| 020000132 |
Fremont HealthCare Center |
020008964 |
B |
01-Feb-12 |
V6XV11 |
4029 |
F323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the regulation by failing to ensure that Resident 1 received adequate supervision to prevent accidents when she was given hot water in a Styrofoam cup intended for staff use only. The cup spilled in her lap and caused a 14 centimeter (cm) by 7 cm burn to her left thigh (5.5 x 3 inches), with a 4 cm by 3 cm area (1.5 x 1 inch) within the burned area where the full thickness of the skin peeled off. Record review on 8/3/11 showed that Resident 1 was a 93 year old woman who resided in the facility for 3 years. According to her most recent minimum data set (MDS) quarterly assessment, dated 5/26/11, she was independent with all of her activities of daily living except for bathing. She needed extensive assistance with help from one person for bathing. She was also cognitively aware, and knew the date, month and year. She could move around on her own with the use of a front wheel walker and a wheelchair. She had full range of motion in all of her joints. On 7/27/11, according to a nurse's note written at 6:30 p.m., the resident requested a hot tea from the receptionist. Under the cup of tea was a piece of paper which the resident accidentally pulled. The hot tea spilled, causing a redness burn and her skin peeled off on part of her left thigh. The physician was called, and he ordered Silvadene cream (burn and wound treatment) to be applied twice a day for seven days. According to the "Weekly Non-Pressure Ulcer Record", dated 7/27/11, the wound was described as a "14 x 7 centimeter burn with redness/ skin peeled off part of L (left) thigh, 4 centimeters by 3 centimeters. In an interview with Resident 1 on 8/3/11 at 10:00 a.m., she stated that she asked for a cup of tea and the receptionist brought her tea in a Styrofoam cup without a lid. It was on a piece of paper to absorb any spills. She stated, "I pulled on the paper mistaking it for the cup and it spilled." She said because it was a Styrofoam cup it just toppled over and if it had been in a regular coffee cup (plastic mug) it wouldn't have happened because, "They are more sturdy." The Dietary Services Supervisor (DSS) stated in an interview on 8/3/11 at 10:20 a.m. which took place in the kitchen, that the 8 ounce Styrofoam cups that were kept in a dispenser on the wall adjacent to the coffee machine were for staff use only and not be served to the residents.In a telephone interview on 8/3/11 at 10:35 a.m. with the Receptionist, she stated that on the evening of 7/27/11, she went to the kitchen to get a cup of tea for Resident 1 who was sitting in the lobby. She stated that she went into the kitchen and took a Styrofoam cup and put the hot water from the middle spigot of the coffee machine and brought it without a lid to the resident. She stated that she was not informed that the Styrofoam cups were not to be given to the resident. At 9:30 a.m. on 8/3/11 the DSS brought a plastic coffee mug full of hot water from the middle spigot of the coffee machine to the front lobby. The DSS used two different thermometers to measure the water temperature. It was 160 degrees Fahrenheit. According to, "Moritz, A.R., Henriques F.C.Jr. (1947). Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720," The time required for a 3rd degree (full thickness) burn to occur at 155 degrees Fahrenheit is 1 second. Therefore, the facility failed to prevent the accidental burning of Resident 1's left thigh by giving her a hot cup of tea in a Styrofoam cup which was not a stable vessel intended for resident use, which fell in her lap as she pulled on the paper under the cup.This violation had a direct or immediate relationship to the health, and safety of Resident 1. |
| 040000035 |
FRANCISCAN CONVALESCENT HOSPITAL |
040009139 |
B |
27-Mar-12 |
0I8311 |
6935 |
72301. Required Services (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. The facility failed to ensure physician orders were carried out when Patient 1's physician orders for a personal alarm when in chair or out of bed were not implemented. This failure resulted in Patient 1 sustaining a right femur (upper leg) fracture when the resident was left unattended in the dining room without the personal alarm in place, got out of her chair, and fell to the floor. On 10/12/11, an unannounced visit was made to the facility to investigate Entity Self Report #CA00285512, regarding Quality of Care/Treatment-Resident Safety/Falls. Patient 1 was admitted to the facility on 11/18/09, with diagnoses that included general muscle weakness, Alzheimer's disease, history of hip fractures, Deep vein thrombosis (DVT) and psychosis. The nurse's notes dated 10/1/11 at 7:02 p.m., indicated Patient 1 "requires 1-2 person extensive assist with bed mobility, toileting, grooming, transfers. Able to ambulate with FWW (front wheel walker) with one-two person assist with unsteady gait with gait belt in place." Nurses notes dated 10/2/11 at 2:35 p.m., indicated, "Alert and responsive to care with noted usual confusion secondly to Alzheimer's disease." On 10/12/11 at 3:25 p.m., during observation, Patient 1 was incoherent and unable to respond to simple questions.Facility Reported Event dated 10/3/11 indicated, "Resident is a patient of ACU (Alzheimer's Care Unit) with diagnoses of Alzheimer's disease, history of DVT with confusion and forgetfulness; has previous history of fracture and fall...needs 2 person assistance during ambulation and needs extensive assistance during mobility.Resident on Coumadin (blood thinning medication) therapy. On 10-2-11 at 5:10 pm resident was noted combative and tried getting up while in the TV room; staff decided to take resident to the dining hall to prevent fall. Staff placed the resident (in) the dining room and went down to the TV room...to get the alarm. Charge Nurse heard a sound in the dining hall and found resident lying on the floor on her right side. Assessment done, noted with skin tear on right forearm 9 cm (centimeters) long. Noted to have discoloration on the femur as evidenced by hard swelling on the right side, evident deformity noted...pain level 10/10...resident immobilize(d) on the floor...(MD) ordered to send the resident to the hospital... for evaluation..." On 10/12/11 at 2:10 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated at about 4:30 p.m. on 10/2/11, she took Patient 1 from the TV room to the Sun dining room because the patient was "acting out" and it was close to dinner. CNA 1 stated she placed the patient into a regular chair in the dining room without her alarm on and left Patient 1 alone. CNA 1 stated she went back to the TV room to get the patient 's personal alarm, and on her way back to the dining room where she left Patient 1 she was called away to assist another patient. CNA 1 stated she guessed after she left Patient 1 alone in the dining room the patient fell. CNA 1 stated she knew that Patient 1 had a history of falls and needed her personal alarm on at all times, but stated she "just didn't think this time."Patient 1's physician orders dated 7/29/11 indicated, "Tab/Personal alarm when in chair or OOB (out of bed), check placement and function Q (every) shift. Mobility alarm for (safety) and fall prevention." Patient 1's Departmental Notes (nursing notes) dated 10/2/11 at 8:02 p.m., indicated, "Per staff, resident was already combative and tried getting up while in the TV room, staff decided to take resident to the dining hall to prevent further falls b/c (because) it was almost dinner time, per staff she couldn't hold the mobility alarm b/c the resident is getting 'antsy' and she wanted to hold the resident with both of her hands to prevent falls, staff placed resident on [sic] the dining hall and went back to TV room to get the alarm, writer heard a sound on [sic] the dining hall, found resident lying on the floor on a side lying position...able to tell writer what part she is hurting, resident complained of excruciating pain and rated (it) as 10/10 (Wong-Baker scale), facial grimacing, moaning and screaming notes, skin tear on rt (right) forearm approximately 9 cm (centimeters) long, appears to have a dislocation on the femur (upper leg bone) as evidenced by hard swelling on the right side, evident deformity...on the right side of her legs...huddle staffs [sic] on fall precaution, high risk residents should be closely monitored...and check placement of mobility alarm at all times..." Patient 1's Care Plan dated 7/29/11 indicated, "Problem onset: 7/29/11. I have personal history of fall. I am at risk for additional falls due to my unsteady gait and confusion, I had previous right hip surgery. I have also Dx (Diagnoses) of Syncope (dizziness) and Collapse. I had multiple falls in the past. I had hx (history) of fracture on my left hip. I need extensive assistance on transfer and bed mobility. I have all the safety precaution in place." The specified goal was for "Resident will have no falls through next review." "Approaches" to meet the goal included "Mobility alarm for safety and fall prevention." Patient 1's Departmental Notes (nursing notes) dated 10/2/11 at 5:41 p.m., indicated, "Resident sent to the ER (Emergency Room) per MD order, resident had a fall with excruciating pain...ST (skin tear) to rt forearm..." Patient 1's X-ray report dated 10/2/11 indicated, "There is complete transverse (across) fracture through the proximal (nearest the point of attachment) femoral (upper leg bone) shaft near the tip of the femoral prosthesis (bone implant)...Conclusion: Acute fracture of the proximal right femur as described." Patient 1's Hospital Consultation report dated 10/2/11 indicated under Physical Examination, "Patient presented to the emergency room complaining of right leg pain, inability to ambulate and right lower extremity gross deformity...at the midthigh. Internal rotation is present..." Therefore, the facility failed to ensure physician orders were carried out when Patient 1's physician orders for a personal alarm when in chair or out of bed were not implemented. This failure resulted in Patient 1 sustaining a right upper leg fracture when the patient was left unattended in the dining room, got out of her chair, and fell to the floor. Patient 1 experienced excruciating pain after the incident. Patient 1 sustained a 9 cm skin tear to the right forearm. She was transferred to the acute hospital and admitted for surgery of a complete transverse fracture to the right femur which was grossly deformed at the mid-thigh area. This violation had a direct relationship to the health and safety of Patient 1 and therefore constitutes a class "B" citation. |
| 040000035 |
FRANCISCAN CONVALESCENT HOSPITAL |
040009448 |
B |
21-Aug-12 |
OHVE11 |
8740 |
