hospice care (to relieve pain, provide comfort) or surgery was recommended.
The RN stated when the oncologist first ordered the test on April 15, 2015, the oncologist did not write the order with the correct billing codes. The RN stated she called the oncologist to request the proper documentation. The RN stated did not document she made any calls to the oncologist. She stated the oncologist again ordered the PET scan May 20, 2015, and once again did not write the order with billing codes. The corrected forms were obtained two months later, on June 17, 2015. The request was then submitted to Client 12's insurance for approval.
On June 19, 2015, at 10:40 a.m., during an interview with the RN and Qualified Intellectual Disability Professional 3 (QIDP 3), they stated the Interdisciplinary Team met on May 26, 2015, when Client 12's sister requested hospice care. The Inland Regional Center indicated they could not advocate hospice care at that time because they were awaiting the PET scan results. The hospice decision was delayed until the physician ordered hospice June 16, 2015, a three week delay after the family requested hospice care.
On July 8, 2015, at 8:30 a.m., the RN stated, "I could not make it to the May 26, 2015, IDT meeting. There was another IDT meeting June 18, 2015, but I was not there either. I had other engagements."
The facility failed to ensure nursing followed up to obtain a physician ordered PET scan for Client 12, which led to a delay in treatment options for the client. This delay in the facility follow up contributed to Client 12's pain and suffering being prolonged.
Client 12 expired on June 21, 2015, before the PET scan could be performed.
2. On June 19, 2015, the Interdisciplinary Notes, written by Direct Care Staff (DCS) for Client 12 were reviewed. The notes documented:
January 15, 2015, "... Staff noticed a sore on the left buttock."
January 23, 2015, "... Screaming loudly at dinner, hitting her thighs, rubbing face."
March 23, 2015, "... Up whole night crying, shaking side rails."
March 24, 2015, "... Crying all night."
April 14, 2015, "...Started Remeron (a sleeping medication), 7.5 mg at bedtime."
(The sleeping medication was ordered 21 days after the documented, "crying all night.")
April 15, 2014, "Crying during night."
May 15, 2015, "Screamed and cried 5 minutes after wound dressing change, her wound looked bigger."
June 16, 2015, "...Did not want staff to touch her; she kept pushing staff away every time staff would change her. She would cry even to move her to adjust her to the right position. She would stiffen up and cry."
June 17, 2015, "...Seen today by oncologist (cancer specialist)...recommend that she see pain management."
June 17, 2015, "...Became a little agitated today when staff tried to get her up for dinner. She became aggressive and bit her hand."
June 18, 2015, "...Very resistive today...while putting her in the wheelchair she held on to the arms of the Hoyer (equipment to assist with lifting) and would not let go...she becomes very stiff."
In an interview with DCS 10, on July 7, 2015, at 3:50 p.m., DCS 10 stated, "When we would change the dressing for Client 12, she would cry, sort of loud. You could tell she was in pain. Later, she would cry even to dress or shower. She only had the Tramadol (pain medication), and she had that before, for her back pain. We would call the RN... she did not discuss something for pain before the dressing change....We would call the nurse almost every day...especially April and May, (2015), when it got worse."
In an interview with DCS 6 on July 8, 2015, at 2:50 p.m., she stated, "I have worked here five years. I think she was in pain once she got the sores (decubitus ulcer). She (Client 12) would cry like a baby. We'd be out in the living room, and we could hear her crying in her room, that's how we knew she was in pain. I know a couple of times in the past she fell and did not cry. I would say to myself, "What a trooper she is," so when she cried now, I knew she was in pain ... We told the nurse ...we did not get advice. I felt I needed more training before giving a Tylenol (acetaminophen brand pain reliever) prn (as needed). Especially since Client 12 was nonverbal."
In an interview with DCS 14 on July 8, 2015, at 3:00 p.m., she stated, "We all told the nurse about the pain. I think it was her (Client 12)'s whole body that was sore. The RN told us to chart in our notes, and she would see Client 12 the next morning. I usually wasn't here when she came in. It was frustrating; it was so hard to move Client 12. My personal opinion, Client 12 should not have been here. She required 1:1 care."
In an interview on July 8, 2015, at 8:30 a.m. with the RN, she stated, "I never trained the DCS about the pain, what to look for, and when to call. I do not know why a pain management plan was not put in place... I told the DCS, before you change her dressing, give her pain medication, the Tylenol, I do not know if I wrote it, or if it was just word of mouth. I know Tramadol would not cut it, or even Tylenol, but that is all we had... The staff did not say she looked like she was in pain."
The RN added, "When they call me, I am at home. If I am around, I will come by. I am here three to four days a week."
In a record review on July 8, 2015, there was no RN assessment of Client 12's increased pain. There was no nursing care plan for the increased pain. There was no indication the physician was notified of the client's increased pain level or any orders for pain management.
The facility failed to ensure Client 12's need for pain management was not neglected, which lead to the client experiencing increased pain related to the wounds and the client's cancer progression with no indication the facility made an effort to address the client's increased pain level. This lead to the client displaying symptoms of pain such as moaning, crying, and screaming, with no relief offered to her for this pain.
3. On June 25, 2015, Client 12's health record was reviewed. The Interdisciplinary Team (IDT) notes, by Direct Care Staff (DCS), the Nursing Notes, and Physician Orders were reviewed regarding Client 12's vaginal discharge. The IDT notes indicated the following:
January 20, 2015, "Gray vaginal discharge with a very foul odor...RN called...stated to observe if it happens again;"
January 21, 2015, "Same gray discharge, very bad odor;"
January 28, 2015, "Vaginal discharge thick, dark yellow and foul odor...RN notified, said to monitor;"
January 29, 2015, "Noted discharge at all diaper changes with very foul odor...RN notified, said to monitor;"
February 2, 2015, "More discharge from vagina, dark yellow, really bad odor...RN saw it, said keep monitoring;"
February 8, 2015, "Yellow, green discharge from vaginal area, really bad odor;"
February 10, 2015, "Staff noticed yellow, green discharge from vagina with foul odor. RN notified;"
March 11, 2015, "Still has discharge coming from vagina, and it has a bad odor;"
March 16, 2015, "Still had a very bad odor from her vagina due to her discharge;"
March 19, 2015, "Still has discharge coming from her vagina, and it has a bad odor; " and,
May 6, 2015, "Still has vaginal discharge and a bad odor."
During the months of February and March, 2015, the DCS documented Client 12's vaginal discharge on six occasions. There was no treatment ordered for Client 12's vaginal discharge in February or March, 2015.
In an interview with DCS 10 on July 7, 2015, at 4 p.m., she stated, "...The smell was really bad, the color was dark grayish. It kept coming back. The nurse would say, "Monitor." We (the DCS) were all upset. Why didn't they try something that would work? Why not take her to the MD?"
In an interview with DCS 6 on July 8, 2015, at 2:55 p.m., she stated, "The discharge was a foggy gray, and had a foul odor to it. I always noticed it when I changed the diaper. It would stop, and then come back. Every time we called the nurse she said to, "Monitor it," or, "The doctor would be coming." I wondered, OK, what am I to monitor? ...After a while we didn't bother to document it, it was always the same...staff would talk among themselves, why isn't more being done? ..."
On July 8, 2015, at 8:30 a.m., a "Nurses Notes" record review, and concurrent interview was conducted with the RN.
The RN confirmed the only nursing note documenting Client 12's vaginal discharge was on February 2, 2015, which indicated, "Yellowish discharge is noted from vagina with a foul smell."
The RN verified Client 12 was not transported to the physician's office for the vaginal discharge.
The RN stated, "Once a week they (DCS) would call me, but when I would come I could not see it." The RN confirmed she had not documented her observations.
The RN verified:
1. There was no training provided to DCS about what to monitor for the vaginal discharge; and,
2. There was no nursing care plan for the vaginal discharge.
The facility failed to ensure the RN assessed Client 12 after frequent reports of a foul smelling vaginal discharge. In addition, the RN failed to provide in-service training for the DCS on what they should monitor for the vaginal discharge.
Client 12 suffered pain and physical harm due to the facility's failure to obtain needed tests for the extent of the client's cancer, failure to assess the client for pain levels and acquire appropriate/ adequate pain control, and failure to ensure a nursing assessment was conducted and the RN provided oversight of treatments for the vaginal discharge for six months.
The violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000129 |
EMERALD TERRACE CONVALESCENT HOSPITAL |
910010414 |
A |
06-Feb-14 |
KYRO11 |
9210 |
483.25F309 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 September 13, 2011, at 12:45 p.m., an unannounced visit was made to the facility to investigate a complaint alleging that when Patient C turned blue and went into cardiac arrest, the nurses did not call emergency medical services (911) in a timely manner. On August 30, 2011, when Patient C was found pale with shallow breathing, low blood oxygen saturation, a slow heart rate and low blood pressure, the facility failed to: 1. Administer oxygen at a flow rate to maintain Patient C?s blood oxygen saturation (a measurement of how much oxygen the blood is carrying) at a rate above 90 percent to prevent respiratory distress (patient is unable to get enough oxygen).2. Call 911 as soon as a life threatening situation involving Patient C was discovered.As a result, Patient C went into cardiac arrest, cardiopulmonary resuscitation (CPR) was performed, paramedics were called but could not revive Patient C, who was pronounced dead at 4:35 a.m. at the facility. A review of Patient C?s admission record indicated a 56 year-old female was admitted to the facility on September 21, 2004, with diagnoses that included, anemia (low blood count), peptic ulcer disease (a sore in the inner lining of the stomach or upper small intestine), malnutrition and arthritis. The Minimum Data Set (MDS) a standardized assessment and care screening tool dated July 4, 2011, indicated the patient had intact cognitive skills for daily decision making.A review of the Licensed Personnel Progress Notes, dated August 30, 2011, at 4 a.m., indicated Patient C was noted to be very pale with a shallow breathing.According to the documentation, the patient had a blood pressure of 80/50 (normal 120 to 139/80 to 89), heart rate fluctuated from 45 beats per minute (bpm) down to 35 bpm (normal 80 to100) and her oxygen saturation was 50 to 55 percent on a room air (normal range is 95 to 100 percent).The patient was administered oxygen at two liters per minute through a nasal cannula (a device used to deliver oxygen through two small tubes that are inserted into the nares), which increased her oxygen saturation to 60 to 65 percent, but was still below a normal range. There was no documentation regarding the patient?s respiratory rate. According to the Licensed Personnel Progress Notes, dated August 30, 2011, at 4:15 a.m., Patient C was observed to be unresponsive and not breathing. The patient?s oxygen saturation was 30 percent while receiving oxygen at two liters per minute through a nasal cannula, her vital signs could not be obtained, CPR was started and 911 was called. Paramedics arrived at the facility at 4:30 a.m., and pronounced the patient dead at 4:35 a.m.On September 13, 2011, at 3:55 p.m., during an interview, licensed vocational nurse 3 (LVN 3) stated that at approximately 4 a.m., she went to Patient C?s room and observed that she was pale. She asked the patient if she was o.k., the patient grunted. She took the patient?s vital signs, which were blood pressure 80/50.LVN 3 stated she did not document the quality of the patient?s respiration or the rate, but remembered they were shallow at approximately 30 to 45 breaths per minute. She stated the patient?s oxygen saturation did not register on the machine initially, but it eventually indicated 50 to 55 percent on a room air.LVN 3 then asked certified nursing assistant 2 (CNA 2) to get the oxygen tank, and LVN 3 administered oxygen to Patient C at two liters per minute through a nasal cannula. LVN 3 stated the patient?s oxygen saturation increased to 60 to 65 percent, but began to decrease again until it no longer registered on the machine. She tried to attain the patient?s heart rate with a stethoscope, but could not get one. She then asked CNA 1 to call 911. After a couple of minutes she looked outside the door of the patient?s room and CNA 1 told her that 911 had put her on hold.LVN 3 stated she left Patient C's room and called the physician, left a message and then called 911. She stated she left CNAs 2, 3 and 4 with Patient C, performing CPR.LVN 3 stated she was afraid to administer oxygen higher than two liters per minute because she did not know if the patient had any lung problems. She stated she should have designated staff to call 911 immediately when she first discovered Patient C with shallow breathing, abnormal oxygen saturation, an abnormal heart rate, and low blood pressure. A review of Patient C?s clinical record with LVN 3 revealed there was no documented evidence the oxygen flow rate was increased when the patient?s oxygen saturation was not improved with the oxygen at two liters per minute. According to the facility?s policy on Oxygen Emergency Administration, dated October 2010, the purpose is to provide emergency oxygen administration when the patient is found to be unconscious, pulseless, or no signs of breathing. Administer oxygen at two to three liters per minute initially and closely monitor for oxygen saturation improvement, increase oxygen administration to six liters per minute if it is not contraindicated.On September 13, 2011, at 3:47 p.m., during an interview, CNA 1 stated that on August 30, 2011, at approximately 4:15 a.m., LVN 3 asked her to call 911, which she did, but was put on hold for a couple of minutes. CNA 1 stated LVN 3 came out of Patient C?s room, called the patient?s physician, and then called 911.On September 22, 2011, at 1:30 p.m., during a telephone interview, CNA 4 stated that at approximately 4 a.m., he was called to Patient C?s room by a CNA. When he got into the patient?s room, LVN 3 was putting a device on Patient C?s finger. LVN 3 instructed him to get the hard board and instructed CNA 2 to get the oxygen tank. When he returned to the room, LVN 3 was doing chest compressions but asked him to take over and LVN 3 left the room. CNA 4 stated he, CNA 2 and CNA 3 were left in the room with the patient to continue CPR until the paramedics arrived.A review of Patient C?s clinical record with LVN 3 revealed there was no documented evidence the nursing staff called 911 immediately after the patient?s condition of a life threatening situation was discovered. Instead, it was documented the nursing staff called the patient?s physician and left a message. According to the American Red Cross Guidelines for emergency cardiovascular care 911 should be called as soon as a life treating situation (such as difficulty or no breathing, chest pain, unconsciousness or discomfort lasting more than five minutes associated with bleeding) is discovered (Standard First Aid Guidelines, 2010). A review of the Prehospital Care Report Summary, by the Los Angeles Fire Department (LAFD), dated August 30, 2011, indicated the following:Call Received: at 04:25:10 (25 minutes after Patient C was found in respiratory distress). Dispatched: at 04:26:20 En Route: at 04:27:48On Scene: at 04:31:00 (arrived to facility 6 minutes after call received) Patient Contact: at 04:32:00 Left Scene: at 05:02:00 According to the LAFD report the resident?s initial assessment indicated the following: Airway: Patent (open) Breathing ? Rate: Apneic (cessation of breathing), Quality: (left blank) Lung Sounds: Left: Absent, Right: Absent Skin ? Color: Pale, Temperature: Cool, Condition: Dry, Capillary Refill: AbsentEdema: None Pupils ? Left: Unreactive, Right: Unreactive Glasgow Coma Score - (a method used to determine a patients conscious state ranging from 3-15 a score of 3-8=coma): Eye opening (E) =1, Verbal Response (V) =1, Motor response (M) =1. Total Score =3 AVPU (alert, voice, pain, unresponsive): Unconscious Rhythm: 1: Asystole (no heart activity) Rhythm 2: AsystoleAccording to the LAFD report the resuscitation was not initiated at the scene due to obvious signs of death, resuscitation considered futile.Patient found in bed with positive (+) lividity (pooling of blood that begins 20 to 30 minutes after the heart stops), absence of apical pulse for 60 seconds, absence of breath sound for 30 seconds, absence of neuro response, absence of response to painful stimuli, pupils fixed/dilated, determined death at 4:35 a.m. On August 30, 2011, when Patient C was found pale with shallow breathing, low blood oxygen saturation, a slow heart rate and low blood pressure, the facility failed to: 1. Administer oxygen at a flow rate to maintain Patient C?s blood oxygen saturation (a measurement of how much oxygen the blood is carrying) at a rate above 90 percent to prevent respiratory distress (patient is unable to get enough oxygen).2. Call 911 as soon as a life threatening situation involving Patient C was discovered.As a result, Patient C went into cardiac arrest, cardiopulmonary resuscitation (CPR) was performed, paramedics were called but could not revive Patient C, who was pronounced dead at 4:35 a.m. at the facility. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 920000062 |
EISENBERG VILLAGE |
920013202 |
A |
16-May-17 |
None |
9566 |
CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
CFR 483.25 (h) Accidents
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 11/18/16, at 11 a.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI) regarding Resident 1 sustaining a fall resulting in fractures.
Based on interview and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including:
1. Failure to ensure Resident 1, who required extensive assistance with transfers and walking, who was assessed as high fall risk due to confusion and poor safety awareness, and who manifested episodes of restlessness and attempts to get out of the wheelchair, was provided with the necessary supervision and assistance to prevent accidents.
2. Failure to implement the facility?s policy and procedure on Fall Risk Management by not providing Resident 1 with adequate supervision.
3. Failure to implement a plan of care for the use of the medication Ativan (for anxiety or nervousness) by not monitoring Resident 1 for side effects that placed the resident at increased fall risk.
As a result, on 11/2/16, while left unattended in the dining room, Resident 1 fell and sustained fractures to the left wrist and left thigh bone (hip area), and required surgery to repair the left hip fracture and a long cast to the left arm.
A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX16, and re-admitted on XXXXXXX16, with diagnoses including osteoporosis (a condition in which the bones become weak and brittle), dementia (a progressive decline in memory and at least one other cognitive area, such as attention, orientation, judgement, abstract thinking and personality), Alzheimer's disease (a brain disorder that slowly destroys memory and other important mental functions), and anxiety (feeling of worry, nervousness, or unease).
A review of the Minimum Data Set (MDS ? a standardized assessment and care planning tool) dated 9/7/16, indicated Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and required extensive assistance with transfers, walking, and toilet use.
A review of a care plan developed on 6/2/16 and updated on 9/27/16, for Resident 1?s risk for falls related to poor safety awareness, dementia and decreased mobility, had a goal for the resident to be free from falls or injury. The interventions included keeping the environment free from safety hazards.
According to a care plan developed on 7/21/16 and updated on 9/27/16, for Resident 1?s behavioral symptoms manifested by restlessness and trying to get out of the wheelchair, the intervention included staying and talking to the resident one to one.
A Fall Risk Predictive Factors Assessment dated 9/6/16, indicated Resident 1 was at high risk for falls due to impaired mobility, poor recall ability, judgement and safety awareness. Resident 1 required the use of a wheelchair as an assistive device.
A review of the psychiatric visit note dated 9/9/16, indicated a recommendation for Ativan (antianxiety medication to calm, moderate, or tranquilize nervousness) 0.5 milligrams (mg) every six hours as needed for irritability and restlessness.
According to Nurses Drug Guide, 2017, the side effects of Ativan include drowsiness, sedation, dizziness, unsteadiness, and disorientation.
According to an Interdisciplinary Team (IDT) notes for Psychoactive (medication that affect the mind) Follow up dated 9/28/16, Resident 1 had increasing anxiousness and poor safety awareness.
A review of the medication administration history (MAH) from 10/1/16 to 11/1/16 indicated Resident 1 received Ativan a total of 37 times (more than one Ativan a day), but there was no documentation in the MAH or in the clinical record to indicate nursing staff was monitoring Resident 1 for the presence of side effects from the Ativan.
According to a nursing progress note dated 11/2/16, timed at 10:26 a.m., licensed vocational nurse 3 (LVN 3) documented the activity director (AD) found Resident 1 in the dining room on the floor, lying on her left side with the left arm underneath her, approximately eight feet away from her wheelchair. LVN 3 documented Resident 1 complained of severe pain to the left shoulder and was unable to move left leg. The physician was notified and ordered to transfer Resident 1 to a general acute care hospital (GACH) via 911 (emergency rescue team).
On the same day, at 3 p.m., Resident 1 returned to the facility with a left wrist splint and continued complaints of pain. At 4:09 p.m., the nursing note indicated Resident 1 was unable to move and had severe pain to left leg. The physician ordered X-ray to the left leg. At 11:30 p.m., the physician was notified the X-ray results showed a fracture to the left proximal femur (fracture to the upper part of the thigh bone - hip). The physician ordered again to transfer Resident 1 to the GACH via 911 due to left femur fracture.
According to the GACH X-ray report of the left wrist, dated 11/2/16, Resident 1 had an intra-articular fracture of the distal left radius [fracture that extends into the wrist joint towards the end of the radius (forearm) bone].
According to the GACH X-ray report of the left hip, dated 11/3/16, Resident 1 had an intertrochanteric comminuted fracture of the left proximal femur (fracture to the upper part of the thigh bone into more than two fragments).
A review of the Operating Room note dated 11/4/16 indicated Resident 1 went to surgery for a left hip fracture and had a closed reduction with intramedullary rodding (reducing a fracture without making an incision in the skin and rods were used to align and stabilize the broken bones), and a long arm cast was placed to the left upper extremity.
On 11/18/16, at 11:32 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 was alone in the dining room when AD found her on the floor. The DON stated staff is instructed to stay with the residents when in the dining room.
On 11/18/16, at 11:45 a.m., during an interview, AD stated when she entered the dining room, she found Resident 1 on the floor and there was no staff in the room.
On 11/18/16, at 12:15 p.m., during an interview, LVN 1 stated she was in the medication room when she received a call regarding Resident 1's fall in the dining room. LVN 1 stated, "There is always staff in the dining room with the residents, but in that moment AD had left and was on her way back when the fall happened." LVN 1 stated Resident 1 usually remained with staff because the resident had a "tendency to try and move herself out of her wheelchair."
On 2/27/17, at 10:14 a.m., during another interview, the DON stated there was no routine monitoring for the Ativan side effects but should be monitored and captured in the nursing weekly summary reports.
A review of the facility's policy and procedure titled, "Fall Risk Management," dated 12/2014, indicated the purpose of the policy was to make every reasonable effort to ensure each resident received adequate supervision.
The facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including:
1. Failure to ensure Resident 1, who required extensive assistance with transfers and walking, who was assessed as high fall risk due to confusion and poor safety awareness, and who manifested episodes of restlessness and attempts to get out of the wheelchair, was provided with the necessary supervision and assistance to prevent accidents.
2. Failure to implement the facility?s policy and procedure on Fall Risk Management by not providing Resident 1 with adequate supervision.
3. Failure to implement a plan of care for the use of the medication Ativan (for anxiety or nervousness) by not monitoring Resident 1 for side effects that placed the resident at increased fall risk.
As a result, on 11/2/16, while left unattended in the dining room, Resident 1 fell and sustained fractures to the left wrist and left thigh bone (hip area), and required surgery to repair the left hip fracture and a long cast to the left arm.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 940000044 |
EL RANCHO VISTA HEALTH CARE CENTER |
940010271 |
B |
19-Nov-13 |
3Y5H11 |
10410 |
T22 ?72321Nursing Service- Patients with Infectious Diseases. (b) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. On 10/7/13 at 12:20 p.m., an unannounced visit was made to the facility regarding a complaint alleging that Patient A had a scabies infection.Based on observation, interview, and record review, the facility failed to implement established infection control policies and procedures by failing to: 1. Consult the dermatologist (a doctor who specializes in treating conditions that affect the skin, hair, and nails) promptly for diagnostic confirmation of symptomatic case of scabies after Patient A was re-admitted to the facility from the acute hospital with skin itching and rashes on 9/5/13. Patient A was seen by a dermatologist on 9/30/13 which was 25 days after re-admission.2. Place the resident on isolation to protect other patients, staff and visitors from scabies. Patient A was placed in a room with two other patients on admission.3. Develop a tracking record of patients arranged chronologically with onset of signs, symptoms and exposures. The record indicated a list of all affected patients and staff members with and without signs and symptoms of scabies infection.Failure to consult the dermatologist promptly resulted in delayed confirmation of Patient A's scabies infection and delayed the control and prevention of the scabies infection to other patients in the facility. As a result, 13 (excluding Patient A) out of a total of 83 patients and six facility staff members exhibited the signs and symptoms of skin rashes and/or itching and were later treated with Elimite (a medication applied to the skin to treat scabies).On 10/7/13 at 1:20 p.m., during a tour of the facility, Patient A was observed sitting in a wheelchair in the hallway near Nurses' Station 2. The patient's skin between his fingers was dry and crusty. The patient stated during an interview that he had rashes and itching around the neck area.On 10/7/13 at 1:40 p.m., during an interview, the director of nursing (DON) stated that Patient A was re-admitted from the acute hospital on 9/5/13 with severe dryness of the skin. The DON stated that the facility continued treating him with hydrocortisone (a medication applied to the skin to treat skin irritation, allergic reactions, and other types of skin problems) and Atarax (a medication taken orally to treat anxiety disorders and allergic skin conditions) and the patient's attending physician was notified of his condition. The DON also stated that on 9/12/13, the facility scheduled to have Patient A seen by a dermatologist on 9/18/13 because his skin condition was not improving. The DON further stated on 9/18/13, that the dermatologist did not evaluate and treat Patient A due to lack of co-payment from her family. On 9/24/13, the facility again notified the patient's attending physician due to Patient A?s persistent itching. On 9/28/13, the attending physician ordered Elimite cream for the patient and for his roommate (Patient B), who was also complaining of rash and itching. The DON stated that on 9/30/13, the facility got a new dermatologist, who diagnosed Patient A as having non-classic scabies (Norwegian scabies). Prophylaxis (action or treatment taken against scabies) was provided and the County Public Health Department was notified of an outbreak of scabies in the facility. A review of Patient A's admission sheet indicated that the patient was initially admitted to the facility on 11/8/12 and was readmitted on 9/5/13 with diagnoses which included malaise and fatigue, muscle weakness and Dyshidrosis (a skin condition in which small blisters develop on the soles of the feet and/or the palms of the hands). A review of the acute care hospital History and Physical report, dated 9/2/13, indicated that Patient A's past medical history also included dermatitis (an itchy inflammation of the skin that is not contagious but can be uncomfortable) to both legs and had also been having persistent itching in the legs. According to the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 9/19/13, Patient A was alert, oriented, and required extensive assistance (weight bearing support and at times requires full staff performance) from the staff to perform most of his activities of daily living.The Patient Data Collection report dated 9/5/13 indicated that Patient A was re-admitted to the facility with generalized dermatitis and skin dryness to both upper and lower extremities. According to the census log dated 9/5/13, Patient A was placed in a room where his bed was located in between two other patients, including Patient B in Bed-B.A review of the Non-Pressure Skin Condition Report indicated that on 9/5/13, Patient A had dry, leathery skin and was complaining of itching at the time of his re-admission to the facility. Further review of the Non-Pressure Skin Condition Report indicated that on 9/12/13, the patient was scheduled to see a dermatologist on 9/18/13. On 9/18/13, the patient came back from the dermatologist's office without being evaluated due to an insurance issue. There was no documented evidence that the attending physician was notified. On 9/24/13, six days later, the patient was scratching and was complaining of itching. Four days later, on 9/30/13, the patient was seen and examined by a new dermatologist and was diagnosed with scabies. Patient A was seen by a dermatologist 25 days after re-admission. In an interview on 10/8/13 at 2:50 p.m., the DON and the administrator stated the following: That out of the total census of 83 patients at the time of the scabies outbreak; One (1) patient was confirmed with a clinical case of scabies and was treated with Elimite, 13 patients (excluding Patient A) and six (6) facility staff members had signs and symptoms of rashes and/or itching and were treated with Elimite and a total of 70 patients and all the rest of the staff, who were not having signs and symptoms of rashes were prophylactically treated.A review of the facility's Scabies Case/Contact Line-Listing Record dated 9/30/13 did not indicate that a tracking of patients arranged chronologically with onset of symptoms and exposures was established according to their policy and procedure. The record indicated a list of all affected patients and staff members with and without signs and symptoms of scabies infection.http://www.publichealth.lacounty.gov/acd/procs/b73/DiseaseChapters/B73Scabies.pdf REVISION-FEBRUARY 2013 Norwegian, atypical or crusted scabies are the terms used to designate a severe infection with the same mite that causes typical scabies. Crusted scabies is characterized by unusual skin manifestations such as scaling or thickening of the skin. A single case of atypical/crusted scabies in a healthcare facility (non-acute care) is defined as an outbreak. Investigate single cases of atypical (crusted Norwegian) scabies and known or suspected outbreaks of regular and crusted scabies. Initiate evaluation within 24 hours. CASE: 1. Isolation: DIAGNOSTIC PROCEDURES Skin scraping. Microscopic demonstration of the mite, ova, or fecal matter obtained from a skin scraping and/or based on clinical signs and symptoms. A negative skin scraping does not conclusively rule out scabies infestation. Mites are easily recovered, however, in skin scrapings from persons with atypical or crusted scabies.According to the facility's policy and procedure (P&P) titled, "Prevention and Control of Scabies in California Long-Term Care Facilities," dated March 2008, stipulated that the facility should conduct an assessment of the skin, hair, and nail beds of all new admissions as soon as possible following arrival. Pruritus (itching), rashes, and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. The P&P stipulated for atypical scabies infestation, to place the resident(s) on isolation precautions in a private room and for crusted or keratotic scabies, to place symptomatic resident on contact isolation precautions in a private room until at least three negative skin scrapings have been documented. The P&P stipulated that, as soon as a possible case of scabies is identified, the infection control practitioner should develop a contact identification list. This list should identify every resident (patient), health care worker, visitor, and volunteer who may have had direct, physical contact with the case within the previous month.In summary, the P&P indicated that once a suspected or a symptomatic case of scabies is identified, appropriate diagnostic procedures should be performed. Controlling the transmission of scabies once a case has been identified required immediate action. Contacts must be identified, isolation precautions must be implemented, and a determination of who should be treated must be made. During an interview on 10/15/13 at 4:40 p.m., the DON and the facility administrator acknowledged the need to ensure that a suspected case of scabies is identified timely so as to control and prevent the transmission and spread to other facility patients, staff, family members and visitors. The facility failed to implement established infection control policies and procedures by failing to: 1. Consult the dermatologist (a doctor who specializes in treating conditions that affect the skin, hair, and nails) promptly for diagnostic confirmation of symptomatic case of scabies after Patient A was re-admitted to the facility from the acute hospital with skin itching and rashes on 9/5/13. Patient A was seen by a dermatologist on 9/30/13 which was 25 days after re-admission.2. Place the resident on isolation to protect other patients, staff and visitors from scabies. Patient A was placed in a room with two other patients on admission.3. Develop a tracking record of patients arranged chronologically with onset of signs and symptoms and exposures. The record indicated a list of all affected patients and staff members with and without signs and symptoms of scabies infection.The above violation had a direct or immediate relationship to the health, safety, or security of all patients and staff members in the facility. |
| 960001457 |
EL ENCANTO HEALTHCARE AND HABILITATION CENTER |
940011312 |
A |
18-Mar-15 |
XCO611 |
12033 |
? 72311 (a) (1)(C) 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: (C) Reviewing, evaluating and updating of the patient?s care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient?s condition. The Department received an entity reported incident (ERI), dated August 29, 2013. According to the ERI, on August 27, 2013, Patient A was being assisted with her shower by a certified nurse assistant (CNA1). CNA1 observed the patient?s left inner ear was dark purple in color and her left shoulder had a light purple discoloration. The ERI report indicated the patient told CNA1 she had fallen several days prior. On August 28, 2013, the patient was sent to the GACH for further evaluation and treatment. On September 19, 2013, an onsite investigation was initiated; a follow-up investigation was conducted on November 13, 2014, and concluded on February 26, 2015. Based on interview and record review and interview, the facility failed by not: 1. Revising Patient A?s care plan after each fall to address the care needed to prevent further falls after the previous plan of care failed to prevent the patient from falling. 2. Creating a care plan for Patient A?s after there was a change of condition which included decreased ability to walk. These failures resulted in Patient A falling again and being diagnosed with a fractured pelvis requiring transport to a general acute care hospital (GACH). Patient A had a history of three falls over a six month period, (February 24, 2013 to August 27, 2013). On August 14, 2013, Patient A was identified as having a change in condition that affected her walking and the facility failed to create a plan of care.A review of the facility?s investigation report, dated August 29, 2013, and timed at 7 p.m., indicated Patient A was being assisted with her shower and CNA1 noticed the patient?s left inner ear was dark purple in color and the left shoulder had a light purple discoloration. The investigation report indicated the patient told CNA1 she had fallen several days prior. The report also indicated on August 28, 2013, the patient was assessed by the physician and an order to transfer the patient to the GACH for evaluation was written.A review of Patient A?s medical record face sheet indicated the patient was a 82 year-old female, who was initially admitted to the facility on May 11, 2004. Patient A?s diagnoses included seizure disorder (a condition in which the neurons in the brain function abnormally, resulting in sudden, brief changes in the brain), hypertension (high blood pressure), asthma (a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms) and Lumbago (common disorder involving the muscles and bones of the back resulting in low back pain).According to the Minimum Data Set (MDS) an assessment and care screening tool, dated June 26, 2013, the patient was alert with no memory problems. The MDS indicated the patient required limited assistance and set-up help only with walking in her room and corridor. The MDS indicated the patient was not steady, but was able to stabilize without staff?s assistance while moving from a seated to a standing position, walking, turning around, and moving on and off the toilet and transferring from the bed to chair or wheelchair.A review of the incident reports for Patient A?s past falls indicated the patient had the first fall on February 24, 2013. The report indicated at 11:25 a.m., on February 24, 2013, the patient was heard calling for help and when staff arrived, they found the patient sitting on her buttocks on the floor in front of her closet. The report indicated the patient complained of mild pain to her buttocks. The staff?s plan was to remind the patient to use the call light when needing assistance and to check on the patient even though she was independent, and to anticipate the patient?s needs.A care plan titled, ?Resident Short Term Care Plan? dated February 24, 2013, with a target date February 27, 2013, indicated the patient vitals would be done every shift for 72 hours, monitor change of condition and level of consciousness, monitor for adverse reaction of fall, monitor for pain and discomfort, put the bed in lowest position, call light within reach, hourly checks withy verbal reminders to use call light for assistance, post-fall screening by the rehabilitation department, post fall medication review by pharmacy if indicated and monitor for any adverse reaction form fall and report to physician. However, there was no evidence of an entry update on the long term care for the February 24, 2013 fall.Patient A had a second fall on March 31, 2013. The incident report, dated the same day, and timed at 11:45 p.m., indicated a CNA noted discoloration with swelling to the patient?s right lower leg. The report indicated the patient told the staff she had fallen two days prior. The report also indicated on March 30, 2013, the CNA reported to the charge nurse the patient had hit her right ankle while transferring from the bed to the wheelchair. At that time, Patient A denied pain and continued with her activities of daily living (ADL). The patient?s x-rays were negative for fractures. The report indicated the corrective action was to continue with the interventions already in place.A review of the long term care plan titled, ?Resident Care Plan?, initially dated March 26, 2012, indicated the staff?s approaches was to anticipate patient?s needs, low bed with one full side rail up for bed mobility, bed wheels in locked position, monitor decreased ADL (activity of daily living), frequent visual check, out of bed daily via wheelchair, monitor side effects of medications, assist with transfers while encouraging as much independent as possible. There was no short term care plan for the fall.On August 27, 2013, the patient was identified as having a third fall. The incident report, dated the same day, indicated the patient was being assisted with her shower and CNA1 noticed the patient?s left inner ear was dark purple in color and the left shoulder had a light purple discoloration. The investigation report indicated the patient told CNA1 she had fallen several days prior. The patient was assessed and sent to the GACH as ordered by the physician.A review of the GACH?s discharge summary, dated August 30, 2013, and timed at 5:58 p.m., indicated Patient A was seen for an unwitnessed fall sustaining a bruised left ear. The chief complaint was confusion with decreased mobility. A computed tomography (CT) scan initially showed a left temporal fracture without any intracranial hemorrhage (bleeding, within the skull) and the impression was a skull fracture with altered mental status. However, the final diagnosis indicated no skull fracture. The patient was also noted to have multiple lumbar (lower back) compression fractures (compression of one bone, especially a vertebra, against another bone), chronic in appearance. The final findings were a comminuted (fracture where there are several breaks in a bone creating numerous fragments) and displaced fracture (two ends of the broken bone are separated from one another) through the left inferior pubic rami (a part of the pelvis bone) with several displaced fractures in the left inferior pubic rami, as well as a possible old fracture near the inferior pubic rami and ischium (the lower and back part of the hip bone). There was soft tissue swelling/hematoma (collection of blood outside the blood vessels, usually in liquid form within the tissue) in the musculature (muscle) adjacent to the fracture planes. The impressions were fractures with hematoma. The patient was seen by the orthopedic department who recommended pain control and weight bearing as tolerated on the left lower extremity (LLE). The patient was admitted to the hospital on August 28, 2013, for observation and discharged August 30, 2013.The care plan, dated August 30, 2013, was the same as the prior fall care plans for February 24, 2013 and March 31, 2013, with only the additional problem indicating the patient was known to go to the bathroom without calling for help. The measurable objectives were changed to include a fall will have minimal injuries, and the staff?s approach indicated the staff was to take the patient to bathroom on a toileting schedule.On November 13, 2014, at approximately 10:30 a.m., an interview with the director of nursing (DON) indicated the facility had been monitoring the patient?s falls and inputting into the care plans.A further review of the investigation report, dated August 27, 2013, indicated on August 14, 2013, the licensed nurse noted the patient was requiring more assistance with her ADLs and was incontinent of urine (leakage of urine) and reported these changes to her primary physician. According to the report, prior the patient had been able to independently stand and walk to the bathroom successfully. The reporting nurses reported they noticed a decline in the patient?s physical functioning with increased confusion, loss of previous independent ability to stand and walk to bathroom due to leg weakness. The patient was expressing a desire to stay in bed, rather than wheel herself around the hallways and go to activities. Patient A?s physician was notified. A review of a form titled, ?SBAR? (a communication and progress note for situation, background, assessment and request) dated February 14, 2013, indicated the patient had a change in condition with a decrease in bowel and bladder function and required more than the usual assistance with her ADLs. According to a review of the Restorative Progress notes for August 15 and 18, 2013, and August 21-28, 2013, the patient refused to participate in her walking therapy. According to Restorative Progress notes prior to August 15, 2014, the patient participated in walking therapy almost every day with no complaints. There was no nursing care plan for the patient?s refusal and inability to walk, only for the decrease in bowel and bladder function. According to the facility policy and procedure titled, ?Notification of Change in Resident,? the change in condition would be documented in the nursing progress notes and on the patient?s care plan.On February 6, 2015, at approximately 1 p.m., during an interview and concurrent record review, the facility?s nurse supervisor and director of medical records stated there was no care plan for Patient A?s change in condition for August 14, 2013 and they acknowledge the facility?s lack of care planning for the patient prior falls. On February 26, 2015, at approximately 10:30 a.m., the DON was asked why the February 24, 2014, fall was not included on the long term care plan to ensure accurate monitoring of Patient A?s falls. According to the DON the February 24, 2014, fall was an episode event that did not required a long term care plan. When asked why the March 31, 2014, fall was included on the long term care plan and not the February 24, 2014 fall, the DON acknowledged that the February 24, 2014, fall should have been included on the patient?s long term care plan to assist with monitoring the patient?s falls.The facility failed by not: 1. Revising Patient A?s care plan after each fall to address the care needed to prevent further falls after the previous plan of care failed to prevent the patient from falling. 2. Creating a care plan for Patient A?s after there was a change of condition which included decreased ability to walk. 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. |
| 940000044 |
EL RANCHO VISTA HEALTH CARE CENTER |
940011424 |
B |
29-Apr-15 |
None |
10068 |
The facility failed to implement their written policies and procedures, which prohibited abuse for one of 17 sampled residents (Resident 6). Resident 6 alleged, on March 7, 2015, during the 11 to 7 shift , while being cleaned, a certified nursing assistant (CNA) 1 was rough with her and bumped her head on the side rail of the bed. Resident 6 reported CNA 1 to the charge nurse, and the CNA continued to work in the same area where Resident 6 resides. On March 20, 2015, before 8 a.m., Resident 6 called the local sheriff department and reported the CNA's treatment and the allegation of abuse. This caused Resident 6 to tear up while conveying the incident of "rough handling? by a Certified Nurses ' Assistant (CNA) 1.On March 18, 2015, at 11:45 a.m., in an interview Resident 6 stated a Certified Nurses ' Assistant (CNA) 1, who worked on the 11 p.m. to 7 a.m. shift, roughly handled her over a week earlier. Resident 6 stated CNA 1 was assisting another CNA (CNA 3) to clean her perineal area (the area between the vagina and rectum) when the resident started complaining CNA 1 was cleaning her too roughly and hurting her. She told CNA 1 to stop and exchange places with the other CNA (CNA 3) which was assisting her. CNA 1 went to the other side of the bed and began to pull Resident 6 over so CNA 3 could finish cleaning her. While CNA 1 was positioning Resident 6 over on her right side the resident complained CNA 1 was pulling her left arm roughly and hit her head on the side rail. Resident 6 complained loudly and told CNA 1 she was hurting her. Resident 6 stated, CNA 1 did not stop, turned the resident over more on her right side, and hit her head again on the side rail. Resident 6 stated she told both CNA?s to stop and screamed for the charge nurse. The Registered Nurse (RN) 1 came into the room, listened to Resident 6's complaint, assessed the resident's head for injuries, and made a report to the administrator.Resident 6 medical record indicated an admission date on January 27, 2011 with diagnoses of major depression, insomnia, diabetes mellitus( high blood sugar levels), severe obesity, status post gastric bypass (surgical weight loss surgery) and amputation (surgically removing )the left second toe. On May 3, 2013, Resident 6 was diagnosed with mental disorder. An annual Minimum Data Set (MDS) a standardized assessment tool, dated January 29, 2015, indicated the resident was alert and responsive incontinent of bowel, bladder, required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and needed supervision with eating. The resident did not walk and required a mechanical lift to transfer from surface to surface.Review of Resident 6's Nurses Notes indicated an entry dated March 7, 2015 at 8:15 a.m., RN 1 wrote vital signs refused. The entry indicated Resident 6 made a cell phone call to the nurse's station to request a mild analgesic. RN 1 asked Resident 6 why she did not use her call light or call for the CNA 1. The resident told RN 1 she did all that. RN 1 documented that no call light was heard even though the call light was within the resident's reach and no staff members heard Resident 1 calling out. The Nurses Notes indicated Resident 6 told RN 1 she had a headache due to an assigned CNA who was "rough" with her and "tossed her around ". The documentation indicated the resident was yelling and cursing at the CNA to stop and be gentler. RN 1 documented he did not hear Resident 6 yelling. Resident 6 stated the "rough treatment" had been going on since the shift started. Resident 6 continued to allege CNA 1 was being rough because they do not get along.On March 7, 2015, at 2 p.m., a licensed nurse wrote an entry in the Nurses Notes, which indicated Resident 6 continued to talk about allegations of CNA 1, on the 11-7 shift, being too rough with her during care. Resident 6 told the licensed nurse "she felt dizzy and was in pain, but refused to have vital signs or her blood sugar checked?.A care plan initiated on March 7, 2015, indicated, "The resident claimed that her head was bumped on side rails during care". The goal indicated, "Will have no complications related to claims of a bumped head on the side rail during rough care". The approaches indicated, "Assess the affected areas and notify the physician of any changes, and investigate further with administrator regarding resident's claim".On March 20, 2015, at 8:00 a.m., parked in the front of the facility was a sheriff's car. On March 20, 2015, at 10:00 a.m., Resident 6 requested an interview after her morning care. At 12:35 p.m., in an interview, Resident 6 stated she had to call the police this morning (March 20, 2015, specific time not indicated) because CNA 1 was in her room again, last night, and tried to render care. Resident 6 stated when she saw CNA 1 she screamed at her, ?You are not supposed to be in here, get out of my room." Resident 6 stated CNA 1 just stared at her and did not move. Resident 6 stated she yelled out for the charge nurse and told him "CNA 1 was not supposed to be caring for me since she abused me the week before".On March 20, 2015 at 5:00 p.m., the administrator stated she knew about Resident 6's call to the police department that morning. The administrator stated, "The police came about a week old allegation of abuse. Resident 6 stated that CNA1 pulled her arm and hit her head after they (CNA1 & CNA3) grabbed her arm. I have documentation. This happened about a week ago. The administrator continued, ?On March 8, 2015, I was notified of an abuse allegation against CNA 1 that was unsubstantiated." The administrator indicated that CNA 1 and CNA 3 were rough when changing Resident 6. On the morning of March 8, 2015, RN1 was the charge nurse and worked the 11-7 shift and CNA 3 was there at 6:00 a.m. The administrator stated she asked both CNAs 1 and 3 if they had roughly handled Resident 6 and they both stated, "No?. The administrator stated, "I had CNA 1 and CNA 3 do a return demonstration (regarding patient handling), trying to work as best as possible, so Resident 6 didn't feel uncomfortable. There is a mandated reporting policy?.Review of the investigation dated March 8, 2015 indicated the administrator asked CNA 1 & 3 if they roughly handled Resident 6 and both employees stated, ?No". The administrator did not remove CNA 1 from the staffing schedule or reassign her to an area away from Resident 6.When asked about the facility's abuse policy and procedure, the administrator stated, "We report it (to the Department) and pull them (CNA's) off the shift. I understand that Resident 6 does not like CNA1 to work with her, and that is why she only has CNA3 assigned to her. On March 9, 2015, we made the determination regarding the abuse allegation against CNA 1 and it was unsubstantiated. CNA1 was off duty on March 8 and 9, 2015, but returned on Tuesday March 10, 2015. When asked if CNA1 assisted with Resident 6's care in the early morning of March 20, 2015, the administrator stated, "I don't think so." Review of the CNA staffing schedule during the 11 to 7 shift for March 19 and March 20, 2015 indicated CNA 1 was on duty and was assigned to the same area where Resident 6 resides.On March 20, 2015 at 5:15 p.m., in a subsequent interview Resident 6 stated, "You know I had to call the police (specific time not indicated). This police call was for CNA1 who hit my head on the railing. She came into the room to help. I screamed at her - she needs to leave! The other CNA (CNA3) ignored me. CNA 1 was still standing there. Registered nurse 1 (RN1) came in the room and when I told him that CNA 1 is not allowed to be in the room, he told me, 'So. All the other nurses are busy'. Resident 6's eyes began to tear up as she stated, "I would wait! I called the sheriff, because I needed to report that CNA1 could not come in my room. He (the sheriff) came in at 7:00 a.m. and left at 8:30 a.m. He talked to CNA1 and the administrator-to my knowledge. The sheriff said that it was reported and not being swept under!" According to the facility's Abuse Prevention Policy (undated) - Section II. Responding to an Allegation indicated, upon an allegation of abuse by a Facility Staff member, the Facility Staff member will be suspended and removed from the premises during the investigation. Section III. Reporting Requirements indicated, If the reportable event does not result in serious bodily injury, the Administrator, or his/her designee will make a telephone report to the local law enforcement agency with twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Department of Public Health, and the local law enforcement agency with twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse. On March 20, 2015 at 6:30 p.m., the administrator was asked if she followed the facility's abuse prevention policy and procedure. The administrator responded, "No". "I didn't suspend CNA 1 because I felt the allegation was not substantiated, so I didn't think I needed to."On March 20, 2015 at 7:30 p.m., the administrator, DON and the RN nursing consultant were informed an immediate jeopardy (IJ) was called. The facility failed to protect Resident 6 from abuse and rough handling by not following the abuse prevention policy and procedure. On March 20, 2015 at 10:10 p.m., in the presence of the administrator, DON and the RN nursing consultant, the facility submitted a plan of action (POA), which included removing the alleged staff members from resident care, physician consults, thorough investigation of any allegations of abuse, contacting the appropriate agencies of any allegations of abuse, and interviewing residents regarding abuse allegations. On March 20, 2015, at 10:10 p.m., the IJ was abated. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 6. |
| 940000044 |
EL RANCHO VISTA HEALTH CARE CENTER |
940011704 |
A |
18-Sep-15 |
None |
9145 |
? 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The Department received an entity reported incident (ERI) on 8/6/2014, alleging a patient (Patient 1) complained of chest pain after being transferred to bed by a certified nursing assistant (CNA1). The physician was notified and x-rays were ordered. The x-ray showed non-displaced 6th-8th rib fractures.An unannounced ERI investigation was conducted on 8/20/14, at 12:50 p.m., regarding quality of care issues.The facility failed by not: 1. Implementing its policy regarding transferring patients. 2. Following the Patient 1?s plan of care to prevent pathological fractures. 3. Using a gait belt for transferring patients, as stipulated in the policy.This deficient practice resulted in Patient 1, who had a history of a fracture and high risk for fractures, being improperly transferred resulting in pain requiring pain medication (Tramadol 50 mg [a narcotic-like pain reliever used to treat moderate to severe pain] every six hours around the clock [ATC]) and sustaining acute non-displaced left 6th to 8th rib fractures with swelling.A review of Patient 1's admission record indicated the patient was an 86 year-old female who was admitted to the facility on 7/14/2014. Her diagnoses included a traumatic fracture of the right lower leg and osteoarthritis (the protective cartilage on the ends of the bones that wear away over time and cause pain).A review of the plan of care, titled, ?Impaired Skeletal Function, dated 7/14/14, indicated Patient 1 had impaired skeletal function and was identified at risk for pathological (altered or caused by a disease) fractures related to osteopenia (bone loss), degenerative joint disease ([DJD]also known as osteoarthritis), and arthritis (joint inflammation which includes swelling, pain, and stiffness). The care plan indicated the staff?s intervention included to assess and observed the patient?s limited physical activities, joint limitation, and history of falls and fractures and provide assistance as needed.A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/21/2014, indicated Patient 1?s cognition was intact (the brain/mind processed information in a normal way). The patient was able to make her needs known and understand others, but required extensive assistance from staff to perform activities of daily living. According to the MDS, Patient 1 required extensive assistance to ambulate, but used a wheelchair for locomotion to get around the facility.A review of a physical therapy treatment encounter, dated 7/30/14, indicated Patient 1 was given training on proper hand/foot placement and correct pivoting technique when moving in/out of the bed while maintaining a non-weight bearing status on the right lower extremities. The patient was able to transfer in and out of the bed with maximum assist at 75 percent (%) verbal cues and 75% tactile (touch) cues from staff.A review of the physician's order, dated 8/4/14, indicated to obtain x-rays to left side of the ribs secondary to Patient 1's complaint of pain and the patient's family request.A review of the diagnostic laboratories x-ray report, dated 8/4/14, indicated Patient 1 sustained an acute (sudden or new) fracture, non-displaced (the bone is broken, but remains in place) of the left 6th to 8th ribs laterally (on the side), with mild swelling. A review of the facility's policy and procedure titled "Transfer of Patients," dated 1/1/12, indicated to use a gait belt for transferring, if gait belts were not contraindicated for the patient.On 8/20/14, at 12:40 p.m., during an observation, Patient 1 was lying in bed with a binder (an elastic fabric that fit snugly around the chest to compress and keep organs in place) wrapped around her chest. A family member (FM1) was sitting at the bed side.At 12:45 p.m., on 8/20/14, during an interview, FM1 stated Patient 1 told him she was hurt by a staff member when the staff transferred her from the wheelchair to the bed. FM1 stated as a result, the patient sustained some ribs fractures. FM1 stated he was not sure if the fracture was caused by wrong transferring techniques.At 2:40 p.m., on 8/20/14, during an interview, Patient 1 stated one day (she could not remember the exact day) around noon time, CNA1 attempted to transfer her from the wheelchair to the bed. Patient 1 stated due to her right ankle fracture, she could not stand up by herself so she asked the CNA to get another staff member to help, but CNA 1 stated the other staff members were busy, and she could do it by herself.Patient 1 stated CNA 1 helped her stand up by using her arms, grabbing her from behind the wheelchair, pulling her up and transferring her from the wheelchair to the bed. Patient 1 stated the CNA was able to transfer her to the bed, but she felt pain at her chest (rib) area. When the Patient was asked how much pain did she experience, she stated 8 on a pain scale from 0 to 10 (0 = no pain and 10 = being the worst pain). Patient 1 stated she did not complain about the pain to the CNA, but she told FM 1. She stated she informed FM1, "I think the lady who transferred me to the bed hurt me." Patient 1 stated the pain started during the transfer and it progressively increased throughout the day. The patient stated on that evening, she complained about the pain to a staff member because the pain was getting worst. She stated the next day; the doctor ordered an x-ray of her chest and the results revealed she had rib fractures.A review of the physician?s order, dated 8/4/24, indicated to administer Tramadol 50 mgs one tablet by mouth every six hours for pain ATC.A review of the Medication Administration Record (MAR) for the month of August 2014, indicated the patient received four dosages of pain medication of Tramadol each day ATC starting on August 4, 2014 and continuing for the whole month.On 8/20/14 at 3:05 p.m., during an interview, CNA 1 stated on 8/3/14 before 12 p.m., FM1 asked her to put the patient back to bed. CNA 1 stated the therapist was not available to help with the transfer so she decided to transfer the patient by herself. CNA 1 stated she put her arms under the patient's underarm, lifted the patient up, and guided the patient from the wheelchair to the bed. CNA 1 stated in the past she always transferred the patient with the help of another staff member. CNA 1 stated she did not know she had caused the patient pain, because the patient did not say anything to her. CNA 1 stated she did not know about the patient?s fractures until the next day when the director of staff development (DSD) called her at home and informed her Patient 1 had rib fractures and she was the one who transferred the patient by herself.On 8/20/14 at 3:40 p.m., CNA 2 stated before the patient had the rib fractures, she required a two-person assist during a transfer with a gait belt (a belt applied below the patient's waist, with two staff members on each side of the patient, each staff put one hand under the patient's underarm and used other hand to hold the gait belt and assist the patient with transferring). CNA 2 stated after the patient had the rib fractures, the patient required a two-person with the use of a Hoyer lift (a device that allows caregivers to lift patients who are unable to stand and transfer without assistance). During an interview, on 8/20/14 at 3:50 p.m., the certified occupational therapist assistant ([COTA 1]/ help patients develop, recover, and improve the skills needed for daily living and working) stated Patient 1 was admitted to the facility with a right ankle fracture and was unable to bear weight on her right lower extremity. COTA 1 stated for the patient's safety, Patient 1 should have been transferred with a two-person assist and the use of a gait belt. COTA 1 stated it was the facility's protocol for the staff to use a gait belt during each transfer, even for high functioning patients. COTA 1 stated it was not safe for Patient 1 to have been transferred by a one-person assist using the hugging method.At 4:05 p.m., on 8/20/14, the physical therapy assistant (PTA1) stated the correct way to transfer Patient 1 from the wheelchair to the bed was to apply the gait belt below the patient?s waist line; one staff would stand in front of the patient using both hands to pull the gait belt and assist the patient with transfer, while the other staff would stand at the back of the patient and help guide the patient during the transfer.The facility failed by not: 1. Implementing its policy regarding transferring patients. 2. Following the Patient 1?s plan of care to prevent pathological fractures. 3. Using a gait belt for transferring patients, as stipulated in the policy.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. |
| 940000044 |
EL RANCHO VISTA HEALTH CARE CENTER |
940012484 |
B |
3-Aug-16 |
68YZ11 |
3557 |
?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 6/14/16 at 7:45 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 up-to-date star-rating information in the following locations: a. An area used for employee breaks. b. An area used for communal activities including a dining area or activities room. During observations of the facility between 6/14/16 and 6/16/16, the evaluator noted that the facility's overall star rating information was only posted in the facility's lobby. The posting indicated the facility had "three stars," there was no overall star rating information posted in the employee's lounge and the facility's dining area or activities room. According to the facility's policy and procedure titled, "Star Rating (5 Star Rating)," dated 2/26/10, the facility was to ensure that the public was to be 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. During an interview on 6/15/16 at 11:10 a.m., the Director of Nursing (DON) stated that she was not aware that the current three stars 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. On 6/16/16, at 1 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 "two stars." On 6/16/16, at 1:40 p.m., during an interview, the administrator stated the facility received a letter from CMS indicating the facility's overall star rating was two stars for April 2016. The administrator stated the three (3) star rating for the year 2015 information was posted in the facility's lobby, because the facility's staff failed to update and post the current information. The administrator stated the facility did not post the current two stars rating in two more areas, such as the employee lounge and 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 up-to-date star-rating information in the following locations: a. An area used for employee breaks. b. 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. |
| 940000043 |
EDGEWATER SKILLED NURSING CENTER |
940012873 |
A |
9-Jan-17 |
FP8811 |
18764 |
[F309] ? 483.25 Quality of care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
On 3/2/16, the Department of Health received a complaint regarding Resident 1 being neglected. On 3/16/16, an unannounced visit was made to the facility.
The facility failed to provide the necessary care and services to Resident 1, who was identified as high risk for bleeding and infection, by failing to:
1. Promptly determine the cause of hematuria (presence of blood in the urine) on 2/17/16.
2. Monitor and assess fluid intake and output to prevent fluid deficit (lack of fluid volume in the body) according to the plan of care.
3. Notify Resident 1's primary physician (MD 1) for persistent hematuria on 2/18/16 according to the care plan.
4. Promptly transfer Resident 1 to the hospital when there was a change in condition.
5. Notify the medical director (MD 2) and director of nursing (DON) when MD1 refused to obtain laboratory tests on 2/17/16 and refused to transfer Resident 1 to the hospital on XXXXXXX16, at 2 p.m. when Resident 1 continued to have hematuria, with increased weakness and heart rate.
As a result of these deficient practices, Resident 1's treatment for bacterial infection and severe fluid and blood loss was delayed for fifty three hours from the onset of hematuria on 2/17/16 at 10:30 a.m. to XXXXXXX16 at 3:30 p.m. Resident 1 was transferred via 911 (emergency number) to the general acute care hospital (GACH) emergency room (ER). Resident 1 was then admitted to the hospital in the Intensive Care Unit (ICU) for fluid resuscitation (replacement of fluid loss) and blood transfusion (administration of blood products by IV [given directly into the vein] to replace blood loss). Resident 1 received antibiotic therapy (medication to treat infection) and was closely monitored. Resident 1 stayed in the GACH for 14 days and was diagnosed with sepsis (a serious complication of a bacterial infection that is potentially life-threatening) due to urinary tract infection ([UTI], an infection of the bladder, urethra, ureters and the kidneys), acute (sudden) hemorrhagic anemia (lack of blood volume and blood count due to blood loss or destruction) and bladder hematoma (collection of blood outside of a blood vessel that leaks into the tissues due to damaged blood vessel walls and cause severe blood loss).
A review of Resident 1's Record of Admission indicated the resident was admitted to the facility on XXXXXXX15, with diagnoses that included multiple sclerosis ([MS] a chronic disabling disease due to damaged nerves on the central nervous system [brain and the spinal cord] which results in loss of movement, sensation, numbness or severe paralysis of the limbs), neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve condition), and pressure sore Stage 4 (wound caused by prolong pressure on the bony part of the body) of the buttock.
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 2/19/16, indicated Resident 1 was able to make her needs known, was able to understand others, and had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1required extensive assistance (resident involved in activity, staff provided weight bearing support) with transfer, eating, personal hygiene, and toilet use, and was frequently incontinent (lacking control) of bowel and had an indwelling urinary catheter (a catheter which is inserted into the bladder and allowed to remain in the bladder used to drain urine).
A review of Resident 1's plan of care, dated 8/11/15, indicated Resident 1 had the potential for urine infection due to the use of an indwelling urinary catheter and neurogenic bladder. The interventions included the facility staff will monitor Resident 1 for signs and symptoms of urinary infection and will observe if there is adequate urine output every shift.
A review of Resident 1's plan of care, dated 2/17/16, indicated Resident 1 had the potential for urinary retention, incomplete bladder emptying and urinary elimination due to hematuria (presence of blood in urine). The intervention indicated the facility staff will notify the physician if severe bleeding and severe pain last for more than one day.
A review of Resident 1's physician's order, dated 8/11/15 to 2/17/16 (a total of 7 months) indicated Resident 1 was to receive Lovenox 40 milligrams (mg) in 0.4 ml solution subcutaneously (under the skin) every day for deep vein thrombosis (blood clot in the veins) prophylaxis (prevention).
According to , dated 4/2014 indicated, Lovenox alters the blood's ability to clot and can cause excessive bleeding (hemorrhage) and can lead to death. All patients should be carefully monitored while taking Lovenox. The doctor should order blood tests that measure your blood count and check for signs of hidden bleeding while on Lovenox.
On 3/17/16 at 1 p.m., Resident 1's closed clinical records were reviewed with Registered Nurse (RN)1. The Advanced SBAR (Situation-Background-Assessment-Recommendation, provides a framework for communication between members of the health care team) Change of Condition Documentation, dated 2/17/16, timed at 10:30 a.m., indicated Resident 1 was observed with large amount of dark red colored urine.
A review of the Resident 1's Licensed Progress Notes on 3/17/16 at 1 p.m. indicated the following:
1. On 2/17/16, timed at 4:14 p.m., MD1 ordered to hold Lovenox (medication that thins blood or blood thinner) for two days.
2. On 2/18/16, timed at 11:14 a.m., Resident 1 was observed with moderate amount of dark red colored urine in the indwelling urinary catheter.
There was no documentation that MD1 was informed of Resident 1's continued presence of hematuria on 2/18/16.
3. On 2/19/16, timed at 2 p.m., MD1 was informed of Resident 1's increased weakness, continued hematuria (after forty eight hours of continued hematuria) and increased heart rate of 120-124 beats per minute ([bpm] normal range 60-100). RN 1 recommended to MD1 if the labs could be done stat (immediately) or if Resident 1 could be transferred to the hospital, MD 1 refused and stated Resident 1 had multiple sclerosis that could cause weakness and still ordered to obtain the following laboratory tests (labs) on Monday, 2/22/15:
a. UA (urine analysis, urine test to check for infection in the urinary tract: bladder, ureters and kidney).
b. CBC (complete blood count, a blood test to check for infection, blood and fluid loss).
c. BMP (basic metabolic panel, a blood test that measures blood sugar level, electrolytes, and fluid balance, and kidney function).
d. C&S (culture and sensitivity test, a Culture is a blood or urine test to check for infection, and Sensitivity is a blood test to determine the type of medication to treat the disease causing organism or infection).
In an interview on 3/17/16 at 1:30 p.m., RN 1 stated, "I saw the patient (Resident 1) with dark reddish brown urine in the Foley (a brand name of an indwelling urinary catheter) bag that was half full (approximately 1000 milliliters) on 2/17/16." RN 1 stated, on 2/17/16, he informed MD1 that Resident 1 had hematuria and MD1 did not order to draw laboratory tests. On Friday (2/19/16) at 2 p.m., RN 1 stated he informed MD1 that Resident 1 continued to have hematuria, with increased weakness and heart rate and asked MD1 if he could do stat (immediately) labs or if Resident 1 could be transferred to the hospital, MD1 refused and he told him that Resident 1 was weak because of MS and ordered, "Do not transfer her (Resident 1) at this time." RN 1 stated, MD 1 insisted to have the labs collected on Monday (2/22/16).
During the interview on 3/17/16 at 1:30 p.m., about Resident 1, RN 1 stated, "At around 3 p.m. on 2/19/16, the patient became confused and her level of consciousness was altered. She could not answer the questions and was not in her usual self. Her heart rate was higher at 140's; her skin was pale and cold. So, at 3:05 p.m., I called 911 and she was transferred to the acute hospital by the paramedics by 3:30 p.m. At 4:21 p.m. that afternoon (2/19/16), I called the doctor again to let him know that I called 911 and transferred the patient to the hospital."
During the interview on 3/17/16 at 1:30 p.m., RN 1 was asked if he informed the DON or MD 2 when MD 1 refused to obtain laboratory tests on 2/17/16 or transfer Resident 1 to the hospital at 2 p.m. on 2/19/16, RN 1 replied, "I don't recall informing any of them on 2/17/16 and at 2 p.m. on 2/19/16, but maybe I should have called them."
On 3/17/16 at 1:30 p.m., in an interview, RN 1 was asked if MD 1 was informed of Resident 1's continued hematuria on 2/18/16, RN 1 replied," No, we did not inform the doctor because she was still on a 72 hours monitoring."
During the interview on 3/17/16 at 1:30 p.m., RN 1 was asked if Resident 1's fluid intake and urine output was monitored and documented to determine Resident 1's fluid loss, RN 1 replied, "No we did not. There was no MD order to do a strict fluid intake and output monitoring."
A review of Resident 1's Licensed Nurse Progress record conducted with RN 1 on 3/17/16 at 1:30 p.m., there was no documented evidence the facility staff informed MD 2 when MD 1 refused to order laboratory test on 2/17/16 and refused to transfer Resident 1 to the GACH on XXXXXXX16 at 2 p.m. for proper evaluation.
During an interview and review of Resident 1's clinical record conducted with RN 1 and the assistant director of nursing (ADON ) on 3/17/16 at 2 p.m., there was no documented evidence that Resident 1's fluid intake and urine output was monitored, recorded, and fluid balance was assessed and analyzed. RN 1 stated, Resident 1's urine remained dark maroon (dark brownish red color) in color and decreased amount with approximately 250 milliliter (ml) in the Foley catheter bag on 2/19/16 at 2 p.m. and did not report the decreased amount of urine to MD 1.
On 3/18/16 at 4:30 p.m., the DON was asked if there could have been other interventions provided to Resident 1 for hematuria, the DON answered, "Yes we could have collected labs like UA and CBC, but if the doctor did not order the labs or the intake and output monitoring, we cannot go beyond what the doctor ordered." When asked if MD 2 was informed regarding Resident 1's persistent hematuria for three days the DON replied, "No, I did not inform him because that could be a conflict of interest. He was not the primary physician of the resident."