The facility failed to ensure patients were free from mental and physical abuse when Certified Nurse Assistant 1 abused six patients. Complaint CA00286785 was investigated on 10/26/11. Patient 1 was an 87 year old female admitted to the facility on 2/28/07 with diagnoses of Alzheimer's disease, Depressive disorder, and dementia with behavior disturbances. Patient 1's Minimum Data Set (MDS) assessment dated 9/20/11 indicated she required extensive staff assistance with all Activities of Daily Living (ADL's); had long and short term memory impairment; was severely impaired in cognitive skills for daily decision making and had trouble with sleeping nearly every day. On 10/26/11 at 9:30 a.m., Patient 1 was unable to be interviewed due to her altered mental and cognitive state.The facility's "Facility Reported Event Addendum" fax date of 10/14/11 at 3:55 p.m., indicated, "The administrator called staff [CNA 2] on 10/13/11 at 8 pm. The Admin asked staff [CNA 2] if she had witnessed staff [CNA 1] abuse any patients. [CNA 2] stated yes she had. She [CNA 2] stated [CNA 1] told Patient 1 she has "Big ole jungle n------", Getting [Patient 1] ready for bed..."look at her big ol jungle n------" then she [CNA 1] would proceed to pinch them, clearly making [Patient 1] agitated .." CNA 2's statement of declaration dated 10/14/11 at 12:48 p.m., indicated, " I started working with [CNA 1] approximately middle of September on the PM shift ...Then she started doing inappropriate things almost on a daily basis, always the same residents ... [CNA 1] would walk by each of them [Patients 1, 2, 3, 4 and 6] and smack them upwards on their breasts with the palm of her hand. Other times she would pinch their nipples and they would respond by yelling loudly ... "The declaration also referred to CNA 1 making crude remarks and gestures toward Patient 5. [CNA] 2 stated that when [CNA 1] was changing patients' brief, if the resident is noisy [CNA 1] puts the patients' shirt in their mouth. [CNA 2] stated she had witnessed [CNA 1] walk by and grab the breast, of the 6 residents mentioned on page one of the Facility Reported Event form, she went on to state she had seen [CNA 1] pinch those afore mentioned patients breast. CNA 2's declaration statement dated October 14, 2011 at 12:48 p.m., indicated..."She [CNA 1] started doing inappropriate things almost on a daily basis, always the same residents. Some examples are- [CNA 1] would walk by each of them [Patients 1-6] and smack upwards on their breasts with the palm of her hand, other times she would pinch their nipples and they [residents] would respond by yelling loudly or [Patient 3] would say "hey don't be doing that." CNA 2s' declaration statement dated October 14, 2011 at 12:48 p.m., indicated..."She [CNA 1] started doing inappropriate things almost on a daily basis, always the same residents. Some examples are- [CNA 1] would walk by each of them [5 residents] and smack upwards on their breasts with the palm of her hand, other times she would pinch their nipples and they [residents] would respond by yelling loudly or [Patient 3] would say "hey don't be doing that."Patient 2's clinical record indicated Pt. 2 was an 83 year old female admitted to the facility on 10/02/06 with diagnoses of Alzheimer's disease, Hallucinations, Osteoporosis, Recurrent Depression with unspecified Psychosis, and Mood disorder.On 10/26/11 at 9:30 a.m., during an interview, Patient 2 was unable to be interviewed due to her altered mental and cognitive state.Patient 2's MDS dated 11/3/11 indicated Pt 2 had severely impaired cognitive skills for daily decision making. Pt 2 had signs of delirium continuously present, does not fluctuate. She required extensive staff assistance with her ADL's.The facility's "Facility Reported Event Addendum with a fax date of 10/14/11 at 3:55 p.m., indicated,"The administrator called staff [CNA 2] on 10/13/11 at 8 pm. The Admin asked staff [CNA 2] if she had witnessed staff [CNA 1] abuse any patients. [CNA 2] stated yes she had. [CNA 2] stated that with [Patient 2], [CNA 1] put the call light by the patient mouth the patient opened her mouth and [CNA 1] stated "She has gone through 6 d---- and see she wants d---." Patient 3's clinical record indicated Pt. 3 was a 75 year old female admitted to the facility on 5/27/08 with diagnoses of Alzheimer's disease, Psychosis, and Dementia with behavior disturbances, Anxiety state. Pt 3's MDS dated 10/25/11 indicated she was severely impaired in cognitive skills for making daily decisions. Behavior of delirium was continuously present, does not fluctuate. Pt 3 required extensive assistance with her ADL's. On 10/26/11 at 9:30 a.m., during an interview, Patient 3 was unable to be interviewed due to her altered mental and cognitive state.The facility's "Facility Reported Event Addendum" with a fax date of 10/14/11 at 3:55 p.m., indicated,"The administrator called staff [CNA 2] on 10/13/11 at 8 pm. The Admin asked staff [CNA 2] if she had witnessed staff [CNA 1] abuse any patients. [CNA 2] stated yes she had. Examples:..."Damm you [Patient 3] stink." Patient 4's clinical record indicated Pt. 4 was an 86 year old female admitted to the facility on 11/16/04 with diagnoses of Alzheimer's disease, Mental Disorder and Muscle weakness generalized. Pt 4's MDS dated 9/7/11 indicated her cognitive skills for daily decision making were severely impaired, and required extensive staff assistance with ADL's.On 10/26/11 at 9:30 a.m., during an interview, Patient 4 was unable to be interviewed due to her altered mental and cognitive state.The facility's "Facility Reported Event Addendum" with a fax date of 10/14/11 at 3:55 p.m., indicated, "The administrator called staff [CNA 2] on 10/13/11 at 8 pm. The Admin asked staff [CNA 2] if she had witnessed staff [CNA 1] abuse any patients. [CNA 2] stated yes she had. One particular resident [Patient 4] she (CNA 1) would say "This one has been married 6 times, look how much she likes the d---" then would put her finger or other object call light up to her mouth to show she would open it, insinuating a sexual act. Patient 5's clinical record indicated Pt. 5 was an 82 year old female admitted to the facility on 12/2/02 with diagnoses of Alzheimer's disease, Abnormality of gait, Depressive Disorder, Osteoporosis and Psychosis. Pt 5's MDS indicated her cognitive skills for daily decision making were severely impaired and signs of delirium were continuously present, does not fluctuate. Pt 5's functional status indicated she required extensive staff assistance with all of her ADL's.On 10/26/11 at 9:30 a.m., during an interview, Patient 5 was unable to be interviewed due to her altered mental and cognitive state.The facility's "Facility Reported Event Addendum" with a fax date of 10/14/11 at 3:55 p.m., indicated, "The administrator called staff [CNA 2] on 10/13/11 at 8 pm. The Admin asked staff [CNA 2] if she had witnessed staff [CNA 1] abuse any patients. [CNA 2] stated yes she had. Getting [Patient 5] ready for bed [CNA 1] states "you used to have nice t---, huh [Patient 5] what happened?" Pt 6's clinical record indicated Pt. 6 was an 89 year old female admitted to the facility on 5/31/05 with diagnoses of Alzheimer's disease, Generalized Muscle weakness and psychosis. Pt 6's MDS dated 8/15/11 indicated her cognitive skills for daily decision making were severely impaired. Pt 6 required extensive assistance for bed mobility and total staff dependence for transfers and locomotion on the unit.On 10/26/11 at 9:30 a.m., during an interview, Pt. 6 was unable to be interviewed due to her altered mental and cognitive state.The facilities' Facility Reported Event Addendum with a fax date of 10/14/11 at 3:55 p.m., indicated, "The administrator called staff [CNA 2] on 10/13/11 at 8 pm. The Admin asked staff [CNA 2] if she had witnessed staff [CNA 1] abuse any patients. [CNA 2] stated yes she had. [Patient 6] would almost fall off the bed, holding on tight to the side of the bed as she (CNA 1) was being changed, and if [Patient 6] yelled to loud, she [CNA 1] would pick up the bottom of their shirt and plane/shove it in her mouth."On 10/26/11 at 9:10 a.m., during an interview, CNA 2 stated her declaration was true and correct. The facility failed to ensure patients were free from mental and physical abuse when six patients with severely impaired cognitive status and requiring extensive staff assistance with all Activities of Daily Living were subjected to emotional, verbal and physical abuse from approximately the second week of 9/2011 to approximately 10/2011.This violation had a direct or immediate relationship to the health, safety or security of patients and therefore constitutes a class "B" citation. |
| 040000035 |
FRANCISCAN CONVALESCENT HOSPITAL |
040012798 |
B |
8-Dec-16 |
LH7H11 |
9378 |
F 223: 483.13(b) Free From Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 9/7/16 an unannounced visit was made to the facility to investigate Entity Reported Incident CA00501613 regarding an allegation of resident abuse. The facility failed to protect the right of one of four sampled residents (Resident 1) to be free from physical abuse when a Certified Nursing Assistant (CNA) 1 punched Resident 1 twice in the abdomen (belly) and once in the left thigh. This failure resulted in psychosocial (mental and emotional) and physical harm to Resident 1. On 9/7/16 at 8:15 a.m., during an interview in the Director of Nurses' (DON) office, the DON stated on 9/6/16 at 1:30 a.m., CNA 2 reported to the night shift nurse in charge, Registered Nurse (RN) 1, she witnessed CNA 1 punch Resident 1 twice in the abdomen and once on the left thigh. The DON stated there was no reason to suspect CNA 2's report was not accurate. The DON stated police were called and CNA 1 was arrested on charges of assault and battery (the crime of threatening a person together with the act of making physical contact with them). On 9/7/16 at 8:45 a.m., Resident 1 was observed sitting in a wheelchair in the facility's "Life's Journey Hallway," a locked dementia (chronic disorder of mental processes marked by memory loss, personality changes, and impaired reasoning) care unit. Resident 1 looked frightened, and responded unintelligibly (impossible to understand) to questions. Review of Resident 1's clinical record titled "Minimum Data Set" (MDS) (an assessment of resident's level of function and health care needs) dated 8/29/16, indicated Resident 1 had moderate cognitive (pertaining to perception, reasoning, judgement and memory) impairment and required extensive staff assistance for mobility, dressing, eating, hygiene and bathing. On 9/7/16 at 9:05 a.m., during an interview on the "Life's Journey Hallway,"CNA 3 stated she was making rounds on 9/6/16 at 6 a.m., when she entered Resident 1's room. CNA 3 stated, "She [Resident 1] looked sad." CNA 3 stated she asked Resident 1, "What's wrong?" CNA 3 stated, "She [Resident 1] started crying. She [Resident 1] always cries, but this time she looked scared." CNA 3 stated, at first, Resident 1 said nothing, but then said, crying in Spanish, "The man, the man." On 9/28/16 at 2:48 p.m., during an interview, RN 1 stated on 9/6/16 at 1:30 a.m., CNA 2 reported to her (RN 1) she was taking care of a resident in Room [ ] and heard Resident 1 screaming so she went to see what was going on. RN 1 stated CNA 2 reported she saw CNA 1 punch Resident 1 twice in the stomach and once in the left leg. RN 1 stated CNA 2 reported she asked CNA 1 what he was doing and CNA 1 said Resident 1 hit him first. RN 1 stated CNA 2 told CNA 1 to get out of Resident 1's room and she would finish providing care. RN 1 stated she went immediately to Resident 1's room to assess Resident 1's condition. RN 1 stated, "[Resident 1] was "bawling [crying] her eyes out. Would not make eye contact..." RN 1 stated Resident 1 rubbed her left leg and cried, "Scared of him." RN 1 stated, "[Resident 1] stated she didn't know what she did wrong. She didn't want him around." RN 1 stated Resident 1 had previously expressed she did not want CNA 1 assigned to her care. RN 1 was unable to provide the timeframe for Resident 1's expressed request. RN 1 stated CNA 1 was still occasionally assigned to care for Resident 1. Resident 1's Nurses Note, dated 9/6/16 at 6:48 a.m., indicated "Staff member [CNA 2] approached CN [Clinical Nurse, RN 1, and author of the note] at approximately [1:30 a.m.] stating that she didn't know what to do about it, but she had heard [Resident 1] screaming and had entered her room to check on her and witnessed [CNA 1] strike resident twice in the abdomen and once on the left upper thigh. She stated that she yelled at [CNA 1] to stop and asked him what he was doing. He replied