A review of the facility's policy and procedure, dated December 2010, titled, "Catheter Care," indicated the facility will minimize or prevent urinary tract infection for residents with indwelling catheter by: the staff will observe the resident's urine for noticeable increase and decreases. If the level significantly changes, report to the physician; and observed the resident for signs and symptoms of UTI and report findings to the attending physician.
According to the National Institute of Health, https://medlineplus.gov/ency/article/003147.htm, article dated 8/31/15, decreased urine output means that when you produce less urine than normal that may be due to dehydration, blood loss, severe infection that leads to shock (life-threatening condition that occurs when the body does not have enough blood flow). Most adults make at least 500 ml of urine in 24 hours (a little over 2 cups).
On 3/21/16 at 9:30 a.m., in a telephone interview, MD1 stated, he was informed by the nurse that Resident 1 had blood in the urine, and he ordered to stop the Lovenox and to observe Resident 1 for further bleeding. MD1 was asked if the facility staff informed him of Resident 1's continued hematuria on 2/18/16, MD 1 replied "No I was not. I told the nurses to hold the Lovenox and the hematuria should eventually resolve after two or three days." When asked for the possible causes of hematuria, MD1 replied, "If a patient have Foley catheter, the catheter can inadvertently (accidentally) cause bladder trauma when the catheter is pulled during patient care because of tugging and she's on a blood thinner." MD 1 stated, "Hematuria can also be due to infection, I do not believe the patient had infection. She had no fever, pain and abdominal tenderness." MD1 was asked what care he provides if a resident had hematuria, MD 1 replied, he would order labs, UA, C&S and CBC to make sure the hemoglobin was not decreasing and then he would transfer the resident to the hospital. MD 1 was asked why Resident 1 was not transferred to the hospital (GACH) for further test and evaluation if she continued to have hematuria for three days and had increased weakness, MD1 answered, "I do not remember why." MD1 was asked if he saw and physically assessed Resident 1 on 2/17/16 to 2/19/16 while Resident 1 had hematuria, MD1 replied, "No, I did not see her."
On 3/21/16 at 9:50 a.m., during an interview with Resident 1's family member (FM1) about Resident 1, FM1 stated, "When I tried to speak to her on the phone on 2/19/16, she answered my question with long pauses; that is not how she normally answers. When I spoke to the registered nurse, he told me that he will call 911 to have her transferred to the hospital. When I arrived in the emergency room, I found her urine bag with a large amount of hematuria. I think the nurses in the facility should have been more assertive."
On 3/21/16 at 4:20 p.m., during an interview, MD 2 stated, "If it was reported to me that the resident (Resident 1) continued to bleed after three days, I would have handled the situation a little different." When asked how soon should the resident be transferred, MD 2 replied, he would order labs right away to rule out infection or cause of bleeding and transfer the resident to the hospital as soon as possible if the hematuria does not resolve. It is always best to transfer the resident to the hospital to be evaluated for the possible cause of infection or bleeding."
According to the Emergency Department Clinical Record from the GACH, dated XXXXXXX16 timed at 4:12 p.m., indicated Resident 1 was admitted emergently to the GACH due to persistent hematuria and progressive weakness, heart rate of 142 (normal range 60-100) and with high temperature of 102.3 Fahrenheit (normal range 98.6-99.6 F).
The following were Resident 1's GACH laboratory tests report, dated 2/19/15 at 4:48 p.m.:
1. White blood count 24,000 (normal range 4,000 to 11,000 leukocytes per cubic millimeter) can indicate the presence of infection.
2. Hematocrit 22.1 (test for anemia, indicates percentage of red blood cells in the blood, normal range 36 to 44%)
3. Hemoglobin 7.4 (test for anemia, refers to a protein, found in red blood cells, that is responsible for carrying oxygen from the lungs to all other tissues, normal range 12-15 grams per deciliter)
4. Urinalysis, dated 2/19/15 timed at 4:21 p.m. indicated urine was red, bloody, with bacteria.
5. Culture and sensitivity (C&S), dated 2/21/16 timed at 6:55 p.m. indicated:
a. Urine culture had Proteus Mirabilis (bacteria found in putrid meat (rotten), and feces and is the leading cause of urinary tract infections).
b. Blood culture had gram negative rods organism (disease causing bacteria).
A review of Resident 1's Computed Tomography (CT) scan (an enhanced form of x-ray that evaluates or visualizes the body) result that was completed in the GACH on 2/21/15 at 11:28 a.m., indicated, Resident 1 had a bladder hematoma (leakage of blood from a blood vessel in the bladder).
A review of Resident 1's discharge summary record from the GACH, dated 3/4/16, indicated Resident 1 was admitted to the Intensive Care Unit (ICU) for treatment of sepsis due to urinary tract infection and received Levofloxacin 750 milligrams (medication to treat infection) intravenously (IV), fluid resuscitation (urgent replacement of fluids) with two liters of Sodium Chloride (solution for fluid and electrolyte replenishment), was given two units of packed red blood cells (blood product to replace the blood loss) and laboratory and diagnostic tests were obtained. Resident 1 remained in the GACH for 14 days from XXXXXXX15 to XXXXXXX15. Resident 1's discharge diagnoses included acute (sudden) post hemorrhagic anemia (anemia due to blood loss), sepsis due to urinary tract infection and bladder hematoma.
According to http://www.merckmanuals.com/home/blood-disorders/anemia/anemia-due-to-excessive-bleeding, article dated 2016, Anemia from excessive bleeding results in rapid blood loss, decreased blood pressure, and people may be dizzy, tired, short of breath, pale and reduce the number of oxygen-carrying red blood cells quickly which may lead to a heart attack, stroke, or death.
Therefore, the facility failed to provide the necessary care and services to Resident 1, who was identified as high risk for bleeding and infection, by failing to:
1. Promptly determine the cause of hematuria on 2/17/16.
2. Monitor and assess fluid intake and output to prevent fluid deficit according to the plan of care.
3. Notify Resident 1's primary physician (MD 1) for persistent hematuria on 2/18/16 according to the care plan.
4. Promptly transfer Resident 1 to the hospital when there was a change in condition.
5. Notify the medical director (MD 2) and DON when MD1 refused to obtain laboratory tests on 2/17/16 and refused to transfer Resident 1 to the hospital on XXXXXXX16, at 2 p.m. when Resident 1 continued to have hematuria, with increased weakness and heart rate.
As a result of these deficient practices, Resident 1's treatment for bacterial infection and severe fluid and blood loss was delayed for fifty three hours from the onset of hematuria on 2/17/16 at 10:30 a.m. to 2/19/16 at 3:30 p.m. Resident 1 was transferred via 911 to the general acute care hospital emergency room. Resident 1 was then admitted to the hospital in the ICU for fluid replacement of fluid loss and blood transfusion to replace blood loss. Resident 1 received antibiotic therapy and was closely monitored. Resident 1 stayed in the GACH for 14 days and was diagnosed with sepsis due to urinary tract infection, acute hemorrhagic anemia and bladder hematoma.
The above violations either jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 940000044 |
EL RANCHO VISTA HEALTH CARE CENTER |
940013306 |
A |
12-Jul-17 |
11FU11 |
19211 |
?483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
F309 ?483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
F 323 ?483.25 (d) Accidents
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
F279 ?483.20 (d) Use.
A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan.
?483.21(b) Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at ?483.10(c)(2) and ?483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
(ii) Any services that would otherwise be required under ?483.24, ?483.25 or ?483.40 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(c)(6).
On 3/29/17 at 7 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care.
Based on interview and record review, the facility failed to provide the following care and services to Resident 1:
1. Review and revise Resident 1's care plan interventions for effectiveness after a fall in accordance with facility policy and procedures.
2. Provide adequate supervision to Resident 1 who was known to remove her seat belt and required to be closely monitored as stipulated by her care plan.
Resident 1, who had history of falling (4/24/16, 6/22/16, 8/5/16, 11/6/16, and 12/20/16), was placed in a wheelchair with a self-release belt (an intervention that was identified not effective) and was taken to the nursing station for close monitoring on 3/5/17, at 4:40 a.m. Resident 1 was left unsupervised in the nursing station and fell.
This deficient practice resulted in Resident 1 being transferred to the hospital on 3/5/17, and was diagnosed to have subdural hematoma (pooling of blood around the brain that is mainly due to head trauma) and left hip fracture (a break in the upper part of the thighbone where it forms the hip joint).
A review of Resident 1's record titled, "Face Sheet (admission record)," indicated Resident 1 was admitted to the facility on XXXXXXX12, and was re-admitted on XXXXXXX17, with diagnoses that included abnormalities of gait (the manner or style of walking) and mobility (the ability to move or be moved freely and easily), muscle wasting and atrophy (muscle loss that can cause inability to move certain body parts), Alzheimer's disease (a progressive disease of the brain), dementia (a group of symptoms affecting memory, thinking, and social abilities), hemiplegia (paralysis of one side of the body) following a stroke (interrupted blood flow to the brain that results in brain cell death causing temporary or permanent disabilities); pseudobulbar affect (emotional instability due to a neurologic disorder), and osteoporosis (a condition that causes bones to become weak and brittle).
A review of Resident 1's record titled, "Minimum Data Set ([MDS], a resident assessment and care screening tool), dated 1/11/17, indicated Resident 1 had severe cognitive (ability to reason and think) impairment. The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight, at times full staff performance of activity) with one person physical assistance for the following activities of daily living ([ADLs], routine activities that individuals tend to perform every day without needing assistance): bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces), locomotion on and off unit (how resident moves between locations), dressing, eating, toilet use (how resident uses the toilet room), and personal hygiene. The MDS indicated Resident 1's balance was not steady and was only able to stabilize with staff assistance. The MDS indicated Resident 1 used a walker and wheelchair for mobility.
A review of Resident 1's record titled, "Fall Risk Data Collection," dated 1/16/17, indicated Resident 1 was assessed as high risk for fall. The Fall Risk Data Collection indicated Resident 1 was assessed high risk for fall on 4/13/16, 4/24/16, 6/22/16, 8/5/16, 10/10/16, 11/6/16, and 12/20/16.
A review of Resident 1's record titled, "History and Physical Examination," dated 2/7/17, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's record titled, "Progress Note," dated 2/21/17, the psychiatrist indicated Resident 1 had shown confusion, disorganization, disorientation, and a noticeable decline in cognitive functions. The progress note indicated Resident 1 continued to be restless, constantly fidgeting and unable to keep still. The progress note indicated Resident 1's self-care skills were impaired and the resident required cues and assistance to perform self-care skills, and that Resident 1 was dependent on others.
A review of Resident 1's record titled, "COC (Change of Condition)/ SBAR ([Situation, Background, Assessment, and Recommendation], a tool to help improve communication between healthcare staff), dated 4/24/16 at 7:30 p.m., indicated Resident 1 was in her wheelchair, took off self-release belt, and dropped to her knees.
A review of Resident 1's record titled, "Post-Fall Assessment," dated 4/25/16, indicated another resident witnessed Resident 1's fall on 4/24/16 in the hallway. The interdisciplinary team ([IDT], a group of health care professionals from diverse fields who work together in establishing a plan and goals for the achievement of a resident's maximum potential) recommendations included to refer Resident 1 to physical therapy for evaluation, remind Resident 1 not to get up unassisted and to ask for assistance (MDS indicated Resident 1 had severe cognitive impairment), continue the use of the wheelchair alarm (an alarm used for fall prevention and safety) and self-release belt (a belt that the resident was able to remove or release) to remind Resident 1 not to get up unassisted; provide frequent visual checks; and continue to attend and anticipate resident's needs promptly.
A review of Resident 1's COC/SBAR, dated 6/22/16 at 8:30 p.m., indicated the wheelchair alarm was heard from Resident 1's room. Resident 1 was found on the floor lying on her back. Resident 1 sustained redness on the left lower back.
A review of Resident 1's Post-Fall Assessment, dated 6/23/16, indicated Resident 1 was last seen with self-release belt and alarm in wheelchair. The Post-Fall Assessment indicated Resident 1 was able to release the self-release belt and attempted to stand up, lost her balance, and fell. The IDT recommendations included to continue physical therapy, provide frequent visual checks, continue the use of the wheelchair and bed alarms and self-release belt, remind Resident 1 not to get up unassisted and instruct Resident 1 to use wheelchair brakes.
A review of Resident 1's COC/SBAR, dated 8/5/16 at 8:55 p.m., indicated a Certified Nurse Assistant (CNA X) was fixing Resident 1's bed while Resident 1 was in her wheelchair inside her room. CNA X heard the wheelchair alarm and then saw Resident 1 on the floor with blood coming out from the right nostril. The COC/SBAR indicated Resident 1 was agitated and 9-1-1 (emergency number) was called.
A review of Resident 1's Post-Fall Assessment, dated 8/5/16, indicated Resident 1 was able to release the self-release belt. The IDT recommendations included to continue safety belt as a fall prevention intervention, provide frequent visual checks, and to continue the use of the wheelchair and bed alarms.
A review of Resident 1's COC/SBAR, dated 11/6/16 at 2:50 p.m., indicated Resident 1 was found on the floor, lying on her right side and the wheelchair alarm was going off and the safety belt was off. The COC/SBAR indicated Resident 1 sustained a bump on the right side of the forehead with reddened discoloration. The COC/SBAR indicated Resident 1 was transferred to the emergency room for evaluation due to the fall.
A review of Resident 1's Post-Fall Assessment, dated 11/7/16, indicated Resident 1 was in the hallway, witnessed getting up from the wheelchair unassisted and falling. The Post-Fall Assessment indicated Resident 1 had episodes of forgetfulness and confusion, and noted at various times removing the safety seat belt (self-release belt). The IDT recommendations included visual checks every hour for 72 hours for Resident 1.
A review of Resident 1's record titled, "Physician and Telephone Orders," dated 11/7/16, indicated to discontinue self-release belt and put non-release seat belt for safety secondary to diagnosis of Alzheimer's disease, may release every two hours and PRN (whenever necessary for ADLs and skin evaluation.
A review of Resident 1's COC/SBAR, dated 12/20/16 at 12:20 a.m., indicated Resident 1 was observed restless in the wheelchair and was calling out for no apparent reason. The COC/SBAR indicated Resident 1 was placed in the lobby across from the nursing station and Resident 1 continued to pull on the seat belt. The COC/SBAR indicated Resident 1 was administered Ativan (a medication used to treat anxiety) but Resident 1 "continued to yell out and reach down at socks and pull at her gown with the seat belt." "RN (not identified) continued on to check rooms down heading to the outside patio when flagged down by a Certified Nurse Assistant CNA (not identified) to alert RN patient on floor." The COC/SBAR indicated Resident 1 was found on the floor next to the wheelchair. The COC/SBAR indicated Resident 1's seat belt remained intact and the wheelchair alarm was crumpled from friction.
A review of Resident 1's Post-Fall Assessment, dated 12/20/16, indicated Resident 1 had a fall from the wheelchair with non-release seat belt after least restrictive measures had been provided and ineffective. The IDT recommendations included to continue visual checks as previously done at least every one hour and as needed and continue with current interventions.
A review of Resident 1's COC/SBAR, dated 3/5/17 at 4:45 a.m., indicated the Licensed Vocational Nurse (LVN) 1 documented that on 3/5/17 at 4:20 a.m., Resident 1 was observed trying to slide herself from the bed onto the floor mats. At 4:40 a.m., Resident 1 was trying to slide herself onto the floor mats and the bed alarm kept going off. LVN 1 placed Resident 1 in her wheelchair for close monitoring at the nursing station. The self-release seat belt and wheelchair alarm were applied for Resident 1 in the wheelchair. LVN 1 was asked to assist with another resident in the room. LVN 1 then heard the alarm sound in the room and ran to check Resident 1 who was observed on the floor beside her wheelchair. LVN 1 stated that Resident 1 knew how to take off the seat belt. Resident 1 sustained a cut to the left eyebrow that was bleeding. At 5 a.m., Resident 1's physician was notified of the fall with order to transfer to the hospital for evaluation and treatment. At 6:50 a.m., Resident 1 left the facility by ambulance.
On 3/29/17 at 1:50p.m during a review of Resident 1's records and concurrent interview with the Director of Nursing (DON) regarding Resident1?s falls, she stated, Resident 1 was known to take off the self-release belt and the resident would stand up without staff assistance. The DON stated the facility implemented the self-release belt to prevent falls but Resident 1 continued to have fall incidents. The DON stated another facility intervention was to provide visual checks for Resident 1. The DON stated there was no documentation that staff was providing visual checks for Resident 1. The DON stated Resident 1's care plan should have specified the frequency of the visual checks, and the care plan interventions should have been evaluated for effectiveness and revised to address Resident 1's problem.
On 5/5/17 at 7:07 a.m., during a telephone interview, LVN 1 stated on 3/5/17, at 4:20 a.m., Resident 1's bed alarm was making a lot of sound and she saw Resident 1 was moving a lot in bed, with both legs hanging off the bed, trying to slide herself off the bed. LVN 1 stated that she decided to place Resident 1 on the wheelchair with the self-release belt and alarm in the wheelchair, and then took Resident 1 in the nursing station by the hallway so that she could closely monitor Resident 1 to prevent falls. LVN 1 stated that Resident 1 knew how to unhook the self- release belt on her own and was fast in releasing the self-release belt. LVN 1 stated CNA 2 asked her to assist with a Randomly Sampled Resident (RSR) 1 in RSR 1's room, and she left Resident 1 in the wheelchair at the nursing station without staff supervision. LVN 1 stated she heard the alarm sound while she was in RSR 1's room and ran out of RSR 1's room and saw Resident 1 on the floor next to the wheelchair. There was no staff present during the time of Resident 1's fall. LVN 1 stated she felt the self-release belt was enough to prevent the fall. LVN 1 stated Resident 1 could have been placed on one to one staff supervision (one resident by one staff member who remains with the resident at all times) to prevent the fall. LVN 1 stated Resident 1 sustained a cut to the left eyebrow area with minimal bleeding and small amount of blood in her mouth due to possibility that Resident 1 may have hit her head on the floor from the fall.
On 5/8/17 at 12:08 p.m., during an interview and concurrent review of Resident 1's COC/SBAR, dated 3/5/17, DON stated LVN 1 left Resident 1 at the nursing station to assist RSR 1 and Resident 1 had a fall. DON stated, "The staff (LVN 1) should not have turned her back on the resident (Resident 1) and should not have left the resident because the resident was quick to release the self -release belt." The DON stated, "The resident?s fall could have been avoided if the resident was supervised and the staff (LVN 1) did not leave the resident."
A review of the facility's policy and procedures titled, "Care Planning," revised 3/1/14, indicated the care plan will be periodically reviewed and revised by the IDT at intervals that included when there was a change of condition.
According to the facility's policy and procedures titled, "Fall Management Program," dated 6/1/15, the facility is responsible for providing a safe environment that minimizes complications associated with falls.
A review of Resident 1's hospital admission records dated 3/5/17, at 11:23 a.m., indicated Resident 1 arrived in the emergency room (ER) and was seen at 7:17 a.m. The ER record indicated, "Critical care (involves close, constant attention by a team of specially-trained health care providers) was provided to prevent clinically significant and life-threatening deterioration of the patient's condition." The ER record indicated Resident 1 was to be admitted to the intensive care unit ([ICU], a special department that provides intensive treatment medicine) due to subdural hemorrhage.
A review of Resident 1's hospital diagnostic test result, dated 3/5/17, indicated computerized axial tomography ([CT scan], x-ray equipment that helps reveal internal injuries and bleeding quickly) of the head with findings of left subdural bleed, subdural hematoma (a collection of blood outside the brain that causes increased pressure on the brain that can be life-threatening), subarachnoid hemorrhage (bleeding in the space that surrounds the brain), and fracture in the anterior wall of the left maxillary sinus (area of the facial bone).
A review of Resident 1's hospital diagnostic test result, dated 3/7/17, indicated CT scan of the pelvis (joint area of hip and thigh bone) with findings of fracture (broken bone) of the left femur (thigh bone) with angulation (abnormal position of fractured bones).
A review of Resident 1's hospital record titled, "Discharge Summary," dated 3/19/17, indicated, "Option of surgery was considered for left hip surgery, because of the patient's condition it was thought she is high risk, so family did not want to go through surgery and opted for palliative and hospice (a multidisciplinary approach to specialized medical care) care services." The Discharge Summary indicated Resident 1's final diagnoses included: history of fall with subdural hematoma, history of left hip fracture, and advanced dementia. The Discharge Summary indicated Resident 1's prognosis (the likely course of disease or ailment or the outcome of one's chance of survival) was poor.
Therefore, the facility failed to provide the following care and services to one of two sampled residents (Resident 1):
1. Review and revise Resident 1's care plan interventions for effectiveness after a fall in accordance with facility policy and procedures.
2. Provide adequate supervision to Resident 1 who was known to remove her seat belt and required to be closely monitored as stipulated by her care plan.
Resident 1, who had history of falling (4/24/16, 6/22/16, 8/5/16, 11/6/16, and 12/20/16), was placed in a wheelchair with a self-release belt (an intervention that was identified not effective) and was taken to the nursing station for close monitoring on 3/5/17, at 4:40 a.m. Resident 1 was left unsupervised in the nursing station and fell.
This deficient practice resulted in Resident 1 being transferred to the hospital on XXXXXXX17, and was diagnosed to have subdural hematoma (pooling of blood around the brain that is mainly due to head trauma) and left hip fracture (a break in the upper part of the thighbone where it forms the hip joint).
The above violations jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result to Resident 1. |
| 950000029 |
ELMCREST CARE CENTER |
950008893 |
A |
27-Jan-12 |
0Y5B11 |
14535 |
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 November 2, 2010, at 10:10 a.m., an unannounced complaint visit was made to the facility.The facility failed to provide necessary care as indicated on the care plan to ensure a diabetic resident?s blood sugar was maintained within an acceptable parameter that resulted in extremely high blood glucose level of over 600 mg/dL and required treatment at an acute care hospital emergency room by failing to:1. Notify Resident 1?s physician of the resident?s refusal of Amaryl and Januvia (oral medications for diabetes which lower blood sugar) in accordance with the resident?s short-term care plan. 2. EnsureResident 1?s Diabetes Mellitus care plan goal to maintain blood sugar between 70-110 milligrams (mg)/deciliter (dL) was met, by including care plan interventions of regular testing of blood glucose for on- going monitoring of Resident 1?s blood sugar so as to maintain the blood sugar within the normal range as indicated on the care plan.Resident 1?s skilled nursing facility Face Sheet indicated that Resident 1 was an 82 year old male who was re-admitted to the facility on September 5, 2010. Resident 1?s diagnoses included pneumonia, altered level of consciousness, a history of cerebral vascular accident and type 2 diabetes (the body does not produce enough insulin or is unable to use its own insulin).Resident 1?s admission Physician?s Orders dated September 5, 2010, included the following: Amaryl 4 mg twice a day and Januvia 100 mg daily with breakfast, Risperdal (antipsychotic medication) 1 mg at bedtime for psychosis manifested by striking out, and Ativan (medication for anxiety) 0.5 mg at bedtime for anxiety. There were no physician orders for routine blood sugar checks to be done for Resident 1, to determine the resident?s blood sugar level.Resident 1?s care plan goals for diabetes dated September 5, 2010, included to maintain blood sugar between 70-110 mg/dL daily for three months. The care plan approaches included monitor for thirst, excessive appetite or voiding, change in level of consciousness or mood and report to physician, medications as ordered, and monitor food intake and record. However, the care plan approach to perform blood sugar checks was not stipulated or addressed.Resident 1?s ADL (activities of daily living) record revealed that Resident 1 had consumed the following: 80% of breakfast on September 6, 7, and 8, 70% on September 9, 40% on September 11, and refused breakfast on September 10 and 12, 100% of lunch on September 10, 11, and 12, 90% on September 6 and 8, 70 % on September 9, and 50 % on September 7, 80% of dinner on September 10, 50% on September 6 and 7, 30% on September 5, and refused dinner on September 8, 9, and 11.Resident 1?s short-term care plan dated September 8, 2010, for refusal of medications and treatments stipulated to notify the physician and family of any refusals.Resident 1?s skilled nursing facility Medication Administration Record (MAR) and Daily and Every (Q) Shift Charting revealed Resident 1 refused both the Januvia and Amaryl on the mornings of September 8, 9, 10, and 12, 2010. Resident 1?s MAR indicated Resident 1 refused the Januvia four out of the seven times when it was offered in the morning and refused Amaryl four out of the thirteen times it was offered since the resident?s re-admission to the skilled nursing facility on September 5, 2010.However, there was no documentation in Resident 1?s Daily and Every Shift Charting that Resident 1?s physician was informed of the resident?s refusal of the Januvia and the Amaryl on the mornings of September 8, 9, 10, and 12, 2010. There was also no evidence anywhere in the medical record, that the physician was notified of the resident?s refusal of Januvia and Amaryl until September 12, 2010, at 12:45 p.m., the same day Resident 1 was transferred to the Acute Hospital.On November 2, 2010, at 12 p.m., an interview was conducted with Staff 1. Staff 1 stated Resident 1?s family usually visited in the late afternoon and brought the resident food. The resident ate the food from home and not the facility?s food. The family was able to convince the resident to take the dinnertime medications. Staff 1 stated the facility policy is that after three refusals of medications the physician is notified. Staff 1 further stated that Resident 1 had no blood sugar checks while at the facility until Family Member 1 requested a blood sugar check to be done on September 12, 2010 at 12:45 p.m., the day Resident 1 was transferred to the Acute Hospital.Resident 1?s Daily and Q Shift Charting dated September 11, 2010, at 5:00 p.m., indicated the following: ?The resident?s physician was notified that the resident had been sleeping during the day. The resident was able to be aroused by calling the resident?s name but would go back to sleep. The resident?s Risperdal and Ativan were held the night before.?Resident 1?s Daily and Q Shift Charting dated September 12, 2010, at 12 p.m., indicated the following vital signs for Resident 1: blood pressure 123/75, temperature 98.6 degrees, pulse 88 beats per minute, and respiration rate of 20 breaths per minute. The Daily and Q Shift Charting dated September 12, 2010, indicated Resident 1?s family noticed that the resident was drowsy and at 12:45 p.m., the family requested Resident 1?s blood sugar to be checked. At the same time, Resident 1?s blood sugar was found to be 557, and the resident?s physician was notified and ordered 10 units of Regular insulin (reduces blood sugar rapidly) to be given by injection immediately and follow-up with the physician in two hours.The Daily and Q Shift Charting dated September 12, 2010, at 2:15 p.m. further indicated that the transportation service staff arrived (at the skilled nursing facility) and attempted to obtain Resident 1?s oxygen blood saturation level, however, the transportation service staff, were not able to obtain an oxygen saturation reading and Resident 1 was provided oxygen at four liters/minutes via facemask. , Resident 1 was breathing but lethargic, pulse was 50 beats per minute, and 911was called.The Daily and Q Shift Charting dated September 12, 2010 at ?2:35 p.m.?, [Sic] indicated Resident 1?s blood sugar was checked again and found to be too high to register on the facility blood sugar meter and Resident 1?s vital signs indicated the following: blood pressure 97/55, temperature 98.6 degrees, pulse 88 beats per minute, and respirations 20 breaths per minute.Resident 1?s physician was notified and the physician ordered an additional 10 units of regular insulin be given and to transfer Resident 1 to the acute care hospital.The Daily and Q Shift Charting dated September 12, 2010, at 2:25 p.m., indicated the paramedics arrived and attempted to obtain Resident 1?s blood sugar level however, the patient?s blood sugar level was still too high to register on the paramedic?s blood sugar meter. Resident 1 was transported to the acute hospital on Sept. 12, 2010, at 2:25 p.m.On November 3, 2010, at 11:00 a.m., an interview was conducted with Family Member 1 who stated that he visited Resident 1 every other day, and Family Member 2 visited the resident every day and brought food for the resident. Resident 1 appeared to be getting more lethargic the longer the resident was in the facility and on September 12, 2010, Family Member 1 requested the staff to do a finger stick on Resident 1. It was at that time the resident?s blood sugar level measured high. Family Member 1 stated Family Member 2 did daily blood sugar testing on Resident 1 when the resident was at home.The package insert for Amaryl, Sanofi-Aventis U.S. LLC, revised July 2009, included the following information for Patients: ?Patients should be informed of the potential risks and advantages of Amaryl and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of blood glucose.?The prescribing information for Januvia, Merck & CO., INC, Copyright 2010, included the following Patient Counseling Information: ?Patients should be informed of the potential risks and benefits of Januvia and of alternative modes of therapy. Patients should also be informed about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring.? ?Testing of blood sugar allows you to respond quickly to high blood sugar (hyperglycemia) or low blood sugar (hypoglycemia), Medline Plus, A service of the U.S. National Library of Medicine National Institutes of Health, Internet Website, November 30, 2011.? The Acute Hospital Laboratory Comparative Report indicated Resident 1?s blood glucose level on September 12, 2010, at 3:57 p.m. measured greater than 600 mg/dL High Critical (Acute Hospital reference range 70-100 mg/dL).The Acute Hospital, ?Hospital Course, and Treatment?indicated that Resident 1 was admitted to the Acute Hospital on September 12, 2010, due to pneumonia, aspiration, renal failure, altered level of consciousness, dehydration, and diabetes out of control.Resident 1 was treated with intravenous hydration, antibiotics, received bronchodilators (medications to open lung passageways) including bronchoscopy (procedure to examine the resident?s airway and lungs), and a gastrostomy tube (surgically placed tube into the stomach into which medications and nutrients are given) was inserted due to the residents dementia and high risk for aspiration (entry of foreign matter into the lungs). Resident 1 was discharged on September 23, 2010, to another skilled nursing facility. On December 28, 2010, at 11:00 a.m., an interview was conducted with Staff 2 who stated that when Resident 1 was admitted to the skilled nursing facility on September 5, she received the resident?s admission orders and spoke with Physician 1 and mentioned to Physician 1 that Resident 1 was taking two oral diabetic medications. Physician 1 told her to follow the Acute Hospital physician orders, which did not include routine blood sugar testing.Staff 2 stated Resident 1?s family brought the resident food in the evening and the resident would take medications when the family was visiting the resident.On January 4, 2011 at 3:20 p.m., an interview was conducted with Physician 1 who stated that he had been Resident 1?s physician for a long time.He was aware of Resident 1?s condition including the resident?s diagnosis of diabetes. Physician 1 stated he reviewed Resident 1?s Acute Hospital record and further stated that during the resident?s previous admission to the acute hospital on September 2, 2010, the resident?s blood sugar level was high (331mg/dL) and decreased to 162 mg/dL when the patient was transferred to the skilled nursing facility on September 5, 2010. Physician 1 stated the resident?smedical record indicated that the Acute Hospital physician did not order any routine blood sugar tests for the resident, while the resident was at the acute hospital. He further stated he did not realize routine blood sugar tests were not ordered while the resident was at the acute hospital and when the resident was transferred to the skilled nursing facility. Physician 1 stated he did not remember being informed by the skilled nursing facility staff of Resident 1?s refusal of the Januvia and Amaryl. If he had been informed of the resident?s refusal of the diabetic medications, he would have ordered blood sugar testing to be done. Physician 1 added that Resident 1?s pneumonia contributed to the resident?s increased blood sugar level.On January 19, 2011, a review of website: http://www.medicinet.com/script/main/art.asp?articlekey=86261 indicated the following: Hyperglycemia or high blood sugar is a serious health problem for those with diabetes. Hyperglycemia in diabetes may be caused by skipping or forgetting insulin or oral glucose-lowering medicine, infection, illness, and increased stress. Early symptoms of hyperglycemia include increase thirst, difficulty concentrating, frequent urination, fatigue (weak, tired feeling), and blood glucose more than 180 mg/dL. Hyperglycemia can be prevented by making sure you are following your medicine schedule and testing your blood glucose regularly.http://www.endocrineweb.com/conditions/hyperglycemia indicated the following: early symptoms of hyperglycemia include: increased thirst and/or hunger, frequent urination, and fatigue. Hyperosmolar hyperglycemic nonketonic syndrome (HHNS) is severe hyperglycemia for type 2 diabetics. HHNS is most likely to occur when you?re sick, and elderly people are most likely to develop it. It starts when the blood glucose level starts to climb, when that happens your body will try to get rid of the excess glucose through frequent urination, which leads to dehydration. If you are not able to rehydrate your body the blood glucose level will continue to rise until it could lead to a coma. Signs and symptoms of HHNS include: extremely high blood glucose level of over 600 mg/dL and sleepiness. Preventing hyperglycemia includes taking your glucose-lowering medications as prescribed.The facility failed to provide necessary care as indicated on the care plan to ensure a diabetic resident?s blood sugar was maintained within an acceptable parameter that resulted in extremely high blood glucose level of over 600 mg/dL and required treatment at an acute care hospital emergency room by failing to:1. Notify Resident 1?s physician of the resident?s refusal of Amaryl and Januvia (oral medications for diabetes which lower blood sugar) in accordance with the resident?s short-term care plan. 2. EnsureResident 1?s Diabetes Mellitus care plan goal to maintain blood sugar between 70-110 milligrams (mg)/deciliter (dL) was met, by including care plan interventions of regular testing of blood glucose for on- going monitoring of Resident 1?s blood sugar so as to maintain the blood sugar within the normal range as indicated on the care plan.The above violations presented an imminent danger that death or serious harm would result. |
| 950000029 |
ELMCREST CARE CENTER |
950008981 |
B |
07-Feb-12 |
05XU11 |
5871 |
F226 CFR 483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. F223 CFR 483.13(b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On February 8, 2010, at 11:50 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an incident of alleged resident abuse.Based on interview and record review the facility failed to implement its abuse policies and procedures by failing to ensure that:1 Employee 1 immediately notified the charge nurse of Resident A?s aggressive behavior while attempting to provide care.2. Employee 1 acted according to Policy and Procedure when handling an aggressive resident.3. Resident A was not subjected to physical abuse by Employee 1. Findings: A Review of Resident A?s medical record revealed that she was a 71 year-old female who was first admitted to the facility on January 18, 2005, with diagnoses that included schizophrenia, (a thought disorder) and mental disorder.The Minimum Data Set (MDS- a standardized assessment and care planning tool) dated October 27, 2009 indicated that Resident A had long and short term memory problems, was severely impaired in cognitive skills for daily decision-making was sometimes able to understand others and sometimes able to be understood by others. In addition she exhibited socially inappropriate/disruptive behavioral symptoms such as yelling and screaming but was not physically abusive. A review of the licensed nurses notes dated January 24, 2010, indicated that Resident A had a purple discoloration on the 2nd and 3rd fingers of her right hand.A review of an internal facility investigation report dated January 24, 2010 at 8:30 a.m. indicated that Resident A had swelling to her 2nd and 3rd fingers of her right hand. An x-ray of the fingers was taken on January 25, 2010 that revealed no fracture or dislocation. The conclusion read: ?Mild osteoarthritis of the right hand.?A review of a second internal facility investigation report that described the alleged incident between the resident and Employee 1, dated January 25, 2010, at 11 a.m., indicated that: ?Allegedly said CNA who worked from 11pm grabbed her (R) hand and slapped her on FridayThe facility?s investigation report further indicated that when Employee 1 was interviewed, he stated that on the morning of January 24, 2010, at some point during his work shift between 11pm -7am, Resident A got agitated when her doll fell to the floor, and when he (Employee 1) proceeded with Resident A?s nursing care, Resident A got angry and was about to slap him. He then grabbed both her hands and told her ?No?. Employee 1 also stated that he did not report the aggressive behavior to anyone.During an interview with Employee 2 on February 8, 2010, she stated that Employee 1 should have handled the situation with Resident A by first backing off. Secondly, he should have checked to see if the side rails on the bed were up, and thirdly, he should have reported the aggressive behavior of Resident A to the charge nurse. A review of a facility?s lesson plan on Abuse Prevention, Recognition and Reporting indicated in the course content that, employees should not try to touch the resident but to call the nurse when applying appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. The facility?s lesson plan was part of a class given to the staff of the facility on February 25, 2009 that Employee 1 attended as evidenced by the sign-in sheet. A review of the personnel file of Employee 1 indicated he was in-serviced regarding abuse and also on the proper handling of difficult residents on February 25, 2009. He was also in-serviced regarding incident reporting and on the residents? right to refuse care on May 20, 2009. The employee file also contained a written warning dated January 27, 2009, indicating that Employee 1 had left the floor on 6:30 a. m., without giving prior notification to the charge nurse that he was leaving the floor. The evaluator?s attempts to interview Employee 1 were unsuccessful because his cell phone line had been disconnected. Employee 1?s termination notification indicated that he was terminated on January 28, 2010. A review of the facility?s policy titled ?Abuse Prevention? that was revised on July 1, 2005, indicated that each resident has the right to be free from physical abuse and that resident?s must not be subjected to abuse by anyone, including, but not limited to facility staff. It further notes on page 6 that the first responder or first staff member informed will be responsible for informing the immediate supervisor and initiating an incident report. It also indicated that any employee who suspects an alleged violation shall immediately notify the administrator or designee.All incidents of abuse shall be reported to the administrator. All incidents of abuse and aggressive behavior shall be reported to the charge nurse. As a result of Employee 1?s failure to report the incident to the Charge Nurse, there was a delay in the initiation of the abuse investigation and the protection of Resident A.The facility failed to implement its abuse policies and procedures by the failing to ensure that:1. Employee 1 immediately notified the charge nurse of Resident A?s aggressive behavior while attempting to provide care.2. Employee 1 acted according to Policy and Procedure when handling an aggressive resident.3. Resident A was not subjected to physical abuse by Employee 1. These violations had a direct relationship to the health, safety and security of Resident A. |
| 970000161 |
EISENHOWER HEALTHCARE CENTER |
950009368 |
B |
19-Jun-12 |
H6GQ11 |
9119 |
F 323 CFR 483.25 (h) Accidents: The facility must ensure that the resident environment remains as free from accident hazards as is possible. On March 28, 2012, at 9:30 a.m., the evaluator initiated a complaint received from a resident during the annual Recertification survey regarding an incident of an injury he sustained in the facility. Based on record review, observation and interview, the facility failed to provide a resident with an environment that was free from accident hazards by failing to ensure that all bed cranks/handles were tucked under the bed, as indicated in the facility?s policies and procedures, to prevent accidents/injuries to the residents that ambulate (walk) close to, and around the bed. As a result, Resident 7 sustained a four centimeters laceration to the left lower leg by bumping into a bed crank/handle that was protruding from under the bed while ambulating to the bathroom. A review of Resident 7?s admission record indicated the following: Resident 7 was a 67 year old male, who was initially admitted to the facility on October 8, 2011, and was readmitted on January 11, 2012, from the acute hospital. Resident 7?s diagnoses included: chronic kidney disease (progressive loss in renal function), difficulty walking, bilateral lower extremity edema (swelling caused by accumulation of excess fluids in the tissues of the body), bladder carcinoma (cancer), Parkinson?s disease (A progressive nervous disorder that affects movements), paranoid schizophrenia (A chronic mental illness) and emphysema (the lungs are gradually destroyed, making the resident progressively more short of breath, known collectively as chronic obstructive pulmonary disease) (COPD). A review of the most recent Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 17, 2012, indicated that Resident 7 had unclear speech, had decreased ability to make self- understood or to understand others and had modified independence in decision making skills in new situations. Additionally, Resident 7 required supervision in ambulation due to impaired gait. The care plans developed on January 11, 2012, indicated the following:a. Impaired mobility due to muscle rigidity/tremors related to Parkinson?s disease. The approaches included that staff were to monitor the resident for safety hazards and to remove potential hazards as needed and protect from possible physical injury.b. At risk for blurred vision related to bilateral cataracts (a clouding of the lens in the eye which affects vision). The approaches included staff were to assist the resident with all mobility as needed when vision is blurred and to maintain appropriate lighting in room.c. At risk for injury due to loss of sensation related to diabetes (High sugar level in the blood) and peripheral neuropathy (A result of nerve damage often causing numbness to the hands and feet). The approaches were for staff to keep room free of safety hazards and to assist with ambulation. d. Has potential for disturbances of thinking, mood or behavior, altered concept of reality, delusions (Is a belief that is clearly false and that indicates an abnormality in the affected person's content of thought), and or hallucinations (Involve sensing things while awake that appear to be real, but instead have been created by the mind) related to diagnosis of paranoid schizophrenia. The approaches were to monitor the resident for safety hazards and remove potential hazards as needed and to protect the resident from physical injury. A review of the fall risk assessment dated January 11, 2012, indicated that the resident had a total score of 11 (A total score of 10 or above represents ?High Risk?) due to difficulty walking and functional decline. The facility?s incident report dated January 17, 2012, at 8 p.m., indicated that, Resident 7 sustained a laceration approximately four centimeters in length with acute bleeding on the left lower extremity while the resident was going to the bathroom. The resident hit the crank of the bed of Resident 35. The step taken to prevent reoccurrence was for staff to keep bed cranks tucked under the bed. On March 28, 2012, at 3:10 p.m., an interview was conducted with the Registered Nurse (RN) Supervisor regarding the incident of January 17, 2012, at 8 p.m., who stated that Certified Nurse Assistant (CNA) 3 reported that Resident 7 was bleeding profusely on the left lower leg while in the bathroom. The RN Supervisor stated the incident happened after dinner and at that time the resident?s room was dark. When the RN supervisor asked Resident 7, what happened, Resident 7 replied ?I don?t know.? However, Resident 7?s roommate, Resident 34 reported to the RN supervisor, that he saw Resident 7 hit his leg on the edge of Resident 35?s bed while he was on his way to use the bathroom. Emergency measures were immediately rendered to the affected leg and the resident?s physician was notified with an order to monitor Resident 7 for 72 hours. The RN supervisor further stated that the resident had been ambulatory but his gait was slow and unsteady at times because of swelling on both lower extremities. On March 29, 2012, at 8:20 a.m., Resident 31, who was one of Resident 7?s roommates, stated during an interview, that one night sometime after dinner (unable to recall date and time) he saw Resident 7 walking towards the bathroom then suddenly Resident 7 cried, ?Ouch? and was holding his left lower leg. Resident 7 said ?I? m OK? when Resident 31 asked what was wrong. At that time of the incident, Resident 7 was standing next to Resident 35?s bed. Resident 31 observed that one of the bed cranks was sticking out from under the bed with blood on it. Resident 31 further stated that Resident 7?s over bed light was turned off. In the past Resident 31 had seen the nurses leaving Resident 35?s bed cranks sticking out from under the bed. Resident 31 also stated that a few months ago while wheeling himself in the room; he had hit his toes with socks on, on one of the bed cranks that was sticking out from under Resident 35?s bed. Resident 31 stated he did not report this to the staff because he did not sustain any injury. On March 29, 2012, at 8:35 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed and stated that Resident 34, was alert with periods of confusion but was able to verbalize his needs appropriately. The resident required minimal supervision to perform activities of daily living and propelled the wheelchair for locomotion. LVN 3 further stated that Resident 31 was alert and oriented and was able to verbalize needs. The resident required extensive to maximum nursing assistance to carry out activities of daily living including personal hygiene and grooming. Resident 31 used the motorized wheelchair independently for locomotion around the facility. LVN 3 stated Resident 35, had difficulty communicating his needs verbally because of a slurred speech and required maximum nursing assistance to carry out activities of daily living. Resident 35 ambulated with the aid of a front wheel walker but needed staff support. During the survey on March 26, 2012, at 2:30 p.m., March 27, 2012, at 2 p.m., and 4:20 a.m., and on March 29, 2012, at 9:30 a.m., and 4 p.m., Resident 7 was observed ambulating around the hallway then would go in and out of his room. The resident?s gait was unsteady at times and had on and off shortness of breath.During an interview conducted on March 30, 2012, at 4:30 p.m. with the Director of Staff Development (DSD), she stated CNA 1 who was the assigned staff for Resident 7, was given one on one in-service after the incident on preventing falls and injuries by putting the bed crank handles under the bed after use. The DSD further stated that all of the staff received an in?service regarding potential hazards and safety issues that could cause falls and injuries. The staff had been instructed to tuck all bed cranks under the bed to prevent falls causing injuries to residents. A review of the facility?s policy and procedure (revised on February 16, 2009) titled ?Safety/Risk Management? under section (f) revealed to ?Turn all handles on beds in and under the bed to avoid bumping or tripping. Another facility?s policy titled ?Standard Precautions? from the Nursing Services and Procedure manual (undated) indicated that ?All bed cranks properly closed when not in use.? The facility failed to provide a resident with an environment that was free from accident hazards by failing to ensure that all bed cranks/handles were tucked under the bed, as indicated in the facility?s policies and procedures, to prevent accidents/injuries to the residents that ambulate (walk) close to, and around the bed. And as a result, Resident 7 sustained a four centimeters laceration to the left lower leg by bumping into a bed crank/handle that was protruding out from under the bed while ambulating to the bathroom. The above violation had direct relationship to the health, safety and security of Resident 7 and other residents in the facility. |