to her that resident had struck him first. She told CN that she told him to leave her [Resident 1] alone and leave the room and that she would finish up care for the resident. Resident [1] noted crying when CN entered room to ask what had happened. She did not want to make eye contact or speak to writer. Asked LVN [Licensed Vocational Nurse, LVN 1] to talk to her [Resident 1] in Spanish and see if she would open up. [LVN 1] was able to get her talking and she told her that that man had hit her while rubbing her left thigh and crying. She also stated that she is scared because she doesn't want him to come back again ...Spoke with resident to obtain her side of incident. Stayed with resident and ensured her she was safe and he would not come back until she calmed down. Informed [CNA 1] that I was sending him home for the night and that either the DON or Administrator would contact him in the morning. Performed head to toe physical assessment on resident. multiple spider veins to the left along with approximately 1.5 cm [centimeter - metric measurement] x 1.5 cm discoloration to thigh that is deep purple in color. Notified RP [Responsible Party] and he stated that he would be in as soon as work is over today. Paged [Resident 1's physician] to notify and ask for STAT [immediate] X-ray of left leg. Awaiting return call." Resident 1's Nurses Note dated 9/6/16 at 8:16 a.m., written by the Social Services Director (SSD), indicated, "[Resident 1] is being monitored for emotional distress regarding staff witness abuse by staff member. [Resident 1] is not in her usual spirits today but did eat a portion of her breakfast..." On 9/28/16 at 3:45 p.m., during an interview, CNA 2 stated, "I was toileting another resident across the hall from [Resident 1's] room. [CNA 1] was with her [Resident 1]. [Resident 1] was distressed and calling out. [Resident 1] yelled, Aye! Aye! Stop it! I went to go see what was going on. I walked across the hall to [Resident 1's] room." CNA 2 stated the curtain was closed, so CNA 1 did not see CNA 2 enter Resident 1's room. CNA 2 stated she saw CNA 1 and Resident 1 struggling. CNA 2 stated she saw Resident 1's hand swinging wildly, hit CNA 1's forearm. CNA 2 stated she saw CNA 1 punch Resident 1 with his right fist into her abdomen and left thigh. CNA 2 stated Resident 1 "continued to flail (swing wildly), scrambling, to fight him off." CNA 2 stated she walked towards the bed and yelled, "Stop it! Leave! Get away from her!" CNA 2 stated she told CNA 1 to leave but CNA 1 stayed, looked angry, and stated, "She [Resident 1] hit me first." CNA 2 stated she could not make CNA 1 leave. CNA 2 stated, "She [Resident 1] was crying, sobbing with tears. I told her it's going to be okay. He's not supposed to do that." CNA 2 stated Resident 1 stated, "I know. I know." On 10/20/16 at 2:15 p.m., during a telephone interview with the Director of Staff Development (DSD), the DSD stated Resident 1 did not go to an acute care emergency room for follow up after being punched on 9/6/16. The DSD stated the physician was phoned and an X-Ray of Resident 1's left thigh was obtained. The DSD stated the X-Ray of the thigh was ordered due to Resident 1's complaint of pain to her left thigh. The facility policy and procedure (P&P) titled, "Right to Be Free of Abuse," dated 1/10, indicated "Guidelines: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal [physical] punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including facility staff... Definitions of Abuse: 1. Abuse - The willful infliction of injury,...intimidation or punishment with resulting harm, pain, or mental anguish...This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, pain or mental anguish [pain or suffering]... 4. Physical Abuse - Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 5. Mental Abuse - Includes, but is not limited to: humiliation, harassment..." The facility P&P titled, "Prevention of Abuse," dated 1/10, indicated, "Policy: The facility must use all practicable means to prevent resident abuse..." The facility P&P titled, "Staff Treatment of Residents," dated 1/10, indicated "Guidelines: ...the facility must not use ...physical abuse, corporal punishment..." Review of Local Police Department report indicated the following: "[Address] POLICE DEPARTMENT Case Number: 2016-00047648 00501613 Offenses Incident Type: ASSAULT/BATTERY Occurred From: 09/06/2016 01:40 [9/6/16, 1:40 a.m.] Occurred Thru: 09/06/2016 01:45 [9/6/16, 1:45 a.m.] Reported Date: 09/06/2016 05:33 [9/6/16, 5:33 a.m.] Description: ELDER OR DEPENDENT ADULT ABUSE RESULTING IN GREAT BODILY HARM... Offense Status: ARRESTED Suspect/Offender: [CNA 1] Victim: [Resident 1]" The facility failed to protect Resident 1's right to be free from physical abuse when CNA 1 punched Resident 1 twice in the abdomen (belly) and once in the left thigh. As a result, Resident 1 sustained emotional and physical pain. The above violation had an immediate direct relationship to Resident1's health, safety, and security and therefore constitutes a Class B Citation. |
| 050001071 |
FARROLL HOME |
050011520 |
B |
06-Jul-15 |
DDWV11 |
2700 |
CLASS B VIOLATION ? HSC 1419.91(A)(B)(C)(D) (a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class ?B? violation. (c) For purposes of this section, ?abuse shall mean any of the conduct described in subdivision (a) and (b) of section 15610.07 of the Welfare and Institutions Code.? (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code.The facility is in violation of the above statute by its failure to report an allegation of abuse of a client to the Department immediately or within 24 hours.On December 26, 2014 Client B was playing with a new Christmas gift, an accordion, in his room, when Client A entered Client B's room and staff heard Client B yell "Stop" and Client A "Cursing and yelling." Staff observed Client A take Client B's accordion away and struck Client B on the right side of his head. Client A was admitted to the facility with diagnoses including impulse control disorder (characterized by an intense need to gratify one's immediate desires and failure to resist impulse or temptation). On January 3, 2015 Client A was observed to shove the dinner table into Client B with his electric wheelchair, spilling all of the food.The facility?s Updated Behavioral Consultation dated March 1, 2014 indicated Client A had "Recent aggressive behaviors both verbally and physically." The consultation additionally indicated Client A has developed "A pattern of verbally putting down others, both staff and peers, and has been physically aggressive as well." Record review and concurrent interview on January 13, 2015 at 6:17 p.m. revealed an Incident Report dated January 9, 2015 that identified the incident on December 26, 2014 and was sent to the Department. The Qualified Intellectual Disability Professional (QIDP) stated, "I'm not sure which incidents have been cross-reported to the Department." The QIDP could not provide evidence the incident reports of December 26, 2014 or January 3, 2015 had been faxed, mailed, emailed, or communicated to the Department with the required time frames. The QIDP confirmed the incident on December 26, 2014 had been reported late to the Department, on January 9, 2015 (14 days later).The violation of this regulation had a direct relationship to the health, safety, or security of residents. |
| 060001166 |
Foothill Regional Medical Center D/P SNF |
060009257 |
B |
24-Apr-12 |
PRGN11 |
8117 |
72311(a)(1)(A).The facility failed to continuously assess the care needs for Patient 1. Patient 1 has cerebral palsy, seizure disorder, and was staying in bed 22 hours a day due to a recent surgery and a healing wound. The medication the patient was receiving for seizures, valproic acid, combined with long periods of inactivity, can cause demineralization of the bones (osteopenia and osteoporosis). Physician 1 recommended Patient 1 receive vitamin D supplements on 11/16/10, to prevent osteoporosis, but the supplement was not added until 13 months later and at a lower dose than recommended. The facility did not assess Patient 1's need for additional calcium and vitamin D to address the high risk for fractures until after his first fracture on 12/28/11. In addition, the patient's minimum dietary needs for calcium and vitamin D were not being provided. Patient 1 fractured both his left and right femur (thigh bones) in a five week period. His x-ray reports show the patient has an osteopenic skeleton on the left hip, knee, and femur and the right femur and hip. Physician 2 stated the facility should have been aware of the potential of bone fractures and initiated a preventive protocol for Patient 1.Failing to continuously assess Patient 1's need for additional vitamin D, resulted in injuries to the patient. According to the Nutritional Care Manuel, the standard nutritional Manuel used by the facility, the most common nutritional concern among children with seizure disorders are osteopenia and osteoporosis. Children who are immobile have an additional risk of bone demineralization. The American Academy of Pediatrics recommend a higher intake of vitamin D for these children. Children with seizure disorders are routinely found to have inadequate intake of calcium, phosphorus and vitamin D.Health record review for Patient 1 was initiated on 2/10/12. Review of the Dietary Administration Record showed Patient 1 was receiving a nutritional consultation monthly since 11/22/04. Review of the Neurology Output Note dated 11/4/10, showed Patient 1 had diagnoses of spastic cerebral palsy (a group of disorders including brain disorders), scoliosis (abnormal curvature of the spine) and seizure disorder. The patient is receiving valproic acid 140 milligrams (mg), three times a day. Physician 1 recommended Patient 1 receive a supplement of 800 mg of vitamin D due to the risk of osteoporosis from the use of valproic acid. The physician recommended to follow up in six months.Review of the Progress Note dated 11/4/10, from the hospital's epilepsy center, showed a recommendation to add vitamin D to the patient's diet. Review of the Medication Administration Record (MAR) dated June, 2011, showed Patient 1 was receiving a diet of Nutren Jr. 220 milliliters (ml) bolus feedings, five times a day via a feeding tube since 10/28/10. Two scoops of Beneprotien powder, a protein supplement, was being administered once a day since 6/8/10. No vitamin D supplement was being provided.Review of the History and Physical dated 9/19/11, showed Patient 1 was admitted to the acute care hospital on 8/31/11, for spinal surgery. After the surgery, Patient 1 is noted to have weak lower extremities which are without movement. Patient 1 was readmitted to the facility on 10/3/11. The diet orders for Patient 1 were Nutren Jr. 244 ml six times a day. Patient 1 remains on valproic acid, 140 mg three times a day. The patient is receiving a vitamin C supplement, but no vitamin D or additional calcium supplement was ordered. According to the Problem List dated 10/5/11, Patient 1 developed a urinary tract infection, wound infection and dehiscence (surgical wound reopened) and was readmitted to the hospital. Review of the Interval History showed Patient 1 was readmitted to the facility on 11/21/11. The diet ordered for the patient was Nutren Jr. 250 ml every four hours with Beneprotien 1 scoop four times a day. Patient 1 was receiving a vitamin C supplement. No vitamin D supplement was being provided. The Interval History showed on 12/23/11, Patient 1 was sent to the emergency room due to swelling of the right knee. The hospital's x-ray report dated 12/23/11, showed the right distal femur had a fracture. According to the report, the skeleton is osteopenic