| 970000161 |
EISENHOWER HEALTHCARE CENTER |
950009401 |
B |
18-Jul-12 |
H6GQ11 |
6081 |
F249-483.15(f)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the State in which practicing; and is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or has 2 years of experience in a social or recreational program within the last 5 years, 1 of which was full-time in a patient activities program in a health care setting; or is a qualified occupational therapist or occupational therapy assistant; or has completed a training course approved by the State. On March 28, 2012, at 9:10 a.m., during the annual recertification survey, an investigation was made by Evaluator 2, regarding the activities program.The facility failed to ensure that an on-going program of activities designed to meet the interests and the mental and psychosocial well-being of each resident, was provided by failing to:1. Ensure that the activity assessments for the residents were completed by or conducted under the direction of a qualified activity director as indicated in the facility's policy and procedures.2. Ensure that activities were being conducted under the direction of a qualified activities director as indicated in the facility's policy and procedures.As a result thirteen facility residents did not have an on-going program of activities designed by a qualified therapeutic recreation specialist or an ?Activities? professional to meet their activity needs.During an interview on March 28, 2012, at 9:10 a.m., the director of nursing (DON) stated that the facility's full-time activity director had been on leave since January 2012. The DON stated that in the meantime, the facility's activities program was conducted by two certified nursing assistants (CNA 1 and CNA 2); CNA 1 was a full-time staff member and CNA 2 worked on the days when CNA 1 was off. Both CNA 1 and CNA 2 did not have the qualifications of an activity director. During an interview on March 28, 2012, at 9:35 a.m., the administrator stated that the facility's activity director went on a temporary leave on December 31, 2011, and that the facility hired a staff (Staff 1) to be trained to conduct activities with the residents during the absence of the activity director. However, Staff 1 could not train to become a qualified activity director and quit working at the facility on February 2012. Up to now (March 28, 2012), the facility still has had no qualified activity director. All activities were being conducted by CNA 1 and CNA 2. There was no evidence that CNA 1 and CNA 2 were qualified to provide activities to the residents or were conducting activities under the direction of a qualified activity director. During an interview on March 28, 2012, at 9:52 a.m., CNA 1 stated that she started conducting activities last week. CNA 1 stated that she had no proper training or experience in ?running activities?. CNA 1 stated that the facility had no qualified activity director at this time.On March 28, 2012, at 9 a.m., a review of Resident 5's clinical records revealed a completed and signed assessment form entitled ?Resident Activity Assessment?.During an interview on March 29, 2012, at 9:10 a.m., the administrator stated that he completed Resident 5's activity assessment and that he (the administrator) had signed in the section of the ?Resident Activity Assessment? form reserved for the activity director. When asked if he had any prior training and qualifications as an activity director, the administrator stated, "No." A review of all of the residents' clinical records revealed that the administrator had also completed and signed the Resident Activity Assessment forms for the following residents: Residents 2, 3, 4, 5, 9 and Randomly-Selected Residents (RS) 16, 19, 21, 22, 23, 24, 25 and 26.The review of all of the residents' clinical records revealed that Staff 1 also completed and signed the Resident Activity Assessment forms for the following residents: Resident 7 and RS 18, 20, 27, 28, 29, 30, 31, 32, 33 and 34. The administrator stated that Staff 1 was not qualified to perform the assessment duties of an activity director. In the absence of the facility's full-time qualified activity director, the facility's administrator and Staff 1 performed the activity assessments. However, there was no evidence that the administrator and Staff 1 were qualified to perform the assessment duties of an activity director or were conducting activity assessments under the direction of a qualified activity director. The facility's undated policy and procedures, titled "Activity Director," indicated that, "The primary purpose of the Activity Director's job position is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current federal, state, and local standards, guidelines and regulation, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident." The facility failed to ensure that an on-going program of activities designed by a qualified therapeutic recreation specialist or an activities professional to meet the interests and the mental and psychosocial well-being of each resident by failing to:1. Ensure that the activity assessments for the residents were completed by or conducted under the direction of a qualified activity director as indicated in the facility's policy and procedures. 2. Ensure that activities were being conducted under the direction of a qualified activities director as indicated in the facility's policy and procedures.This violation had a direct relationship to the physical, mental and psychosocial well-being of the residents. |
| 970000161 |
EISENHOWER HEALTHCARE CENTER |
950009402 |
B |
18-Jul-12 |
H6GQ11 |
8561 |
F248- 483.15(f) (1). The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident. On March 27, 2012 at 2:30 p.m., during the annual recertification survey, an investigation was made by Evaluator 1 and Evaluator 2, regarding activities.The facility failed to provide an ongoing program of activities designed to meet the interests and the needs of each resident by failing to: 1. Provide individualized activities to reflect the activities of choice and interest for the facility residents, such as religious/Bible studies, reading, and provide activities away from the facility, as indicated in the facility?s policy and procedures titled, "Activity?s Program". 2. Provide activities as indicated on the facility activities schedule to meet the needs of the residents.As a result, five residents (11 and 13, RS 20, RS 31, and RS 32 were provided with activities that were not reflective of their interests and lifestyles for three months.During the group meeting held on March 27, 2012 at 2:30, p.m., three of ten alert and oriented residents stated that they had no activities away from the facility as they usually do such as; picnics since January 2012, when the Activity Director went on leave. A review of the activity calendar for the months of January, February and March 2012, did not contain documentation that activities away from the facility were scheduled. During an interview with the Director of Nursing on March 28, 2012, at 9:10 a.m., she stated that the facility had not taken the residents for activities away from the facility for about three months, since the absence of the Activity Director. A review of the admission information record on March 28, 2012, indicated that Resident 13 was admitted to the facility on November 25, 2009. The resident's diagnoses included: chronic obstructive pulmonary disorder exacerbation (a progressive chronic lung disease where there is a worsening of shortness of breath), hypertension (high blood pressure), anxiety and psychosis (a severe mental disorder characterized by a loss of contact with reality). A review of the most recent Minimum Data Set (MDS), a standardized assessment and care planning tool, dated March 1, 2012, indicated that Resident 13 was assessed as being oriented with no short and long term memory impairment and was able to verbalize her needs appropriately and required limited assistance with the performance all aspects of daily living. The Resident 13?s plan of care dated June 17, 2011, revealed a goal that addressed the resident's preference and favorite activities. The goal was that the resident would be able to participate in preferred activities of choice daily. Another plan of care dated December 2, 2011, addressed the resident's episodes of anxiety. The care plan goal was to limit the resident's feelings of restlessness due to shortness of breath. The listed approaches included to encourage the resident to participate in activities of choice, divert her attention as much as possible and encourage the resident to come to activity of choice. On March 28, 2012, at 1:45 p.m., an interview was conducted with Resident 13. The resident stated that no one from the facility had asked her about her activity preferences. The resident further stated that she would love to attend bible studies maybe for an hour at least twice a week, which was about as much as she would be able to tolerate without having shortness of breath. The activity was not offered to her even though she had informed a staff member about her needs.A review of the facility's activity calendar for the months of January, February and March 2012, indicated that at 11:30 a.m. on Mondays, and at 11 a.m. on Saturdays, a church volunteer was listed. However, the calendar was not specific as to what type of activity the church volunteer would be doing.During an interview with the director of nursing (DON) on March 30, 2012, at 2 p.m., she stated a Christian church volunteer would come to the facility and visit the residents. The DON was not too sure of the specific Christian activities were planned to be done. On March 28, 2012, at 3:30 p.m., RS 31 stated during an interview, that "The activities provided by the facility are as boring as looking at the white walls." The resident stated that he only goes to the activity to have coffee because during the activities there was no peace and order. The activity staff members usually do not monitor the residents while attending activities. During an interview with the LVN Supervisor thereafter, she stated RS 31 was alert, oriented and able to verbalize his needs. The resident required maximum to total nursing assistance in the areas of transferring, personal hygiene and grooming. Resident 11 was admitted to the facility on December 28, 2011, with diagnoses that included hypertension and diabetes mellitus. The MDS dated January 9, 2012, indicated that the resident had no memory problem.During an interview on March 29, 2012 at 1:55 p.m., the resident stated that the activities in the facility did not interest him and therefore he preferred to just be in his room and watch TV. The resident stated that he might go to the activity room if there was for example; good entertainment from a performer(s). He further stated that scheduled activities such as arts and crafts, did not interest him. The resident stated, that no activity personnel (or anybody) had asked him about his likes/interests. The resident stated that he did like to read books, but nobody from the facility had asked and provided him with any reading materials.During an interview on March 29, 2012 at 1:50 p.m., a randomly-selected resident (RS 20) stated that he preferred staying in his room and that he did not like going to the activities. The resident stated that the activities offered in the facility did not interest him. The resident also indicated that nobody from the facility had asked him of his likes and interests. On March 30, 2012 at 2:30 p.m., RS 32, was interviewed and stated that there was no consistency with the activity staff since the activity director left in December 2011. The resident stated that the certified nursing assistants (CNAs) who worked on the floor were also being utilized as activity staff. RS 32 further stated that sometimes, some of the activities were cancelled without their knowledge. Shortly after, the LVN Supervisor was interviewed on the same day and she stated that the activity director will be coming back soon. The LVN Supervisor further stated that RSR 32 was alert, oriented and very pleasant and needed extensive nursing assistance in transferring and performing personal hygiene and grooming. The facility's undated policy and procedures titled, "Activity Program," indicated, "An ongoing program of activities is designed to meet the needs of each resident. Our activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and can include:a. Social activities b. Indoor and outdoor activities c. Activities away from the facility d. Religious programs e. Creative activities f. Intellectual and educational activities g. Exercise activities h. Individualized activities i. In-room activities j. Community activities. Individualized and group activities are provided that:a. Reflect the schedules, choices and rights of the residentsb. Are offered at hours convenient to the residents, includingholidays and weekends c. Reflect the cultural and religious interests of the residents: and d. Appeal to both men and women as well as all age groups ofresidents residing in the facility." The facility failed to provide an ongoing program of activities designed to meet the interests and the needs of each resident by failing to: 1. Provide individualized activities to reflect the activities of choice and interest for the facility residents, such as religious/Bible studies, reading, and provide activities away from the facility, as indicated in the facility?s policy and procedures titled, "Activity?s Program". 2. Provide activities as indicated on the facility activities schedule to meet the needs of the residents.This violation had a direct relationship to the health and safety of Residents 11 and 13, RS 20, RS 31, and RS 32. |
| 950000038 |
EL MONTE CONVALESCENT HOSPITAL |
950009844 |
B |
18-Apr-13 |
9OQV11 |
5662 |
Title 22- Unusual Occurrence 72541- Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility must report any unusual occurrences such as epidemic outbreaks that threaten the welfare, safety or health of patients, personnel or visitors to this Department, within 24 hours. On November 26, 2012, at 2:50 p.m., an unannounced visit was made to the skilled nursing facility (SNF) to investigate an anonymous complaint. During the entrance conference the Director of Nursing (DON) reported to the Surveyor, that at that moment she was reporting a gastrointestinal outbreak (GI outbreak) to the Department. The facility failed to report an unusual occurrence by failing to: 1. Report to the Department within 24 hours of a suspected GI outbreak involving patients and staff. During the investigation of the unusual occurrence regarding the GI outbreak on November 27, 2012, at 4:15 p.m., the DON stated that on November 22, 2012, she did not notify the Department by telephone within the 24 hours of the occurrence as required because she was out of the facility, but she had given her report to the facility administrator. A review of the GI symptoms and treatment histories of the nine patients and two staff revealed the following:1. Patient 1 on November 17, 2012, was noted with vomiting and diarrhea. On the same day, the physician ordered ciprofloxacin (antibiotic used to treat bacterial infection) 500 milligrams (mg) for five days. 2. Patient 2 on November 19, 2012, was noted with diarrhea. On the same day, the physician ordered ciprofloxacin 500 mg for five days and to test for Clostridium difficile (C. difficile/bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). 3. Patient 3 on November 21, 2012, was noted with vomiting and diarrhea. On the same day, the physician ordered to test for C. difficile, flagyl (antibiotic drug used to treat certain parasitic and bacterial infections) 500 mg for five days, levaquin (antibiotic used to treat bacterial infection) 500 mg for five days, and to provide adequate fluid for hydration.4. Patient 4 on November 22, 2012, was noted with vomiting. On the same day, the physician ordered to transfer the resident to the acute hospital. 5. Patient 5 on November 22, 2012, was noted with vomiting. On the same day, the physician ordered Compazine (medication licensed for treating severe nausea and vomiting).6. Patient 6 on November 23, 2012, was noted with vomiting. On the same day, the physician ordered to test for C. difficile and flagyl 500 mg for five days. 7. Patient 7 on November 23, 2012, was noted with vomiting and diarrhea. On the same day, the physician ordered to test for C. difficile and to provide adequate fluid for hydration.8. Patient 8 on November 22, 2012, was noted with vomiting and diarrhea. On the same day, the physician ordered Reglan (used to treat nausea and vomiting) 5mg every eight hours as needed for nausea and vomiting and Imodium (used to treat and control diarrhea) 2 mg every six hours as needed for diarrhea. 9. Patient 9 on November 22, 2012, was noted with vomiting and diarrhea. On the same day, the physician ordered to transfer the resident to the acute hospital. 10. Staff 1 on November 21, 2012, was noted with vomiting and diarrhea. 11. Staff 2 on November 22, 2012, was noted with diarrhea. A review of the facility?s written line list indicated that the facility first notified the Department on November 26, 2012, of the occurrence of the GI symptoms, five days after Patient 1, 2, and 3 and Staff1 were identified with vomiting and/or diarrhea that required treatment. This occurrence should have been identified as an outbreak on November 21, 2012, and should have been reported within 24 hours.During a review of the line list dated December 6, 2012, indicated that a total of 20 residents developed vomiting and/or diarrhea during the period of November 17, 2012 to December 4, 2012. A total of six specimens for six different patients were sent to the public health laboratory. One patient (Patient 10) tested positive for Norovirus (virus that causes stomach or intestines or both to get inflamed that leads to stomach pain, nausea, and diarrhea and vomiting). In addition, the review of clinical records indicated that one patient (Patient 11) tested positive for C. difficile. The undated facility policy and procedure titled, "General Infection Control Policy Statement," indicated that the administrator or DON will be responsible for telephoning a report to the health department of unusual occurrences.The facility failed to report an unusual occurrence by failing to: 2. Report to the Department within 24 hours of a suspected GI outbreak involving patients and staff.These violations had a direct relationship to the welfare, safety and health of patients, personnel or visitors. |
| 950000029 |
ELMCREST CARE CENTER |
950009987 |
B |
01-Jul-13 |
EDNB11 |
8346 |
F- 505 CFR 483.75(j)(2)(ii) Promptly notify the physician of lab results. The facility must promptly notify the attending physicians of the findings. On February 28, 2012, at 10 a.m., during the survey it was noted that Resident A?s critical laboratory results were not reported to the resident?s physician. Based on observation, interview and record review, the facility failed to promptly notify the attending physician of the laboratory (lab) report findings by failing: 1. To notify Resident A?s physician of the abnormal critical results of the CBC (Complete Blood Count) test taken on February 22, 2012. As a result, there was a delay in treatment, such as the administration of Procrit (a medication use to treat anemia) and transfer to the acute hospital for blood transfusion to prevent further bleeding.A review of the admission information record on February 28, 2012, indicated Resident A was readmitted to the facility on August 7, 2011, with diagnoses that included cerebrovascular disease (CVA- stroke), osteoporosis (brittle bones), anemia (low blood cell count), and breast cancer malignancy and neoplasm (a new abnormal growth or tumor) and chronic kidney disease.The most recent Minimum Data Set (MDS- a standardized assessment and care screening tool) dated December 3, 2011, indicated the resident was assessed as having short and long term memory impairment but was able to verbalize needs. Additionally, Resident A required minimum to extensive nursing assistance to perform activities of daily living such as personal hygiene and grooming.On August 7, 2012, a plan of care was developed to address the resident's diagnosis of anemia. The care plan approaches included to monitor the resident?s hemoglobin and hematocrit (h and h) levels as ordered and to report the results to the physician promptly.On February 20, 2012, the physician ordered a CBC (Complete Blood Count- gives important information about the kinds and number of cells in the blood) and a CMP (Complete Metabolic Panel - is a group of 14 blood tests such as glucose, albumin, electrolytes etc. that evaluate organ function to investigate an existing complaint or symptom) to be taken in the morning of February 21, 2012. However, on February 21, 2012, the laboratory report showed abnormal critical values as follows:1) Total protein (a biochemical test to measure the total amount of protein in the blood) was 5.8 grams (g.) (which was low as compared to the normal reference range). The normal reference range is between 6.4-8.3 g. (decreased levels may be related to malnutrition, liver disease and over hydration - taken from: Mosby's "Diagnostic and Laboratory Test Reference" ninth edition, 2009). 2) Hemoglobin (Hgb. is a protein in red blood cells that carries oxygen to the body's organs) was 7.7 g (low- indicates anemia; the normal range is between 11.5- 15.5 g). 3) Hematocrit (is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells) was 22.5 g (normal values is between 34.9- 44.5 for women - low count indicative of anemia or bone marrow loss). The resident's physician was notified on the same day as documented in the laboratory report form and the physician ordered a repeat CBC test to be done on the following day, February 22, 2012. The order indicated to administer ferrous sulfate (iron supplement) 325 milligram (mg) orally two times a day and obtain three stool specimens to be tested for occult blood (OB-a lab test for hidden blood in the stools).On February 22, 2012, 9:44 p.m., the results again showed critical abnormal values as follows:1) Red Blood Cells (RBC- responsible for carrying oxygen to the body tissues) was 1.97 (which was low - normal value is between 4.2 -5.4 milligrams per unit liter-(m/ul) for women, this indicates anemia, immune system disorder and or cancer), hemoglobin (Hgb. was- 7.4 , critically low- normal range is between 11.5- 15.5 grams which indicates anemia or bleeding). 2) Hematocrit (Hct.) was 21.0 (low- see above normal values).A review of the laboratory report form dated February 22, 2012, also contained a section which the nurse is to document and complete to indicate the date and time the physician was notified, along with the signature of the reporter. This section was blank, which indicated the physician was not notified of the result. Furthermore, there was no documented evidence the occult blood test for the stools were taken. During an interview with Staff 1 on February 28, 2012, at 2:30 p.m., she stated she did not know the reason why the resident's critical lab results of February 22, 2012, were not reported to the physician until February 29, 2012, but will inquire from the licensed staff. The Staff 1 further stated the facility's policy is to have the licensed staff report all laboratory results especially with critical values to the physician promptly as soon as received and to document such report in the designated section of the report form. However, upon request, Staff 1 was unable to provide any documented policy and procedure for reporting laboratory results to the physician.On the same day, during a second interview with Staff 1 at 4:30 p.m., she stated Staff 2 who worked on the 3 pm -11 pm shift had attempted to notify the resident's physician on several occasions through the telephone exchange upon receipt of the critical value lab result. However, the physician could not be reached, and Staff 2 left a message. However, Staff 2 still did not receive any response from the physician. The Staff 1 further stated the facility's Medical Director was not made aware of the results. The Staff 1 stated that in the event any resident's physician could not be reached the licensed staff should notify the Medical Director. Additionally, the Staff 1 stated the licensed staff had reported that three rectal swabs were taken to obtain stool specimens from the resident and were sent to the lab on February 23, 2012. However, the lab rejected the specimens because the amount was not sufficient for the type of test and requested sufficient stool specimens. The stool specimens were sent to the lab on March 1, 2 and March 3, 2012, with negative results (no blood). However, further review the medical records (licensed nursing notes and lab results for February 2012) indicated above information was not documented.According to the licensed nursing notes, the staff notified the attending physician of Resident A of the abnormal lab results on February 29, 2012, seven days (7) after the lab test was done. On the same day thereafter, the physician ordered to administer Procrit 10,000 units (a medication to treat low red blood cells (RBC) caused by anemia or chronic kidney failure) subcutaneously (sq) every Monday, Wednesday and Friday for anemia, and to conduct a repeat CBC on March 2, 2012.During an interview with Family Member 1 on February 29, 2012, at 10:45 a.m., he stated the resident had severe anemia for a long time and had received several blood transfusions (the process of receiving products into one's circulation intravenously used in a variety of medical conditions) in the past. At 10:50 a.m. on the same day, an interview with Staff 3 was conducted. Staff 3 stated he had received a report that the resident had some blood tinged bowel movement during the night shift (February 29, 2012) and that the physician was made aware.According to the licensed nursing notes, on March 13, 2012, the resident was transferred to the acute hospital due to a hemoglobin result of 7.6. A review of the acute hospital records indicated, Resident A received two (2) units of red blood cells transfusion on the same day of the resident?s transfer at the acute hospital.The facility?s failure to promptly notify the attending physician of the laboratory (lab) report findings by failing to notify Resident A?s physician of the abnormal critical results of the CBC (Complete Blood Count) test taken on February 22, 2012, resulted in a delay in treatment, such as the administration of Procrit (a medication use to treat anemia) and transfer to the acute hospital for blood transfusion to prevent further bleeding.This violation had a direct relationship to the health of Resident A and other residents in the facility. |