in appearance.Review of the care plan to address the problem of the osteopenic skeleton problem dated 12/28/11, showed a vitamin D supplement of 200 units, twice a day, was added to Patient 1's diet on 12/28/11.The Resident Transfer Report dated 2/1/12, showed Patient 1 had a swollen left knee and was sent to the hospital. The x-ray report dated 2/2/12, showed Patient 1 had an impacted fracture of the left femur. The report further showed the patient has generalized osteopenia of the left femur. Additional x-rays done on 2/2/12, showed osteopenia of the left knee, right hip, left femur and left hip. An interview with Registered Nurse (RN) 1 was initiated on 2/10/12 at 1130 hours. RN 1 stated Patient 1 was started on vitamin C and D supplements in December 2011. She was aware that immobility can cause osteopenia. A telephone interview with Physician 2 was initiated on 2/10/12 at 1600 hours. Physician 2 consulted on Patient 1's fractures on 2/3/12. Physician 2 stated he did not believe Patient 1's fractures were due to any abuse or rough handling of the patient. The physician stated the bones of Patient 1 are crumbling on themselves due to osteopenia and osteoporosis. Physician 2 stated, antiseizure medications are common for depleting minerals in bones. The combination of being bedbound, having cerebral palsy and taking antiseizure medications would cause severe problems with the bones. According to the physician, the facility should have been more proactive for the patient by ordering a metabolic consultation, laboratory studies for vitamin deficiencies and calcium levels. Physician 2 was asked if the facility should have been aware of the danger to Patient 1. Physician 2 stated the facility treats many patients who have the same problems as Patient 1; they should have been aware of the danger to the patient. Physician 2 stated, at the hospital, a protocol has already been put into place to protect children such as Patient 1. The facility should have had there own protocol in place to protect Patient 1. An interview with Pharmacist 1 was initiated on 2/10/12 at 1600 hours. The pharmacist was asked if he had alerted the facility to the danger of the antiseizure medication and osteopenia. The pharmacist stated he was not aware of any problems with the antiseizure medications and osteopenia. An interview with Pharmacist 2 was initiated on 2/16/12 at 1145 hours. Pharmacist 2 stated they looked at Patient 1's medications, but there was nothing that was triggered as a concern regarding the medication. The pharmacist stated her new supervisor suggested the patient receive a vitamin D supplement in December, 2011. Otherwise, patients would not be given extra vitamin D supplements until after eight years of age. An interview and record review with the Registered Dietician (RD) was initiated on 2/16/12 at 1000 hours. The RD stated patients' nutritional needs are monitored monthly. The RD was asked to recalculate the dietary needs for Patient 1 and compare them to what the patient is currently receiving. The RD stated Patient 1 is receiving 1800 mg of calcium in his tube feeding, but requires 3000 mg. The patient is now receiving 180 international units (iu) of vitamin D, but requires 400 to 600 iu. The zinc the patient is receiving is around 16 mg, but he requires 23 mg per day. The RD was asked if these requirements were based on normal children or children with antiseizure medications and/or wound healing. The RD stated these requirements were based on normal children and did not add extra calories, vitamins or minerals that may be needed due to antiseizure medications or wound healing. The facility's failure to provide ongoing assessment resulted in two fractures to Patient 1. This violation had a direct or immediate relationship to the health, safety, or welfare of the patient. |
| 080001538 |
FOUNTAIN CARE CENTER |
060010883 |
B |
24-Jul-14 |
JFNW11 |
2404 |
Class B Citation Fountain Care Center Complaint No: CA00403433 F206: CFR 483.12(b)(3) Permitting Resident to Return to Facility The facility failed to allow Resident 1 readmission to the facility after hospitalization.Closed clinical record review was initiated for Resident 1 on 7/8/13. Resident 1 was admitted on 8/3/12, and transferred to an acute care hospital on 6/20/14, due to a change of condition. When Resident 1 was ready to return to the facility, the facility denied her return. The resident's family filed an appeal. On 6/24/14, the facility informed Resident 1's family member Resident 1 was not permitted to return to the facility. On 6/24/14, the resident's family member filed an appeal with the California Department of Health Care Services Office of Administrative Hearings and Appeals. On 6/30/14, the California Department of Health Care Services Office of Administrative Hearings and Appeals conducted a hearing for Resident 1's refusal to be readmitted to the facility.Review of the Readmission Appeal Decision dated 7/3/14, shows Resident 1 has the right to return to the facility and shall offer Resident 1 readmission to the first available female bed in a semi-private room appropriate for her needs.On 7/8/14 at 1210 hours, an interview was conducted with the SSD. The SSD was asked if she is aware of the reason why Resident 1 is not permitted readmission to the facility. She stated the Administrator had stated it was not in the best interest of other residents to have Resident 1 residing in the facility.On 7/8/14 at 1230 hours, an interview was conducted with the Administrator. The Administrator was asked the reason why Resident 1 was not permitted to return to the facility. He stated they could not accept Resident 1 back because they could not provide care for her. He stated the resident and her family were not happy with the facility, and there were conflicts that caused everyone extreme stress.On 7/10/14 at 1030 hours, a telephone interview was conducted with Resident 1's family member. When asked how Resident 1 is doing. The family stated Resident 1 is still in the acute care hospital and they were having a difficult time finding another skilled nursing facility to admit her. The facility's failure to permit Resident 1 to return to the facility presented likely had a direct or immediate relationship to the health, safety, or welfare of the resident. |
| 060001166 |
Foothill Regional Medical Center D/P SNF |
060011387 |
B |
15-Apr-15 |
5OLP11 |
8118 |
Accidents and Supervision: F323 G; The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 1 was as free from accident hazards as possible. Resident 1 was nonverbal, had contractures to her arms and hands, and was unable to move her extremities. On 1/18/15, while attempting to dry Resident 1's hair, LVN 1 left a hairdryer on and placed in close proximity to Resident 1's left hand. A few hours later, a staff member noticed Resident 1 had sustained blisters from a second degree burn to her left hand and left shoulder.Review of an article titled Hair Dryer Burns in Children published in 1990, by the Official Journal of the American Academy of Pediatrics showed testing of home hairdryers was done to determine their heat output. At the highest heat settings, the hairdryers rapidly generated temperatures in excess of 110øC (230 degrees F). After the hairdryers were turned off, the protective grills maintained sufficient temperatures to cause full-thickness burns for up to 2 minutes. These cases and the results of testing demonstrate that hairdryers must be added to the list of known causes of accidental and non-accidental burns in children. www.medicinenet.com showed a first degree burn is superficial and causes local inflammation of the skin. Sunburns often are categorized as first degree burns. The inflammation is characterized by pain, redness, and a mild amount of swelling. The skin may be very tender to touch. A second degree burn is deeper than a first degree burn and in addition to the pain, redness and inflammation, there is also blistering of the skin. Clinical record review for Resident 1 was initiated on 3/16/15. Resident 1, a pediatric, was admitted to the facility on 11/29/08, with diagnoses including severe encephalopathy, quadriplegia, and near vegetative state.Review of the computerized note (untitled) dated 1/18/15, showed Resident 1 was identified to have blisters to her left hand. The "primary nurse and CNA are unaware of how it may have happened."Review of the Nursing Progress/Summary Notes dated 1/18/15 at 1500 hours, identified Resident 1 had blisters to her left hand. At 2000 hours, staff documented there were multiple open, weeping fluid blisters to her left hand. On 1/19/15 at 1030 hours, staff documented Resident 1 also had a small blister to her left shoulder. Review of Resident 1's physician's order dated 1/20/15 at 1015 hours, showed to administer Motrin and Tylenol (alternate) every four hours for 48 hours for pain prophylaxis. On 1/22/15 at 1315 hours, a physician's order was received to administer Motrin 220 mg via GT every eight hours for four days for pain.Review of Resident 1's Comprehensive Skin Assessments showed the following: * On 1/18/15 at 1600 hours, showed blisters and redness to the dorsal aspect (back) of Resident 1's left hand. The photograph showed multiple raised, fluid filled blisters. Staff documented if the blister was to open to apply Bacitracin (antibiotic) ointment four times a day for 10 days. * On 1/20/15 at 1100 hours, Resident 1's left hand blisters opened and draining serous fluid. The affected area measured 6 cm (length) x 4 cm (width). Staff documented Bacitracin ointment was to be started after the C&S of the left hand blister drainage was obtained. The photograph showed some of the blisters had popped and others remained filled with fluid.* On 1/23/15 at 0900 hours, the left hand blisters and redness were present and continued to be treated with Bacitracin ointment.* On 1/26/15 at 1800 hours, Resident 1's left hand blisters were assessed to be a second degree burn.