| 950000103 |
Eastland Subacute and Rehabilitation Center |
950012855 |
A |
6-Jan-17 |
T2JM11 |
14708 |
F225 483.13 (c)(1) (ll)-(lll) (C ) (2) -(4) Investigate/ report Allegations/individual The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F323 483.25 (h) Free of Accident Hazard/supervision/devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 10/11/16, at 2:55 p.m., an onsite visit to the facility was made to investigate an anonymous complaint to the Department of Public Health, regarding Resident 1 threatening to come back to shoot and stab nursing staff after his discharge. Based on observation, record review, and interviews, the skilled nursing facility (SNF) failed ensure that the resident environment remained as free of accident hazards as possible, by failing to take appropriate actions regarding an alleged threat, that Resident 1 will come back to the facility after his discharge, to shoot and stab nursing staff. There were one hundred thirty five residents in the facility at that time. Resident 2 reported to multiple facility staff of Resident 1's threat but the facility failed to do the following: 1. Report to the Law Enforcement. 2. Report to the Department of Public Health. 3. Have documented evidence of an investigation of Resident 1's threat. These deficient practices created an environment of fear and anxiety to Resident 2 and the staff; and the potential of causing grave danger, serious injury, or death to staff, residents, and/or visitors if Resident 1 returned to the facility to activate his threats. On 10/11/2016 at 2:55 p.m. the SNF Administrator and Director of Nursing (DON) were made aware regarding an anonymous complaint to the Department of Public Health, regarding a threat that Resident 1 was coming back to the facility to shoot and stab nursing staff after his discharge. Both the Administrator and DON stated no staff, resident, or visitor reported the threat to them. During an interview on 10/11/16 at 3:35 p.m., the Social Services Assistant (SSA) stated Resident 1 yelled and was verbally abusive to staff, being easily agitated and upset over not having his usual methadone (medication used to treat people addicted to drugs). A review of Resident 1's "Admission Record" indicated an admission date to the facility on XXXXXXXwith a known history of Anxiety (mental health disorder where the person feels constant panic that interferes with their activities of daily living), Type II Diabetes (inability for the body to control normal blood sugar levels), and partial traumatic amputation of the right and left foot (surgery to remove a part of the foot, or feet, caused after an injury or trauma to the feet) for which Resident 1 was admitted to the SNF. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 7/26/16, indicated Resident 1 had no problems with hearing, speech, vision, cognition, behavior, and mood. The resident was able to move in bed, transfer, and dress with only staff oversight. According to Resident 1's 8/31/16 "Interdisciplinary Team (IDT) Conference Record" documented by the Social Service Assistant (SSA), Resident 1 was requesting increased pain medications while visibly mumbling and having whitish secretions at the mouth during the IDT meeting, was complaining about having dry mouth and verbalizing a flight of ideas (a rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to topic: a symptom of some mental illnesses). During this IDT meeting staff questioned Resident 1 about being on drugs and Resident 1 admitted to self-administering his personal Dilaudid (also known as Hydromorphone, a narcotic drug used to treat moderate to severe pain that can cause decreased respirations, decreased blood pressure, decreased mental alertness, drowsiness, sleepiness, strange dreams, dry mouth, and drug tolerance and drug addiction to narcotics and when combined with other narcotic medication/narcotic recreational drugs can cause serious injury or death). During the IDT meeting Resident 1 continued to exhibit flight of ideas and paranoia (an intense anxious or fearful feelings and thoughts often related to persecution, threat, or conspiracy stating he had seen a man, the boyfriend of his ex-girlfriend, climb out of the fence and pointing at him when he was buying something at the facility vending machine. During an interview on 10/11/16 at 3:35 p.m., the Social Services Assistant (SSA) stated Resident 1 yelled and was verbally abusive to staff, being easily agitated and upset over not having his usual methadone (medication used to treat people addicted to drugs). During an interview, on 10/12/16 at 9:30 a.m., Resident 2 stated on the day Resident 1 was discharged on XXXXXXX, Resident 2 was in the SNF front lobby when Resident 1 came up and waited in the front lobby for his ride. Resident 1 began talking to Resident 2 and showed Resident 2 a knife tucked away in his pants, and stated he would return back to the SNF to shoot and stab the nurses. Resident 2 stated Resident 1 also threatened to come back and steal his motorized wheelchair. Resident 2 stated after Resident 1 left the facility, he informed the front desk lobby staff receptionist immediately. Resident 2 stated after informing the receptionist, he went straight over to the Administrator and informed her of what Resident 1 had said. He stated later that same night on 10/5/16, he informed his two certified nurse assistants (CNAs), CNA 1 and CNA 2, while they assisted him back into bed for the night. Resident 2 stated he also told two other CNAs (he did not remember the names of the CNAs) of Resident 1's threat, a few days later. During this interview, Resident 2 stated Resident 1 made brass knuckles out of the butter-knives. Resident 2 stated many times Resident 1 looked like he was "under the influence" while at the facility and staff knew about all of it. While talking about Resident 1, Resident 2 was observed anxious, nervous, trembling and eyes watering. Resident 2 emphasized how worried he was for the staff here. A review of the Admission Record indicated Resident 2 was admitted to the SNF (Skilled Nursing Facility) on 1/4/2014 with a history of Guillain-Barre Syndrome (neurological disorder where the immune system attacks the nerves triggered by a viral or bacterial infection which causes muscle weakness and eventual paralysis), quadriplegia (paralysis of the torso and all four limbs), and generalized muscle weakness (full body muscle weakness). A review of Resident 2's Minimum Data Set dated 7/9/16 indicated Resident 2 was alert and oriented to person, place, time, and situation with no cognitive, behavior, mood, hearing, vision, or speech problems, and was totally dependent on two staff for transferring, dressing, eating, toilet use, and personal hygiene, and required a motorized wheelchair for getting around. During an interview on 10/12/16 at 8:55 a.m., with a local Police Officer and the SNF Administrator, the Police Officer stated that he had visited the SNF previously for a disturbance caused by Resident 1. He recalled Resident 1 mentioned to the officers and the staff that he was from a local motorcycle gang. On 10/12/16 at 10:50 a.m., after speaking to Resident 2, the local Police Officer was talking to the Administrator. The Police Officer told the Administrator of his investigation, that Resident 1's threat to come back to shoot and stab the nursing staff, was a credible threat. During an interview on 10/12/16 at 1:05 p.m., CNA 1 stated Resident 2 told her that Resident 1 had shown him a gun and a knife and had threatened to come back and shoot and stab the nurses and that he had informed both the Administrator and the Evening Nursing Supervisor/Registered Nurse. CNA 1 stated that Resident 2 told her that Resident 1 called him on his personal cell phone on 10/5/16 around 7 pm to reiterate that he was going to come back and shoot people in the building that night. CNA 1 stated she informed the Evening Nursing Supervisor/Registered Nurse that night on 10/5/16 around 7:00 p.m. of what Resident 2 told her. CNA 1 stated she thought that because she had informed her supervisor; and Resident 2 informed both the Administrator and the Evening Nursing Supervisor/Registered Nurse, that it was being taken care of. CNA 1 stated she was very worried about this. CNA 1 stated Resident 1 had been previously found making two brass knuckles from butter-knives and the Evening Nursing Supervisor/Registered Nurse was aware. During an interview with CNA 2 on 10/12/16 at 3:43 p.m. she stated she was informed by Resident 2 that Resident 1 was going to shoot and stab a few of the staff. CNA 2 stated Resident 1 was very violent, had very bad looking friends, was tall and big, full of tattoos and scary looking. CNA2 stated she was very worried about this. She stated she wouldn't put it past Resident 1 doing something like this. CNA 2 stated she had informed the Evening Nursing Supervisor/Registered Nurse the day Resident 1 was discharged, but had not received follow up from him yet. During an interview with CNA 3 on 10/12/16 at 4:08 p.m. he stated Resident 2 told him that on the day that Resident 1 was discharged, Resident 1 came up to Resident 2 in the front lobby and showed him his gun and knife and said he was going to come back and shoot and stab a few CNAs. Then, two days later Resident 2 told CNA 3 that Resident 1 had called Resident 2 and told Resident 2, he was planning on coming back to shoot and stab a few of the CNAs. In an interview on 10/12/16 at 4:37 p.m., the DON stated staff are expected to report any threats to shoot or stab nurses to the Administrator, the DON, or higher level staff, so that it can be investigated, call it to the Police Department, and report it to the Department of Public Health. The DON was not able to show evidence it was reported to law enforcement or to the Department of Public Health. The DON stated there was no report made to the Police Department or to the Department of Public Health. On 10/14/16 at 3:30 p.m. a concurrent interview with the Administrator and viewing of the video surveillance footage of the front lobby for 10/5/16 from 6:20 p.m. to 6:41 p.m., Resident 2 was seen sitting in his wheelchair at 6:20 p.m. talking to another resident, when he was approached by Resident 1 at 6:35 p.m., and began to talk to him. Then Resident 1 lifted up his white shirt to show Resident 2 something. Resident 1 exited the building a few minutes later at 6:40 p.m., out the front lobby door. At that time Resident 2 was seen in the video footage in his motorized wheelchair, wheeled himself and talked with the receptionist, then wheeled himself back into the hallway. After viewing the video, the Administrator stated that four CNAs and one receptionist in total were made aware of Resident 2 reporting Resident 1 threatening to come back and shoot nursing staff after being discharged home. The Administrator was not able to show any evidence of an investigation, or any action taken regarding the threat. The Administrator stated the SNF had no address or valid contact phone number for Resident 1 to provide assistance to the local Police Department for this investigation. The SNF's undated "Active Shooter Procedure" stated staff should alert administration immediately if they believe an employee or visitor exhibits any of the following: violent behavior, unsolicited comments about violence/crimes, illegal drugs, increased/severe mood swings, increased discussions of problems at home, and unsolicited comments about dangerous weapons. According to the SNF's undated policy on "Unusual Occurrences" the facility was to report unusual occurrences to the local Health Department within twenty-four hours of each occurrence. The policy identified examples of unusual occurrences as occurrences that constitute an interference with facility operations that affect the welfare, safety, or health or residents, personnel or visitors, misappropriation of residents' property by staff, and allegations of abuse, neglect. The facility failed ensure that the resident environment remained as free of accident hazards as possible, by failing to take appropriate actions regarding an alleged threat, that Resident 1 will come back to the facility after his discharge, to shoot and stab nursing staff. There were one hundred thirty five residents in the facility at that time. Resident 2 reported to multiple facility staff of Resident 1's threat but the facility failed to do the following: 1. Report to the Law Enforcement. 2. Report to the Department of Public Health. 3. Have documented evidence of an investigation of Resident 1's threat. These deficient practices created an environment of fear and anxiety to Resident 2 and the staff; and the potential of causing grave danger, serious injury, or death to staff, residents, and/or visitors if Resident 1 returned to the facility to activate his threats. These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 960001522 |
EMILY CARE CENTER |
960009358 |
B |
15-Jun-12 |
IK8111 |
11530 |
W&I 4502Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.It is the intent of the Legislature that person with developmental disabilities shall have rights including, but not limited to, the following:(d) Free from harm On April 24, 2012 during a recertification survey Client 4 physically beat Client 1 in the head and shoulder and verbally threatened to kill Client 1.Based on interview and record review the facility's administrative staff failed to: 1. Ensure the safety of Client 1 who was physically and verbally attacked by Client 4. Client 4 physically beat Client 1 in the head and shoulder and verbally threatened to kill Client 1. Client 1 was taken to the emergency department of an acute care facility and was diagnosed as having a back strain (injury of the muscles in which fibers are stretched, torn or injured). Pain medication was ordered. According to the client's face sheet , Client 4 was admitted to the facility September 1, 2011 with the diagnoses of moderate intellectual disability, (an IQ score in the 36 to 51 range that also has other adaptive behavior problems may be diagnosed with moderate intellectual disability. Other symptoms of this disability include problems learning to talk, seizure disorder (A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations), diabetes type II (the body does not produce enough insulin or the cells ignore the insulin), hypothyroidism (a condition in which the thyroid gland doesn't produce enough of certain important hormones), hypertension (a condition in which the blood pressure in the arteries is chronically elevated), schizoaffective disorder (This condition involves both psychotic symptoms and conspicuous, long-enduring, severe symptoms of mood disorder), and impulse control disorder ( psychological disorders characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others).On April 22, 2012 at 8:45 a.m., a review of Client 4's Individual Program Plan (IPP)dated October 17, 2011 revealed, Client 4 had a history of hallucinations (false sense perception: imagines seeing, hearing, or otherwise sensing when it is not present or actually occurring at the time), delusions (false belief and feelings of paranoia, (unreasonable suspicion of other people). The program plan revealed when the client heard voices he would become angry because the voices would tell him he's a bad person and to do bad things. The report indicated Client 4 would yell, and could become verbally aggressive towards others including staff and peers residing in the facility by using profanity in response to them making request of him.On April 24, 2012 at 8:30 a.m., during a telephone interview the Qualified Mental Retardation Professional (QMRP) reported an incident which occurred March 23, 2012 at 6:00 p.m. The QMRP stated she received a phone call from the facility's administrator April 23, 2012 at 6:00 p.m., informing her that Client 4 had attacked another client and had been arrested by the police.The QMRP further stated on April 23, 2012 at 6:00 p.m., she received a call from the administrator/owner of the facility who informed her that Client 4 had another behavior incident of striking Client 1, and was arrested.On April 24, 2012 at 9:45 a.m., during an interview with the administrator she stated, on April 23, 2012 between 4 p.m., and 5 p.m., she received a call from the staff who informed her that an incident had occurred in the facility which needed her attention. She said Staff N informed her when Client 4 arrived from school he was in a bad mood, and that his eyes were red and he was foaming at the mouth. The client ran into his bedroom, followed by Client 1 who was taunting him, so Client 4 began hitting Client 1. The administrator said Staff N told her, Client 4 hit Client 1 in the head many times, in the shoulder and pushed him against the wall. Staff N attempted to separate the clients but she could not control Client 4 and she was afraid of the client. The administrator stated Staff N called 911 because she was afraid for the life of Client 1. The administrator further stated Staff N told her, Client 4 started hitting the wall, screaming "I will kill you," referring to Client 1. Client 4 was attempting to hit anyone who came his way that included the staff and the clients present in the facility. The administrator stated staff felt that Client 4 was uncontrollable and did what they felt they had to do by calling the police.The administrator said the staff told her, the police asked Client 1 what happened and the client told the police Client 4 hit him in the head many times, he always hits him and he wanted to press charges against Client 4 and have him arrested. At that point the police removed the client from the facility in a peaceful manner. On April 24, 2012, the administrator voluntarily submitted a signed declaration in her handwriting at 3:25 p.m. confirming her interview and further documented, Staff called the police because they feared Client 4 was going to do what he was yelling. Even after he was taken by the police he continued yelling that he will come back and kill Client 1. She further documented, "there are times when you have to pick up choices for the good of others. As much as I want to keep Client 4, I have to give him up for the safety of others. I have to make the first step to improve the safety and care of my other clients. I need to tell my QMRP to start the training of my staff in crucial cases like this. We need guidelines and procedures in order to see the right direction of how to handle the clients in dangerous situations."When the QMRP was asked what was the facility?s staff supposed to do when the client exhibited aggression she stated, "Attempt to calm the client down." The QMRP was then asked if the facility had a behavior plan to deal with his aggression, the QMRP stated, "No." When asked if the behaviorist assessed the client?s behaviors she stated "the behaviorist had not seen the client since the client was admitted September 1, 2011." When asked if the staff received training regarding how to manage the clients aggressive behaviors the QMRP stated, "The staff in the facility did not receive training regarding any of the client ' s behaviors." The QMRP added, "The clients were in need of a behaviorist intervention because most of the clients residing in the facility had behaviors." The QMRP further stated, "The administrative staff knew what they were getting into when they allowed the client to return back to the facility. She said the client was discharged from the facility many years ago because the staff could not handle him then the client was sent to a psychiatric hospital, then to a skilled nursing facility, then back to psychiatric hospital, then back to the facility. The QMRP said the client was very difficult to handle and had many behaviors and probably should not have been re-admitted to the facility since the staff were unable to handle him in the past." When asked if the client was so difficult in regards to his behavior, why did the behaviorist not assess the client and provide the staff with training which would include a plan to manage the clients behavior, the QMRP stated, "I do not train the staff, the administrator was responsible for making certain staff are trained to provide care for the clients and that includes the management of clients with behaviors." On April 22, 2012, during a review of Client 4?s data sheet dated 2012, it was revealed the client had identified behaviors which included physical aggression, property destruction, AWOL (absence without official leave ) attempts, stealing food, self-injurious behaviors, inappropriate masturbation, Obsessive Control Disorder (OCD), and Psychotic episodes.During an interview at 1:10 p.m., with the QMRP she stated, the client does not have a behavior plan to assist in the management of any of the identified behaviors. The QMRP was asked again if any of the staff received training regarding how to manage any of the identified behaviors, the QMRP stated, "No," When the QMRP was asked what was the staff to do when the client exhibits behaviors she stated, "The staff are supposed to follow the behavioral plan which they did not have. On April 24, 2012 the Qualified Mental Retardation Professional (QMRP) voluntarily submitted a signed declaration in her handwriting at 2:55 p.m. which confirmed her interview.During an interview on April 24, 2012 at 2:30 p.m., Client 1 was asked about the incident which occurred on April 23, 2012 he stated, "yesterday when Client 4 arrived from the day program I told him that I told the evaluator on him and that he was now in so much trouble," "I told the evaluator how you hit me and that she knew everything that happened in the facility. Client 1 stated, Client 4 became so angry with him that he hit him in the head many times, hit him on the arm, pushed him and made him fall backwards. Client 1 stated, ?He pushed me against the bathroom window and I went to the hospital. They gave me pain medication and everything is okay." Client 1 stated, he told the police to put Client 4 in jail and that he did not want Client 4 to return to the facility. Client 1 stated crying hysterically, ?I don't like people treating me bad, my tummy is very upset because of what happened yesterday, and that is why I told the police to arrest him, take him to jail because I wanted to press charges."Client 1 stated that he was worried because Client 4 told him that when he came back to the facility, he was going to beat him every day and that made him so afraid. Client 1 continued crying, then said Client 4 pushed him against the bathroom window and had been acting terrible for a long time. Client 1 said the police came to the facility about two months when Client 4 ran away from the staff and was lost for hours. With tears in his eyes Client 1 said, ?Please protect me, my back and my head really hurt, and I am so afraid. Client 1 stated, he told the owner if they bring Client 4 back to the facility he wanted to be transferred out of the facility because he was "tired of the beatings from Client 4." During a review of Client 1?s health record on April 23, 2012 at 1:14 p.m. Client 1 was taken to the emergency department of an acute care facility. According to the After Care Instructions, dated April 23, 2012 at 11:42 p.m., Client 1 was diagnosed as having a back strain (injury of the muscles in which fibers are stretched, torn or injured). Percocet 5/325mg was ordered for pain every four to six hours.Failure of the facility's administrative staff to ensure the welfare and safety of Client 1 exposed the Client 1 to Client 4's aggressive behaviors and resulted in actual harm to Client 1. The above violation had a direct relationship to the health, safety, and security of Client 1. |
| 960001522 |
EMILY CARE CENTER |
960013247 |
A |
8-Jun-17 |
HRDK11 |
15576 |
76872: Developmental Program Services-Staffing
(K) Each facility shall employ sufficient direct care staff to carry out the active treatment programs and meet individual client needs.
On 4/14/17, an unannounced visit was made to the facility to investigate a complaint regarding Client 1 having a black eye, a very large bruise on the left hip and multiple small bruises on arms, thighs, shoulder and underarm area.
The facility's administrative staff failed to:
Ensure sufficient direct care staff was on duty to meet the individual needs for Client 1. The administrative staff failed to provide sufficient direct care staff, for one to one services (staff to client ratio, one staff is taking care of one client) to supervise and care for Client 1. This deficient practice resulted in Client 1 sustaining a black eye and multiple bruises on her body, jeopardizing the client's health and placed the client at risk for potential harm.
During an observation, on 4/14/17, at 7 am, there were 6 clients (4 males and two females) who live in the facility. The clients? intellectual status ranged from mild intellectual disability (slower than typical in all developmental areas) to profound intellectual disability (significant developmental delays in all areas). All six clients required supervision and/or depended on staff for activity of daily livings (ADLs) including walking, transferring, eating and toileting.
During an observation, on 4/14/17, at 7:10 am, Client 1 had a bruise surrounding the client?s left eye (more than 1/2 inch long), a bruise on the left hip (about 3 inches long) a small bruises on the right lower arm (dime size) and a small bruise on the left shoulder (dime size). Client 1 refused to allow the evaluator to check her legs. A concurrent interview was conducted with Client 1 regarding what were the causes of all the bruises on her body; the client did not answer the question. The question was asked in different ways and the client was unable to answer the question.
A review of Client 1's clinical record, on 4/14/17, indicated the client was admitted to the facility on XXXXXXX 16 with diagnoses including mild intellectual disability and Autism (a mental condition, present from early childhood, characterized by difficulty in communicating and forming relationships with other people and in using language and abstract concepts).