* On 1/29/15 at 2000 hours, staff documented all of Resident 1's blisters had popped. The treatment was changed to Silvadene cream (medication used to treat burns) daily and to cover with a non-stick dressing for seven days. On 3/10/15 at 1000 hours, staff documented Resident 1's left hand wound had completely healed.Review of Resident 1's Doctors' Progress Note dated 1/24/15, showed an evaluation was completed by an Infectious Disease Consultant. The doctor documented Resident 1 had a recent appearance of blisters over the left dorsal hand and fingers, and to treat the blisters as a "second degree burn" injury. Review of a (untitled) document dated 3/11/15 at 1616 hours, showed on 2/5/15, the left hand (blisters) healing well and appeared to be in much less pain.Review of the Restorative Administration Record for January 2015, showed Resident 1 was to have PROM to her upper extremities and the application of bilateral elbow extensor splints for 12 hours a day five days per week. However, the RNA documented on the reverse side of the sheet from 1/20/15 to 1/30/15, the PROM and left hand splint were not provided due to the resident's left hand wound.On 3/16/15 at 1405 hours, Resident 1 was observed sitting in her wheelchair next to her bed. She was unable to respond to verbal commands. Her arms and hands were contracted and the top of her left hand had multiple skin (pigment) discolorations as a result of the burn.On 3/16/15 at 1455 hours, Resident 1's attending physician was interviewed. The physician stated Resident 1 had limited movement in her extremities and required total assistance from the staff for all ADL care. When asked how Resident 1 sustained the burn to her left hand, the physician stated he could not think of anything "hot enough" to cause a burn, but the item would have to be very close (to the left hand).An interview with RN 1 was conducted on 3/16/15 at 1540 hours. RN 1 stated Resident 1 was showered every day on the day shift. She stated the resident's hair was washed during the showers.On 3/16/15 at 1550 hours, an interview was conducted with CNA 1. CNA 1 stated before the burn to the resident's left hand, the resident's family and staff used a hairdryer to dry the resident's hair. CNA 1 stated the hairdryer was stored in Resident 1's room but had been removed after the 1/18/15 incident.On 3/16/15 at 1605 hours, an interview was conducted with LVN 1. LVN 1 stated she was assigned to work as a caregiver for Resident 1 on 1/18/15. LVN 1 stated on the morning of 1/18/15, she gave Resident 1 a shower and washed her hair. She stated while Resident 1 was still lying on the shower gurney, she took the hairdryer from Resident 1's bedside to dry the resident's hair. LVN 1 stated when she was going to dry the back of her hair, she took the hairdryer from her left hand and placed it down near the top of the gurney, on the left side, so she could raise Resident 1's head. She stated the hairdryer was remained on while she was repositioning the resident's head. LVN 1 stated Resident 1's arms/hands were contracted (when lying down the resident's hands were up by her head) and the heat from of the hairdryer was blowing in the direction toward the resident's left hand. When LVN 1 was asked if she thought the burn could have been caused by the hairdryer being left on and placed at the head of the shower gurney, she stated the hairdryer was "the only thing it could have been." When LVN 1 was asked if the burn to Resident 1's hand could have been prevented, she stated "yea."She stated she could have placed Resident 1 in a wheelchair before she dried her hair; like she had seen other CNAs do. When LVN 1 was asked if she was aware of Resident 1's left shoulder blister that was observed on 1/19/15, she stated "no." During an interview on 3/16/15 at 1635 hours, the DON stated Resident 1 required total care from the staff for all her ADL care. When asked how Resident 1 sustained the burn to her left hand, the DON stated she was unable to determine the cause. The DON stated since the incident to Resident 1's left hand, all hairdryers had been removed from all residents' rooms and were to have a safety check by the Maintenance Director. The facility?s failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility residents. |
| 080001538 |
FOUNTAIN CARE CENTER |
060011842 |
B |
16-Nov-15 |
VRWS11 |
9772 |
F224: The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to ensure CNA (Certified Nurse Assistant) 1 provided a truthful account of an incident for one of one sampled residents (Resident 1). Resident 1 was cognitively impaired, spoke a foreign language, and required extensive assistance from staff for bathing. Resident 1 fell out of the shower chair onto the tile floor in the shower room and sustained a left knee fracture while being transported by CNA 1. CNA 1 failed to get assistance from a licensed nurse at the time of the incident to assess Resident 1 for injuries. Instead, CNA 1 placed Resident 1 back in the shower chair, transported her to back to her room, transferred her into the bed, and told Resident 1 not to say she had fallen in the shower. Resident 1 complained of pain. CNA 1 reported to LVN (License Vocational Nurse) 1 that Resident 1 had a headache. Resident 1 was medicated with a mild analgesic without being effective. When Resident 1's family member questioned Resident 1 about the source of her pain with LVN 1 present, Resident 1 pointed to her left knee. When questioned by LVN 1, CNA 1 further falsified the events of the incident. CNA 1's falsification of the resident's fall incident delayed an accurate assessment and appropriate medical interventions to treat Resident 1's injuries and associated pain as a result of the fall.Findings: According to the facility's P&P (policy and procedure) titled Incident/Accident Management revised 10/1/10, showed a fall refers to unintentionally coming to rest on the ground, floor, or other lower level surfaces but not as a result of an overwhelming external force. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The P&P also showed when a resident is found on the floor or identified as having experienced another type of incident/accident, the staff member (first responder) will notify the licensed nurse. Staff are not to move the resident until a licensed nurse evaluates the condition of the resident. The licensed nurse will complete a head to toe assessment of the resident, administer first aid if necessary and notify the physician and the responsible party. Clinical record review for Resident 1 was initiated on 9/23/15. Resident 1 was admitted to the facility on 3/26/08, and readmitted on 9/3/15, with diagnoses including dementia.Review of the MDS (Minimum Data Set) dated 8/10/15, showed Resident 1 had severe cognitive impairment, spoke a foreign language, and required extensive assistance from one staff during bathing.Review of the care plan showed a care plan problem dated 8/7/15, to address Resident 1's risk for falls/injuries due to impaired mobility. Resident 1 was identified to be at risk for further falls/injuries due to impaired mobility, impaired vision, and history of falls and fractures. The interventions included to provide verbal cues for safety and sequencing when needed.Review of the Event Summary Report prepared by LVN 1 dated 9/4/15, showed on 8/31/15 at 1630 hours, CNA 1 slipped and lost his balance during the transfer of Resident 1 from the shower chair to her bed. CNA 1 reported Resident 1 hit her left knee on the bed frame. Resident 1 complained of pain and was given Norco (narcotic pain medication). One hour later, Resident 1 reported pain at the level of 10 on the pain scale of 0 to 10 (with 10 = worst and 0 = no pain). After the application of a cold compress to Resident 1's left knee skin discoloration, LVN 1 notified the NP (Nurse Practitioner) who ordered an x-ray. When LVN 1 went to notify the family at bedside of the NP's order, the family insisted on transferring Resident 1 to the hospital. The documentation showed LVN 1 reassessed Resident 1's left knee and no swelling was noted. Resident 1 was transferred to the hospital at 1800 hours on 8/31/15. Review of the Event Summary Report prepared by the DON (Director of Nursing) dated 9/4/15, showed Resident 1 had a fall in the shower room on 8/31/15 at 1630 hours. According to CNA 1, while giving a shower to Resident 1, Resident 1 fell from the shower chair onto the floor. The initial statement by CNA 1 was inaccurate. CNA 1 stated he got scared and changed facts of the incident. On 9/23/15 at 0953 hours, Resident 1 was observed in bed, eyes closed, not moving, family members were at the bedside. An interview was conducted with Resident 1's family member. Family Member 1 stated on 8/31/15, she was visiting in Resident 1's room when CNA 1 came in to assist Resident 1 with her shower. Family Member 1 stated she decided to go to the store. As she arrived at the store, she received a call from Family Member 2 who had just arrived at the facility and told her, "Something's wrong with (Resident 1), you gotta come back here." When Family Member 1 arrived in the room, she stated she saw Resident 1 grimacing. Family Member 1 stated she asked if Resident 1 was in pain, Resident 1 pointed at her left knee. Family Member 1 lifted the blanket off and saw Resident 1's left knee was swollen and slightly bruised. Family Member 1 stated she then asked the charge nurse to call an ambulance to take the resident to the hospital. Family Member 1 stated CNA 1 came in to the room and said she slipped when he was transferring Resident 1 back to bed because "you spilled your drink." Family Member 1 denied spilling anything and stated she again demanded Resident 1 be transferred to the hospital for further evaluation. Family Member 1 stated she went to the hospital the next morning and asked Resident 1 what really happened. Family Member 1 stated she recorded Resident 1's account of the incident on her phone camera. The following was Resident 1's account of the incident as told to Family Member 1:* When CNA 1 collected her for the shower, Resident 1 stated he stopped before entering the shower room to grab a towel to wrap around her. CNA 1 then proceeded to push the shower chair, and when he shook it to move forward, Resident 1 fell forward onto the shower room floor. CNA 1 quickly picked her up and placed her back on the shower chair. Resident 1 stated CNA 1 told her, "Don't tell anybody, they will fire me."* CNA 1 told Resident 1 what to say when someone asked what happened. Family Member 1 stated Resident 1 told her she went along because she was afraid of CNA 1. Resident 1 explained CNA 1 had been rough in the past.Family Member 1 stated she went to the facility and showed the recorded account to the Administrator.Family Member 1 stated the Assistant Administrator called her three days after the incident and informed her. CNA 1 admitted that he had changed the sequence of events. The Assistant Administrator told Family Member 1 that CNA 1 admitted to telling the resident what to say if anyone asked what happened. Family Member 1 stated Resident 1 was able to walk prior to this incident. Family Member 1 stated Resident 1 was constantly on pain medication after the incident, "She's not able to get up and get out of bed like she was able to." After the interview, Family Member 1 showed pictures of Resident 1's injuries she captured on her phone on the day of the incident. The pictures showed Resident 1's left wrist area was red, the left outside elbow had a small cut which was bright red, and the left knee was swollen with some bruising. A telephone interview with LVN 1 was conducted on 9/23/15 at 1537 hours. LVN 1 verified she was the charge nurse at the time the incident occurred. LVN 1 stated on 8/31/15 at 1630 hours, CNA 1 told her Resident 1 was complaining of a headache. LVN 1 went and asked Resident 1 if she was in pain and Resident 1 nodded yes. LVN 1 stated she administer Tylenol (mild pain medication) to Resident 1. LVN 1 stated Family Member 2 was at the bedside when she came back to reassess the resident's pain. LVN 1 stated she suspected something was wrong because Resident 1 was grimacing. Family Member 1 asked Resident 1 in her language if she has pain anywhere else. Resident 1 pointed to her left knee. Family Member 2 asked the LVN to administer Norco (narcotic pain medication) for Resident 1's pain.LVN 1 stated while getting Norco, she asked CNA 1 what happened. CNA 1 told her he slipped as he was transferring the resident and the resident's left knee bumped to the bed frame. LVN 1 stated she called Resident 1's NP and received an order for an x-ray. LVN 1 further stated 45 minutes after giving Norco, Resident 1 was still in a lot of pain, so LVN 1 called the NP to report Resident 1's status. At 1800 hours, LVN 1 called for medical transport to take Resident 1 to the acute care hospital at the family's request and the NP's order. LVN 1 further stated CNA 1 was asked several times, even in front of the family regarding the incident. CNA 1 repeated the same previous account he had provided. When asked if she had interviewed Resident 1 or other staff about the incident, LVN 1 stated she had not. An interview with the Administrator and Assistant Administrator was conducted on 9/23/15 at 1031 hours. The Administrator stated Family Member 1 came in the day after the incident (on 9/1/15) and showed him the video recording of Resident 1's account of the incident. The Administrator stated CNA 1 was called back into the facility and questioned about the accuracy of his account of the resident's fall incident. The Administrator stated CNA 1 admitted to initially having given a false account of the resident's fall incident on 8/31/15, and CNA 1 was suspended.These failures have a direct and immediate relationship to the health, safety or security of patients. |
| 060000033 |
FLAGSHIP HEALTHCARE CENTER |
060012897 |
B |
23-Jan-17 |
J5PM11 |
20198 |
GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: CNA - Certified Nurse Assistant DON - Director of Nursing IDT - Interdisciplinary Team LVN - Licensed Vocational Nurse MAR - Medication Administration Record MDS - Minimum Data Set (a standardized assessment tool) Osteoarthritis - a type of arthritis that occurs when flexible tissue at the ends of bones wears down OT - Occupational Therapist ORIF - open reduction internal fixation (surgical procedure to repair broken bones) P&P - policy and procedure Parkinson's disease - a neurological condition causing tremors and an unsteady gait when walking RD - Registered Dietitian RN - Registered Nurse RNA - Restorative Nurse Assistant SBAR - Situation, Background, Assessment, Recommendation F323: 483.25(h) Accidents and Supervision: The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. The facility failed to ensure the residents remained free from accident hazards and appropriate assistive devices were in place to prevent accidents for Residents 3, 9, 10, and 12). * Resident 10 suffered a fall with injury while being transferred using a Hoyer lift (a mechanical lift to transfer residents to and from the bed or chair). Resident 10 fell from the Hoyer lift sling, resulting in fractured ribs and hospitalization. In addition, Resident 10 was scratched by Resident S's dog and suffered from a skin tear on the right forearm. * Resident 12 got up from the bed and ambulated unassisted. He had dementia and an unsteady gait, had four falls within two weeks, and was then transferred to a room away from the nurses' station where he was not visible from the hallway. This had the potential for Resident 12 to sustain unwitnessed falls with possible injury. * Resident 3 sustained a fall with a right hip pain and fracture. The resident had six more fall incidents which were not investigated thoroughly in an attempt to prevent further falls. * The facility failed to place a pad alarm in Resident 9's wheelchair as ordered by the physician. This had the potential of Resident 9 getting up unassisted, falling, and sustaining injuries. Findings: 1. Clinical record review for Resident 10 was initiated on 11/30/16. Resident 10 was initially admitted to the facility on XXXXXXX, and readmitted on XXXXXXX, with diagnoses including osteoarthritis. a. Review of Resident 10's MDS dated 7/9/16, showed he needed two persons' assistance for transfers. Resident 10 was assessed to need a Hoyer lift for transfers. Further review of Resident 10's clinical record showed a hospital CT scan dated 7/1/16, which showed Resident 10 had rib fractures. On 12/5/16 at 0940 hours, during an interview with Resident 10, Resident 10 stated he fell onto the floor and suffered rib fractures while being transferred via a Hoyer lift. Review of Resident 10's fall investigation showed Resident 10 fell on 7/1/16, while being transferred using a "net" sling (the part of the machine in which the resident is allowed to rest) attached to a Hoyer lift. On 12/6/16 at 1140 hours, an interview regarding Resident 10's fall on 7/1/16, was conducted with the DON. The DON stated Resident 10 had requested a specific sling be used during his transfers with the Hoyer lift. When asked if documentation existed to show Resident 10's sling preference, the DON stated all communication regarding this was done verbally and not documented. On 12/6/16 at 1350 hours, an interview with the OT was conducted. The OT stated she was called to assist CNA 7 with transferring Resident 10 from his bed onto a shower chair using a Hoyer lift on 7/1/16. The OT stated Resident 10 was already on the sling and it was already attached to the Hoyer lift. When asked what type of sling Resident 10 had underneath him during the transfer, the OT stated the sling was made of sturdy mesh material. When asked what the condition of the sling was on 7/1/16, the OT was unable to state; the OT just remembered the sling snapped and Resident 10 fell onto the ground. On 12/7/16 at 1130 hours, an interview with CNA 7 was conducted. When asked about Resident 10's fall on 7/1/16, CNA 7 stated she and the OT were in the room assisting Resident 10 to transfer him via a Hoyer lift onto a shower chair. When asked about the sling used to transfer Resident 10, CNA 7 stated she used a sling she had been informed Resident 10 preferred. CNA 7 stated it was a blue cloth-like material which extended from Resident 10's mid back area to Resident 10's back of the shoulder area. CNA 7 stated the cloth area of the sling then continued underneath Resident 7's legs, which CNA 7 stated she criss-crossed in between his legs and then attached onto the Hoyer lift. CNA 7 stated Resident 10 was to one side of his bed, approximately four feet above the ground when three of the slings straps snapped and Resident 7 fell onto the ground. CNA 7 stated two of the sling's straps snapped at the seam area where the straight edge and looped area of the straps met, and the third strap snapped about midway down. CNA 7 stated she saw drops of blood coming out of the left side of Resident 10's head. CNA 7 stated Resident 10 was transported to the acute care hospital afterwards. On 12/8/16 at 1135 hours, an interview with Resident 10 was conducted. When asked what type of sling was used on 7/1/16, during his transfer and subsequent fall from the Hoyer lift, Resident 10 stated a blue mesh sling was placed underneath him. Resident 10 stated while he was suspended in the air, he felt the back "cord" against his back break and his back hit the floor. When asked if he had expressed a preference of the type of sling to be used on him for transfers with the Hoyer lift, Resident 10 stated he did not request any specific sling; staff chose which sling to use for his transfers. On 12/8/16 at 1426 hours, an interview with the DON was conducted. When asked if she looked at the sling used on Resident 10 on 7/1/16, after Resident 10 fell, the DON stated she did not look at the sling but was focused on caring for Resident 10 after he fell. The DON stated the mechanical lift used on Resident 10 on 7/1/16, was called a Joerns Hoyer Presence 500; however, the sling used with this lift on 7/1/16, was a toileting sling designed to be used with the Invacare mechanical lift, not the sling for the Joerns Hoyer Presence 500. Review of the Joerns Hoyer Presence User Instruction Manual showed to not use a sling unless it is recommended for use with this lift. b. Review of the facility's P&P titled Animals in the Long Term Care Facility revised 9/2015 showed animal-assisted activities and resident animal programs - animals that are fully vaccinated for zoonotic diseases (infectious diseases that can be transmitted from animals to humans) and that are healthy, clean, well-groomed, and negative for enteric parasites (parasites that can infect the gastro-intestinal tract of humans and other animals) or otherwise have completed recent anthelmintic treatment (used to destroy parasitic worms) under the regular care of a veterinarian will be used in the program. During an observation on 11/30/16 at 1600 hours, Resident 10 was observed to have two white dressings on the right hand and forearm. A two inch by two inch white dressing was placed on Resident 10's right hand and a two inch by six inch white dressing was on Resident 10's right forearm. During an interview with LVN 5 on 11/30/16 at 1610 hours, LVN 5 stated Resident 10 was trying to pet Resident S's dog and the dog scratched him. LVN 5 stated Resident 10 acquired a skin tear from the dog's scratch and was getting treatment with normal saline. During an interview with the DON on 12/5/16 at 1440 hours, the DON stated she did not have Resident S's dog's immunization record. The DON stated the Activity Manager was contacting Resident S's husband to bring in the immunization record. 2. Clinical record review for Resident 12 was initiated on 11/30/16. Resident 12 was readmitted to the facility on 10/27/16, with diagnoses including advanced Parkinson's disease and dementia. On 11/30/16 at 1650 hours, Resident 12 was observed walking without assistance in Room H with the bed alarm sounding. Resident 12 walked with an unsteady gait to the opposite side of the room, then back to his bed, and sat down, which then stopped the bed alarm from sounding. Room H was shaped like an "L." Bed A was visible from the hallway, but in order to see Beds B and C, the staff had to walk into the room and turn to the left. Resident 12's bed was the furthest from the door (Bed C) and not visible from the hallway. Further impeding the view were the privacy curtains, which were drawn between the three beds. LVN 9 verified the above. On 12/1/16 at 0650 hours, Resident 12 was observed sleeping in his bed with both legs hanging over the side of the bed touching the floor; the privacy curtains were drawn between the beds. On 12/1/16 at 0700 hours, an interview was conducted with LVN 8. LVN 8 stated at night, Resident 12 went to the bathroom by himself, but the staff listened for the alarm and went to assist him. LVN 8 stated sometimes Resident 12 needed help to lift his legs onto the bed. Review of the MDS dated 11/10/16, showed Resident 12 had severe cognitive impairment and needed extensive assistance with transfers, walking, and toileting. Resident 12's balance was not steady, only able to stabilize with human assistance when moving from a seated to a standing position, walking, turning around, and surface-to-surface transfers. Review of the Incident/Accident Report dated 10/31/16 at 2200 hours, showed Resident 12 attempted to get out of bed unassisted and had an unwitnessed fall with no apparent injury. Review of Resident 12's physician's order dated 10/31/16, showed to move Resident 12 closer to the nurses' station. Review of the Incident/Accident Report dated 11/1/16 at 1530 hours, showed Resident 12 had an unwitnessed fall near his bed, resulting in a head laceration. Review of Resident 12's physician's order dated 11/1/16, showed to apply a pad alarm to the bed and wheelchair to remind the resident not to get up unassisted. Review of the SBAR Communication Form and Progress Note dated 11/8/16, showed Resident 12 had an unwitnessed fall near the bathroom of the resident's room. Resident 12 had no apparent injury. Review of the Incident/Accident Report dated 11/8/16 at 1800 hours, showed Resident 12 was found standing in his bathroom with a laceration to the left eyebrow. The facility did not determine how it had occurred. Review of the SBAR Communication Form and Progress Note dated 12/6/16 at 0317 hours, showed Resident 12 had an unwitnessed fall in his bathroom, resulting in a left elbow wound, measuring 2 cm (length) x 3 cm (width). On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with the DON. The DON was unaware Resident 12 had a fall in the morning. The DON verified Resident 12 had four falls from 10/27 to 11/8/16. The DON verified Resident 12 was moved to his current room on 11/10/16, and the reason was not documented. The DON verified Resident 12 got up and walked without assistance. Resident 12 was observed in his room on the bed. Two straps, holding the mattress to the bed frame, were observed laying on the floor where Resident 12 stood up. The DON verified it was a fall hazard. The DON verified Resident 12 could not be seen from the doorway and the view was further impeded by the curtain being drawn between the beds. The DON verified Resident 12's room was not near the nurses' station as per the physician's order. 