A review of Client 1's incident report, dated 4/9/17 (Sunday), indicated Client 1 had a habit of grabbing the steel napkin holder, salt and pepper shakers and putting them away on the highest cabinet shelf that she could reach. The incident report indicated, on 4/9/17, as Client 1 attempted to put the steel napkin holder on the cabinet shelf, the steel napkin holder slipped out of her hand and hit the left side of her face. The report was signed by DCS 2.
A review of the facility's staff schedule for the month of April 2017 indicated DCS 2 and DCS 3 are the only two staff scheduled to work on Sunday from 7 am to 7 pm.
During an interview with DCS 2, on 4/14/17, at 8:10 am, she stated last Sunday, on 4/9/17, at around 6:45 pm, her partner (DCS 3) was in the first bathroom helping Client 2 and she was in the second bathroom helping Client 3. DCS 2 stated before she went into the bathroom with Client 3, she asked Client 1 to sit down on the chair at the dining table. DCS 2 stated as she assisted Client 3 in the bathroom, she heard a loud noise like something dropping on the floor in the kitchen, so she sat Client 3 down on the toilet and ran out to the kitchen. DCS 2 stated when she got to the kitchen, she saw Client 1 was standing next to the stove, both of the clients' hands were resting on the counter, the kitchen cabinet door was opened and the napkin holder was on the floor. DCS 2 stated she asked Client 1 "what happened" and the client responded "I don't know". DCS 2 stated, after that incident, Client 1 did not complain of pain, she did her coloring and went to bed. DCS 2 stated, her schedule was to work every Monday, on evening shift, but for that Monday, 4/10/17, a day after the incident, there was a shortness of staff so she worked in the morning. DCS 2 stated on Monday, 4/10/17, at 7 am, when she helped Client 1 up to the bathroom for a shower, she saw the bruise on the client's eye. DCS 2 stated she did not see the steel napkin holder actually hit Client 1's eye on Sunday, 4/9/17, but there was no other incident that happened to Client 1 prior to the bruise occurring. Therefore, she concluded that the bruise was caused by the steel napkin holder that hit her eye before it landed on the floor.
During an interview with DCS 2, on 4/14/17, at 9 am, DCS 2 stated it is too hard for two staff to take care of 6 clients, especially with Client 1 due to the client's behaviors. DCS 2 stated her assignment was to take care of two clients (Clients 1 and 3). DCS 2 stated both Clients 1 and 3 have behaviors. DCS 2 stated Client 1 had behaviors of yelling out loud, clapping her hands, throwing herself on the floor, running to the laundry room, turning on the washer, the dryer and jumping on her bed. DCS 2 stated these behaviors occur many times per day. DCS 2 stated Client 1 paced back and forth in the kitchen and constantly ask for food. DCS 2 stated Client 2 has behaviors of grabbing fruits, stuffing them into her mouth and hitting herself (self-injury behaviors). DCS 2 stated she had to constantly pay attention to both clients. DCS 2 stated Client 1 needed one to one staff for her safety. DCS 2 stated she asked the facility's Qualified Intellectual Disability Professional (QIDP) to provide one to one staff for Client 1 but she was not sure if the Regional Center (nonprofit private corporations that contract with the Department of Developmental Services to provide or coordinate services and supports for individuals with developmental disabilities) had approved the request. DCS 2 stated the behaviorist had come to the facility twice since Client 1 was admitted to the facility to assess Client 1's behaviors but she was not sure what the results of the visit was. DCS 2 stated she did not how Client 1 got multiple small bruises on her body but she thinks it probably occurred when the client threw herself on the floor.
A review of Client 1's second incident report, dated 4/2/17 (Sunday), indicated at around 6 pm, Client 1 changed into her pajamas, grabbed her clothes and took off to the laundry room. The incident report indicated as the client took off and ran she crashed into the rails on the step hitting her left hip against the rails. The report was signed by DCS 2 and DCS 3.
During an interview with DCS 2, on 4/14/17, at 9:40 am, she stated on Sunday 4/2/17, after dinner, Client 1 changed into her pajamas. DCS 2 stated Client 1 had behavior of flushing her underwear, socks and bra down the toilet. DCS 2 stated due to Client 1's behavior, she would hold onto the client's underwear, bra and socks after the client changed. DCS 2 stated since Client 1's admission to the facility, the client had clogged the toilet more than five times. DCS 2 stated when she held onto Client 1's socks, underwear and bra; the client would run outside to the laundry room to check the hamper for her underwear, bra and socks. DCS 2 stated on Sunday, 4/2/17, after she held onto Client 1's bra, underwear and socks, the client ran outside to the laundry room. DCS 2 stated she stepped out of the kitchen to follow Client 1 but the client was too fast so it was hard for her to catch up to the client. DCS 2 stated as she was behind Client 1, she saw the client bump her left hip into the stair rails outside of the back door. DCS 2 stated she asked Client 1 to come back inside but she did not check the client's hip to see if there was any injury on the client's hip. DCS 2 stated until the next day, Monday, 4/3/17, after Client 1 got home from the day program; DCS 4 helped the client to the bathroom and saw a bruise on Client 1's left hip. DCS 2 stated it was hard to take care of Client 1. DCS 2 stated Client 1 does not follow instructions and the client is really fast. DCS 2 stated everywhere Client 1 goes, staff need to follow the client but staff could not catch up with her. DCS 2 stated staffs pay most of the attention to Client 1 but it was hard because 5 other clients also have behaviors. DCS 2 stated the bruises on Client 1's body was from her behaviors and the accidents. DCS 2 stated she did not see anybody in the facility hit or pinch Client 1.
During an interview with DCS 3, on 4/14/17, at 10:10 am, DCS 3 stated she worked at the facility every Sunday, from 7 am to 7 pm but she did not witness the incidents when Client 1 injured herself and sustained the two big bruises on her left eye and left hip. DCS 3 stated her job duty was to take care of four male clients (Clients 2, 4, 5 and 6). DCS 3 stated it was not her job duty to take care of the 2 female clients (Clients 1 and 3). DCS 3 stated occasionally she helped Client 1 when DCS 2 yelled out her for assistant. DCS 3 stated whenever DCS 2 asked her to help Client 1 she had to leave her four other clients to help Client 1. DCS 3 stated her four other clients also have behaviors and need close supervision. DCS 3 stated 2 staff working on the weekend was not enough staff to take care of 6 clients. DCS 3 stated Client 1 had behaviors of putting the flower vase and the napkin holder in the cabinet. DCS 1 stated every Sunday morning, after Client 1 ate breakfast, she would try to get more food, scream out loud, clap her hands, run around the house and grab her roommate?s undergarment. DCS 3 stated Client 1's behaviors were disturbing and agitated other clients. DCS 3 stated when Client 1 displayed behaviors; she tried to redirect the client by taking the client for a walk in the back yard or around the block. DCS 3 stated Client 1 likes to walk to the store around the block to buy snack, but she could not take the client out often because that left only one staff at the house to take care of 5 clients. DCS 3 stated Client 1 likes to stand next to her to watch her cook. DCS 3 stated her most worry was Client 1's safety. DCS 3 said the thing that worried her most was Client 1 could grab the food and get burned. DCS 3 stated she likes to close the kitchen door when she cooks so Client 1 would not be in the kitchen, but when she does close the door to cook dinner, it leaves DCS 2 supervising and caring for all six clients. DCS 3 stated she noted Client 1 behaving well after she ate a lot of food, however, staff could not let her eat as much as she wants because she easily gains weight and her family members are concerned about the weight gain.
A review of Client 1's special Interdisciplinary Team (IDT) meeting, dated 3/24/17, indicated the IDT team and the Regional Center's staff agreed that Client 1 needs to continue one to one services for another month (from 3/24/27 to 4/24/17) due to Client 1 does not follow staff directives and the client was fast. The IDT meeting minutes also indicated that Client 1 requires 100% attention from staff to keep her safe from harm. The report indicated for Staff to continue to follow Client 1's behavior plans and the behaviorist will observe the client at the day program.
During an interview with facility's House Manager (HM), on 4/14/17, at 11:35 am, regarding the approval hours for Client 1 one to one services, the HM stated he knew that Client 1 was approved for a one to one services, but he was not sure how many hours per day was approved for Client 1. The HM stated he had to call the Qualified Intellectual Disabilities Professional (QIDP) to find out.
During a telephone interview with the facility's QIDP, on 4/14/17, at 12:55 pm, she stated Client 1 was approved for one to one services but the administrator was the one who get paid and completed the schedule. She does not know how many hours of one to one services were approved for Client 1. When asked who was covering for the facility's administrator when the administrator is on vacation, the QIDP stated she was the one.
A review of the facility's program plan, on 4/14/17, indicated for Saturday and Sunday, from 9 am to 7 pm (10 hours per day), the facility needed to provide three direct care staff, excluding the one to one staff for Client 1.
During an interview with the facility's HM, on 4/14/17, at 1:35 PM, he confirmed there was only 2 staff scheduled to work every weekend from 7 am to 7 pm.
On 4/14/17, at 2:05 pm, during an interview with the facility's QIDP, the QIDP stated she has the approval letter for Client 1's one to one staff for the month of March 2017. The QIDP stated the approved hours were 416 hours per month including the hours for both weekend and weekday. The approval hours were for Monday to Sunday 24 hours per day, excluding the hours while Client 1 was attending the day program (Monday to Friday from 7:30 am to 3 pm). The QIDP further stated she did not have the approval letter for April 2017 but she assumed the approval hours stayed the same (416 hours a month). The QIDP stated the facility provided 2 staff on the weekend and 3 staff on the weekday. The QIDP stated the HM works from Monday to Friday with two staff, although the HM's working hours was not on the staff schedule.
A review of the facility's program plan, on 4/14/17 with the facility's QIDP, the facility?s program plan indicated, beside the one to one staff for Client 1, every Monday to Thursday, from 1 pm to 7 pm, the facility needs to provide 3 staff. Every Friday, from 1 pm to 8 pm, the facility needs to provide 3 staff. Every Saturday and Sunday, from 9 am to 7 pm, the facility needs to provide 3 staff.
During an interview with the facility's QIDP, on 4/14/17, at 2:05 pm, she stated the facility had been operating with 2 staff on the weekend for a while. The QIDP did not specify the month and year. The evaluator requested the actual working hours for the last 30 days for staff but the QIDP was unable to provide the documentation.
During a telephone interview with the Regional Center?s staff (Staff A), on 5/30/17, at 3 pm, she stated the Regional Center approved one to one services for Client 1 since the day the client admitted to the facility (XXXXXXX16). Staff A stated the Regional Center approved averages of 532 hours per month, the break down was from Monday to Friday, 17.5 hours per day and from Saturday to Sunday 24 hours per day. Staff A stated the following hours were billed to the Regional Center:
1. For December 2016, 601 hours.
2. For January 2017, 601 hours.
3. For February 2017, 542 hours.
4. For March 2017, 422 hours.
5. For April 2017, 519 hours.
6. For May 2017 the facility was allowed to bill the Regional Center up to 523 hours.
The facility's administrative staff failed to:
Ensure sufficient direct care staff to meet individual client needs for Client 1. The administrative staff failed to provide sufficient direct care staff for one to one services to supervise and care for Client 1. As a result, Client 1 sustained a black eye and multiple bruises on her body, jeopardizing the client's health and placed the client at risk for potential 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. |
| 100000057 |
Eskaton Care Center Greenhaven |
030013565 |
B |
27-Oct-17 |
7QED11 |
7203 |
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 paragraph 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 paragraph 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 following citation is written as a result of complaint #CA00501126. An unannounced visit was made to the facility on 9/8/16 to investigate patient care allegations of failure to respond to Resident 1's change of condition by Licensed Nurse 2 (LN 2).
The Department determined the facility failed to respond to Resident 1's change of condition when LN 2 did not assess Resident 1 after the Certified Nursing Assistant (CNA) reported Resident 1 was declining This failure resulted in Resident 1 failing to receive medical care and services to treat the significant change of condition. This failure may have contributed to Resident 1's death.
Resident 1 was admitted to the facility with multiple diagnoses including heart disease, dementia (a group of diseases that cause a permanent decline of person's ability to think, reason and manage his own life), skin wounds and diabetes (a condition that occurs when the body cannot use sugar, normally). Her MDS (Minimum Data Set, an assessment tool), dated 9/10/15, indicated her cognition (conscious mental activities) was moderately impaired and she required limited to extensive assistance with ADL's (Activities of Daily Living).
Review of Resident 1's clinical document titled Preferred Intensity of Care (medical orders to be honored by health care workers during a medical crisis), signed by her Responsible Party (RP) 9/5/15, indicated Resident 1 wanted:
1. Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure that is performed when someone's breathing or heartbeat has stopped)
2. Artificial Nutrition/Hydration from a Nasogastric or Gastrostomy Tube (feeding tubes)
3. IV (intravenous) Fluids other than Antibiotics
4. Antibiotics (medications that kill bacteria or slows the growth of bacteria)
5. Oxygen
6. Transfer to Acute Hospital
Review of Resident 1's physician progress note, dated 9/5/15, indicated multiple diagnoses and a recent hospitalization from 8/30/15 to 9/4/15 for persistent weakness, weight loss and a bacterial urinary tract infection. She was sent back to the facility for short term rehabilitation and wound care.
Review of Resident 1's Nurses Notes, dated 10/12/15 at 22:25 (10:25 p.m.) indicated the resident was stable. The next entry, dated 10/13/15 at 9:42 a.m. described how the resident was found at 5:30 a.m. without breathing or pulse. There was no further licensed nurse documentation of Resident 1's condition for 11 hours.
Review of Resident 1's last vital signs (temperature 97.3 degrees Fahrenheit, pulse 78, respirations 16, and blood pressure 113/86), dated 10/13/15, were documented between 12:07 a.m. and 12:08 a.m. Vital signs were not documented subsequent to 12:08 a.m.
Review of Resident 1's nurse's progress notes, dated 10/13/15 at 9:42 a.m., indicated LN 2 checked on the resident around 5:30 a.m. and found her without any breathing or a pulse. Resident 1's blood pressure and oxygen saturation (oxygen level in the blood) were unobtainable and she was cool to touch. Around 5:34 a.m. the emergency medical technicians arrived but stated that resuscitation would not be continued because the resident was beyond resuscitation. LN 2 further indicated in the progress notes "PRIOR TO RESIDENT'S DEATH, ROUNDS PERFORMED EVERY 2 HOURS, KEPT CLEAN AND DRY. PER CNA, AT AROUND 0445 [4:45 A.M.] RESIDENT WAS OBSERVED TO BE USUAL SELF....WOUND CARE PERFORMED AROUND 0417 [4:17 A.M.], RESIDENT TOLERATED PROCEDURE..."
During an interview with CNA 3 on 9/20/16 at 8:18 a.m., she was asked about the night of the incident, 10/12/15-10/13/15. She said, "[LN 2] asked if I could help do a [wound] treatment and said [Resident 1] needed three treatments. First treatment she was very responsive. Then, [Resident 1's] roommate put her [call] light on later. When I went to see [Resident 1] she looked bad. I asked [LN 2] if she was a DNR [Do Not Resuscitate]. I asked, 'What are we going to do?' [He] said, 'I hope it doesn't happen on our shift. I don't want to do CPR.'
Later, [Resident 1] was cold, even with blankets on. [Resident 1] wasn't responding during the second [wound] treatment. I kept [LN 2] informed, but [he] was working, too. I kept going back to tell [him] of my concerns... [Later, LN 2] came and got me to ask if I thought [Resident 1] was still breathing..."
During an interview with the Director of Nurses (DON) on 9/8/16 at 11:40 a.m. the DON was asked about LN 2 and his termination. She said, "He failed to follow procedures, including assessing a change of condition in a timely manner."
During a telephone interview with the Director of Nurses (DON) on 2/10/17 at 1:26 p.m., she said, "When we were reviewing this case, we felt he [LN 2] failed to assess a change of condition..."
Review of the facility policy and procedure titled "Change in a Resident's Condition", revised 1/15/10, established, "This community will assess residents for changes in condition, initiate the event charting system in the EHR [electronic health record], notify the physician(s), and inform the...resident's representative of a significant change in the resident's physical, mental, or psychological status...1. It is the responsibility of the person observing a change in condition to report that change to the Charge Nurse. 2. The Charge Nurse will assess the reported change in condition and determine what nursing interventions are appropriate..."
Therefore, the Department determined the facility failed to respond to Resident 1's change of condition by LN 2 which resulted in Resident 1 failing to receive medical care and services to treat the change of condition. This failure may have contributed to Resident 1's death.
This violation had a direct or immediate relationship to the health, safety or Security of Long Term Care patients or residents. |
| 110001255 |
Evergreen Lakeport Healthcare |
110013326 |
B |
28-Nov-17 |
LFWG11 |
6830 |
?483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including:
(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.
The facility failed to honor resident's rights, when one (Resident 1) of 14 residents moved in March was not notified in advance, in writing, of a room change. The failure to respect Resident 1's rights and to consider her wishes and preferences caused Resident 1 severe anxiety, as well as a mistrust in facility staff.
During an interview on 3/30/17 at 3:28 p.m., Complainant X stated Resident 1 had been moved to a new room in the facility on 3/21/17 without prior written notice to Resident 1 or her family members, Complainants X, Y, and Z. Complainant X stated Resident 1 did not want to be moved, but was not given a choice. Resident 1 was moved from a one-bed room to a two-bed room and had to adjust to sharing a room with another resident and sharing a bathroom with three other residents. Resident 1 was extremely upset about the move. Resident 1 was upset about the noise level in the new room as well as having to share a bathroom. Complainant X stated Resident 1, "reacted with immense anxiety" when told about the move on 3/21/17, the day she was being moved. Complainant X stated there had been, "zero notice" about the move, and Resident 1 had reacted, "frantic" causing her to be, "afraid and shaken" about the move. Complainant X stated Complainant Z had been present the day the move occurred and witnessed the events and Resident 1's reactions. Complainant Z had tried to calm Resident 1 and assisted Resident 1 as much as possible in adjusting to the new room and new environment. Complainant X stated she had spoken with Management Staff A, who was in charge of moving residents, on the day of the move. Management Staff A had apologized for the move. Complainant X stated Management Staff A had informed Complainant X she, Management Staff A, had, "not been made aware of this move."
A document titled, "Face Sheet" dated 12/16/16, revealed Resident 1 was an 89-year-old woman admitted to the facility on 12/14/16. Resident 1 was diagnosed with Hypertension (high blood pressure), Cerebral Infarction (blocked blood vessel in the brain often leading to stroke), Heart Failure, and Major Depressive Disorder.
During an observation and concurrent interview with Resident 1 and Complainant Y on 4/4/17 starting at 11:10 a.m., Resident 1 in her new room with Complainant Y visiting her. Resident 1 stated, with Complainant Y translating, she did not like the new room and had not wanted to move. Resident 1 stated she had not requested to have a roommate; she now had to share a bathroom with three other residents and frequently had to wait using the toilet because the toilet was occupied. Resident 1 stated having to wait to use the toilet increased her anxiety. Resident 1 stated she did not like the new room because it was noisy and too hot. Resident 1 stated staff had come and moved her on 3/21/17, without prior notice.
During an interview on 4/4/17 starting at 11:10 a.m., Complainant Y stated staff had previously informed him Resident 1 would eventually be moved once she finished therapy and no longer received Medicare (higher re-imbursement insurance) benefits. Complainant Y stated no one had asked Resident 1 or family members, but rather informed them that once Resident 1 was no longer receiving Medicare benefits, she would be moved out of the single room and into a room with a roommate because she would be getting MediCal (Medicaid) (lower reimbursement insurance) benefits.
A record titled, "Room Change/New Roommate Form" dated May 2002/Updated November 2016, revealed under, "Reason for Room Move," "Other" with, "Roommate" was handwritten. The form was signed by Management Staff A and dated 3/20/17. The form did not contain Resident 1's, or her responsible party's signature. On the line which should contain the resident or responsible party's signature, a handwritten statement revealed, "Resident's son and daughter aware of move to take place when Rm (room) repair complete." This statement was dated 3/20/17.
A document titled, "Interdisciplinary Notes" dated 3/23/17 at 9:55 a.m., indicated, "...room change done on 3/20/17, per resident's request to be with an appropriate roommate..."
During an interview on 5/16/17 at 3:10 p.m., Management Staff A stated she was in charge of resident room changes/moves. Management Staff A stated Resident 1 had been suddenly moved on 3/21/17, without Management Staff A's awareness or approval. Management Staff A stated Management Staff B had made the decision to move Resident 1 on 3/21/17, without telling Management Staff A, Resident 1, or her family. Management Staff A stated the move had been done, "without notice...just done." Management Staff A stated she had been. "very upset" about how Resident 1's room move had been handled by Management Staff B that day. Management Staff B was no longer employed by the facility and not available for comment.
Documents titled. "Social Services Progress Notes" revealed one entry dated 12/14/16, and then six entries all dated 3/23/17, written by Management Staff A. The fourth entry dated 3/23/17, revealed, "Resident moved to Rm [number], (with the date 3/20/17, written above the line, with a roommate whose date for move-in was 3/21/17.) Resident's (family member) participated in setting up her mother's furniture and pictures in the room. Resident adjusting to change." The document revealed no entry regarding discussions about the move with Resident 1 or family members, any assessments about Resident 1 psychosocial well-being, or any mention of compatibility with the new, still unknown, roommate. The document did not mention any involvement by Resident 1, her preferences, or any options offered to Resident 1 regarding the move.
A document titled, "Policy: Room Change/New Roommate" revealed the, "Policy Statement: Room or roommate changes are considered as required to improve the resident's physical, mental, and psychosocial well-being." The document listed under, "Procedure 1. The interdisciplinary team: a. Evaluates the impact of a room change on the resident before making changes (when possible) by determining the desire to move, roommate compatibility and psychosocial well-being. b. The Center seeks the resident's preference from the available options as appropriate. c. Notifies the resident and or resident representative of the new room change or roommate (prior to the change). d. Documents the decision and notification in the medical record...."
This failure caused significant humiliation, indignity, anxiety, or other emotional trauma to the patient. |