3. Review of the facility's P&P titled Incident Investigation dated March 2008 showed all employee reports of incidents must be thoroughly investigated at the time the incident is reported. The incident investigation process is designed to determine the root cause of the incident. Clinical record review for Resident 3 was initiated on 11/30/16. Review of the Admission Record showed Resident 3 was initially admitted to the facility on XXXXXXX, and readmitted on XXXXXXX. Review of the MDS dated 5/9/16, showed Resident 3 had severe cognitive impairment and was not able to be interviewed. In addition, Resident 3 required supervision for eating and extensive assistance for dressing, bathing, and daily hygiene care. Review of the Fall risk assessments for Resident 3 dated 4/4, 5/2, 5/31, 6/21, 7/7, 8/9, 10/18, 10/21, and 10/25/16, showed Resident 3 was at a high risk for falls. Review of History and Physical Examination form dated 5/3/16, showed the diagnosis of fall with right hip fracture status post ORIF. Review of the history and physical examination from the acute care hospital dated 4/23/16, showed "Yesterday she went to bathroom and lost balance, so fell on the floor. She had severe right hip pain. X ray showed intertrochanteric (upper part of the thigh bone) and proximal fracture at the right hip." Review of Resident 3's care plan showed a care plan problem dated 4/22/16, to address the resident's fall to the floor when attempting to get back to bed from the bathroom. The interventions included to continue safety whenever ambulating, make sure the bed alarm was in place, have staff respond promptly, monitor the resident while in bed, place pads on the floor, offer assistance to the restroom, provide area for safe ambulation, and use of bed and wheelchair alarm. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 4/25/16, showed the section for witnessed or unwitnessed was blank. The section for Injury was blank. The location of the resident prior to the fall was blank, predisposing disease, the footwear or assistive device at time of fall, and the medications that may contribute was documented as none. There was no documentation to identify the circumstances surrounding the fall (i.e. whether the resident was in bed or in a wheelchair when she fell and/or what external factors could have contributed to the resident's fall, etc.). Review of the Incident/Accident Investigation Follow-Up dated 4/23/16, showed Resident 3 was found on the floor complaining of hip pain; she fell when she was trying to get back to bed from the bathroom. Documentation showed the resident was interviewed; however, there was no documented evidence to show the direct care staff and licensed nurse were interviewed. Review of the Interdisciplinary Post Fall Review dated 5/31/16, showed Resident 3 was noted to be sitting on the floor at the bedside complaining of moderate pain to the right hip. The facility interviewed only the OT; however, there was no direct care staff or licensed nurse interviewed. Review of the Incident/Accident Investigation Follow-Up dated 7/2/16, showed Resident 3 was found sitting on the floor in the room at the bedside. The Summary of Investigation (Reasonable Conclusion) showed the resident was trying to get out of bed unassisted. It failed to show if the staff or resident was interviewed and what was the reason the resident wanted to get out of bed. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 7/7/16, showed a resident assisted fall in the hallway in front of the smoking patio by resident care services. The environmental factors and medications that might contribute to the fall were left blank. Review of the Interdisciplinary Post Fall Review dated 9/11/16, showed Resident 3 fell in the front lobby, unassisted transfer from the wheelchair to the sofa. The footwear or assistive devices at the time of the fall were left blank. Review of the Incident/Accident Investigation Follow-Up dated 10/18/16, showed Resident 3 was found sitting on the floor in the front lobby. The Past Interventions Attempted was left blank. The Recommendations/New Interventions showed frequent visual checks. The Summary of Investigation (Reasonable Conclusion) showed when the resident was asked what happened, the resident continuously spoke in her primary language. Review of the Incident/Accident Investigation Follow-Up dated 10/21/16, showed Resident 3 was found sitting on the floor; she stated she was coming out from the toilet and slid. The Past Interventions Attempted were left blank. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 10/21/16, showed the areas to document the injury, vital signs, hypotension on the fall, location of the fall, location of the resident prior to the fall, activity at the time of the fall, predisposing diseases, conditions that might contribute to the fall, footwear or assistive devices at time of fall, environmental factors, and medications that might contribute to the fall were left blank. There was no documentation to identify the circumstances surrounding the fall (i.e. whether Resident 3 was in bed or in a wheelchair when she fell and/or what external factors could have contributed to the resident's fall, etc.). On 12/2/16 at 0915 hours, an interview was conducted with CNA 9. CNA 9 was asked if Resident 3 asked for assistance to the restroom or for toileting, bathing, and dressing. CNA 9 stated Resident 3 could press the call light and asked for assistance to go to the toilet but could not wait long. CNA 9 stated she was very busy helping other residents. Sometimes she helped other residents in the restroom, so she could not go to Resident 3 right away and Resident 3 would get up unassisted to go to the toilet. On 12/6/16 at 1330 hours, an interview and concurrent clinical record review was conducted with the DON and LVN 4. When asked regarding the fall incidents involving Resident 3, LVN 4 stated Resident 3 sustained a right hip fracture after the fall on 4/22/16. Each of the fall incidents was investigated. LVN 4 was asked if the fall incident on 4/22/16, where the location of the resident prior to the fall, predisposing disease, footwear or assistive device, medication, who supervised or monitored the resident and if any staff was interviewed. LVN 4 stated she did not know the location, the predisposing disease should be documented for Parkinson's, hypertension, and dementia, and the medication should be documented for hypertension, and psychoactive. LVN 4 stated she did not know how the resident transferred herself to the bathroom and if the bed alarm or wheelchair alarm sounded. When asked if she could show any documentation for any information regarding the fall, LVN 4 stated she did not have it. When asked what happened on 9/11/16, LVN 4 stated the volunteer who spoke in Resident 3's language left the resident alone in the lobby; the volunteer should not have left her alone. LVN 4 was asked if the volunteer was interviewed about the fall incident or if the volunteer knew or was made aware Resident 3 was at high risk for falls prior to the fall. LVN 4 stated there was no documentation of an interview with the volunteer. When asked what past interventions were in place for the incident on 10/18/16, LVN 4 stated she did not know the details and was unable to provide any information. When asked about the incomplete investigation dated 10/21/16, and the IDT assessment, LVN 4 confirmed the fall investigation was not conducted thoroughly. LVN 4 stated she depended on staff to keep her informed of any incidents that needed the investigation. LVN 4 acknowledged Resident 3 had six more fall incidents in the facility after the fall incident on 4/22/16. These failures had a direct and immediate relationship to the health, safety, and security of the residents. |
| 060000033 |
FLAGSHIP HEALTHCARE CENTER |
060012898 |
B |
23-Jan-17 |
J5PM11 |
16811 |
GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living cm - centimeter(s) CNA - Certified Nurse Assistant DON - Director of Nursing Eschar - black or brown necrotic tissue, can be loose or firmly adherent, hard, soft, or soggy LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) P&P - policy and procedure RN - Registered Nurse Stage III pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Stage IV pressure ulcer - full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone Unstageable ulcer - full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar F314: 483.25(c) Pressure Sores: (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure the necessary care and services were provided to prevent the development and promote healing of pressure ulcers for Residents 11 Resident T and Resident V. * Resident 11 informed staff of pain to the right heel for a week before the staff identified the resident had developed a DTI (deep tissue injury) to the right heel. This resulted in the resident requiring further treatment to attempt to heal the pressure ulcer, further discomfort due to having to wear a special boot, and posing the risk of a possible infection. * Resident V was incontinent and had no pressure ulcers upon admission to the facility on XXXXXXX. There was no care plan intervention to address incontinence care for the resident. Seven days later, on 11/29/16, the resident developed a Stage III pressure ulcer to the coccyx (tailbone) area. Resident V's incontinence brief and wound dressing on his coccyx were observed to be heavily soaked with urine. The resident was not provided with necessary care timely to prevent worsening of the pressure ulcer due to the facility not having enough nursing staff to provide proper care for the residents throughout the facility. The facility had five CNAs on 12/12/16, during the 11-7 shift to care for 153 residents. * Resident T was admitted to the facility with a Stage IV pressure ulcer to the sacrococcyx area. The resident's pressure ulcer was observed to be covered with loose stool. There was no documentation the staff had turned, repositioned, checked every two hours, and provided the resident's pericare after each incontinence episode as care planned, due to the facility not having enough nursing staff to provide proper care for the residents throughout the facility. Findings: Review of the facility's P&P titled Skin Management dated 8/2012 showed upon admission; all residents are assessed for skin integrity by completing a head to toe physical assessment and completing the Braden Scale (for predicting pressure sore risk). Appropriate preventive surfaces of beds, wheelchairs, etc. will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale). Following admission, the Braden Scale will be completed weekly for three additional weeks (for a total of four weeks, including admission). A weekly skin check will be conducted and documented on the Head to Toe Skin Check. 1. Review of the facility's Skin - Weekly Pressure Ulcer Record described a DTI as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Clinical record review for Resident 11 was initiated on 11/30/16. Resident 11 was admitted to the facility on XXXXXXX. The MDS dated 10/29/16, showed Resident 11 to be cognitively intact. On 11/30/16 at 1630 hours, an interview was conducted with Resident 11. Resident 11 stated she needed assistance with bed mobility, transfers, and toileting. Resident 11 stated she had a sore on her right heel which needed treatment and had to wear a boot which was uncomfortable. Resident 11 stated she had been telling the staff her right heel was hurting for at least a week before the blister was found, but nobody had paid attention. Review of Resident 11's physician's order dated 12/1/16, showed to cleanse the right heel blister (dark purple in color) with normal saline, pat dry, paint with betadine (topical antiseptic), and cover with a dry dressing. Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/13/16, showed Resident 11 was at moderate risk with slightly limited mobility (makes frequent though slight changes in body or extremity position independently). Friction and shear was a problem showing Resident 11 required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. Review of the Head to Toe Skin Checks dated 10/13/16, showed Resident 11 was admitted with a Stage 1 pressure area (intact skin with non-blanchable redness) to the coccyx area, bruising to the right upper extremity, and redness to the left under-breast. There was no documentation of any skin breakdown on the heels. Review of Resident 11's care plan problem dated 10/14/16, titled Resident having Potential/Actual Skin Issues related to pressure ulcer related to mobility showed the interventions were to conduct weekly skin checks per facility protocol, document the findings, turn, and reposition frequently to decrease pressure. Review of the clinical record showed no documented evidence of any weekly skin checks and/or assessments as per the care plan. Review of the Nursing Weekly Summary showed no documented evidence the nurse had completed a weekly nursing summary to address the resident's weekly skin assessments. Not until 11/11/16 (almost four weeks since the resident's admission), a Nursing Weekly Summary was completed on 11/11/16, and showed Resident 11 did not have a pressure ulcer; the area for skin conditions was blank. However, review of the Weekly Pressure Ulcer Record dated 11/11/16, showed a new right heel DTI, measuring 3 cm (length) x 2 cm (wh) of dark purple skin with an onset date of 11/9/16. Review of the Weekly Pressure Ulcer Record dated 11/29/16, showed a right heel DTI measured 4.5 cm x 4 cm and covered with black and purple colored skin. Review of Resident 11's care plan problem dated 11/30/16, titled ADL self-care performance deficit related to cervical fracture and chronic pain in the left shoulder showed Resident 11 was at risk for ADL decline and required extensive assistance of two staff persons for repositioning and turning in bed. On 12/5/16 at 1500 hours, an interview was conducted with RN 2. RN 2 verified Resident 11 was admitted without a pressure ulcer to the heels. RN 2 verified a skin assessment/weekly summary should be done weekly, but Resident 11 failed to have one completed until 11/11/16, four weeks after the admission Head to Toe Skin Check dated 10/13/16. RN 2 was unable to find any documentation of preventative care regarding Resident 11's heels. RN 2 verified Resident 11's right heel DTI could have been avoided. On 12/6/16 at 1000 hours, an interview and concurrent clinical record review was conducted with the DON. Upon review of the Incident/Accident Investigation Follow-Up dated 11/9/16, the DON verified the section showing past interventions attempted showed "N/A" (not applicable). The DON was unable to find any documentation of a skin assessment completed between 10/13 and 11/10/16, and was unable to find any documentation regarding preventative measures being done to prevent the right heel pressure ulcer. On 12/8/16 at 1345 hours, a telephone interview was conducted with the DON. The DON verified the facility's Skin Management P&P was not followed. A Braden Scale should have been completed weekly for three additional weeks following admission and a weekly skin check should have been conducted and documented for Resident 11, neither of which were completed. 2. On 12/13/16 at 0735 hours, CNA 15 was observed going in Resident V's room. CNA 15 stated she had changed Resident V's incontinence brief between 0100 to 0200 hours (more than five hours ago). Resident V's incontinence brief was observed soaked with urine. In addition, Resident V had a dressing on his coccyx which was also soaked with urine. CNA 15 was informed the dressing on Resident V's coccyx was soaked. CNA 15 stated the treatment nurse would change it later. CNA 15 was observed putting on a new incontinence brief over the soaked dressing to Resident V's coccyx. Clinical record review for Resident V was initiated on 12/13/16. Resident V was readmitted to the facility on XXXXXXX. The MDS dated 11/29/16, showed Resident V was incontinent of bowel and bladder. The Readmission Skin - Head to Toe Skin Check dated 11/22/16, showed Resident V's skin was intact. Review of Resident V's care plan showed a care plan problem to address increased risk for altered skin integrity. The interventions included providing pressure relieving cushion and low air low mattress. Further review of Resident V's care plan showed there was no intervention included to address Resident V's incontinence in preventing the development of pressure ulcers. The Skin - Head to Toe Skin Check dated 11/28/16, showed Resident V's skin was intact. The Skin - Head to Toe Skin Check dated 11/29/16, showed Resident V had a new stage III pressure ulcer to the coccyx, measuring 1.5 cm (length) x 1.2 cm (width) x 0.2 cm (depth). The Skin - Weekly Pressure Ulcer dated 12/2/16, showed Resident V's pressure ulcer on the coccyx measured 1.5 cm x 1.2 cm x 0.2 cm with 20% slough (dead tissue) with a small amount of serosanguinous (pinkish blood tinged) drainage. The Skin - Weekly Pressure Ulcer dated 12/9/16, showed Resident V's pressure ulcer on the coccyx measured 1 cm x 1.2 x 0.2 cm with 10% slough. On 12/13/16 at 1105 hours, LVN 1 was observed providing wound treatment to Resident V. LVN 1 was asked if Resident V developed the pressure ulcer while at the facility. LVN 1 replied yes. LVN 1 removed the dry dressing on Resident V's coccyx and measured the pressure ulcer. The measurements were 1.4 cm x 1.5 cm with superficial depth. During a telephone interview with RN 1 on 12/14/16 at 1130 hours, RN 1 acknowledged Resident V developed a new pressure ulcer on 11/29/16. RN 1 was asked what the facility's protocol was in identifying skin impairment. RN 1 stated the CNA who provided ADL care should report any skin impairment, i.e. redness, open area to the charge nurse. RN 1 stated the licensed nurse also completed a weekly summary of the resident's status, including a head to toe assessment. RN 1 was informed the Skin - Head to Toe Skin Check for Resident V dated 11/28/16, showed the resident's skin was intact and the next day (11/29/16), the documentation showed Resident V had a Stage III pressure ulcer. RN 1 verified the skin assessment dated 11/28/16, showed Resident V's skin was intact. RN 1 was asked if Resident V had redness to the coccyx. RN 1 replied the documentation showed no redness. RN 1 was unable to explain how Resident V had developed a Stage III pressure ulcer in one day. RN 1 was asked what interventions the facility should have implemented to prevent the development of a pressure ulcer. RN 1 replied the staff should have provided incontinence care every two hours and as needed. RN 1 was asked if the care plan problem to address increased risk for the development of pressure ulcers included an intervention to provide incontinence care every two hours and as needed. RN 1 acknowledged there was no intervention in the care plan to provide incontinence care every two hours and as needed. RN 1 was informed of the above observation of Resident V on 12/13/16 at 0735 hours. RN 1 acknowledged they were short-staffed during that shift and tried their best, but they did not get "enough help." The facility had five CNAs on 12/12/16 during the 11-7 shift to care for 153 residents. 3. On 12/13/16 at 0515 hours, an interview was conducted with CNA 15. CNA 15 stated she was assigned to care for 30 Residents today because a few CNAs had called off. She started her shift with focusing on residents who needed their diapers changed. CNA 15 also stated she had six residents in one hallway who were incontinent and that was not including the other hallway she was assigned to. CNA 15 stated she also tried to answer the call lights in between changing her residents. On 12/13/16 at 0540 hours, CNA 15 was observed at resident T's bedside. Resident T was observed lying on her left side. CNA 15 initiated pericare by removing Resident T's incontinence brief. During the process of removing Resident T's incontinence brief, the dressing to Resident T's pressure ulcer fell off into the soiled brief, exposing the pressure ulcer. Loose stool was noted up on Resident T's lower back and around Resident T's pressure ulcer. CNA 15 wiped the stool from Resident T's lower back, removed the soiled brief and sheet, placed a new sheet under Resident T, and covered Resident T with a clean sheet. CNA 15 stated she needed to inform LVN 14 about placing a new dressing to Resident T's pressure ulcer before she placed a new brief on Resident T. CNA 15 then proceeded to inform LVN 14 of Resident T's dressing and continued with other Resident assignments. On 12/13/16 at 0620 hours, LVN 14 placed a new dressing to Resident T's pressure ulcer and completed Resident T's pericare. Resident T continued to lay on her left side. On 12/1316 at 0720 hours, an interview was conducted with CNA 15. CNA 15 stated she typically changed a Resident's diaper every two hours. CNA 15 stated Resident T was last changed between 0100 and 0200 hours this morning. CNA 15 stated she changed and turned her residents with pressure ulcers every two hours, but "I'm not going to lie; a night like tonight, it is impossible to get to everyone on time." Clinical record review for Resident T was initiated on 12/13/16. Resident T was admitted to the facility on XXXXXXX. Review of the MDS dated 9/27/16, showed Resident T had severe cognitive impairment was incontinent of bowel and bladder with a urinary catheter in place. Resident T was admitted to the facility on XXXXXXX, with a Stage IV pressure ulcer to the sacrococcyx area (tailbone). Review of Resident T's care plan showed a care plan problem to address bowel incontinence. The interventions included checking the resident every two hours and providing pericare after each incontinent episode. Further review of Resident T's care plan showed a care plan problem to address the pressure ulcer. The interventions included to provide wound care and preventative skin care, and turn and reposition frequently. On 12/13/16 at 0830 hours, 0930 hours, Resident T was observed lying on her left side. On 12/13/16 at 0945 hours, LVN 1 was at Resident T's bedside performing daily wound care to Resident T's pressure ulcer. Resident T's incontinence brief was soiled with loose stool. LVN 1 was asked how often Resident T's incontinence brief should be checked. LVN 1 stated very two hours. On 12/13/16 at 1000 hours, CNA 17 was at Resident T's bedside performing pericare. Resident T was placed on her right side. CNA 17 was asked how often she checked Resident T's incontinence brief and turn her. CNA 17 stated every two hours. During a telephone interview with RN 1 on 12/14/16 at 1150 hours, RN 1 was asked what the facility protocol was for a resident who was incontinent of bowel and had a pressure ulcer to the sacrococcyx area. RN 1 stated to keep the resident dry, turned and repositioned every two hours, perform good hand hygiene, check and change soiled diapers every two hours and as needed, perform urinary catheter care, and the treatment nurse should change the dressing daily. These failures had a direct and immediate relationship to the health, safety, and security of the residents. |
| 630010892 |
Fairway Court |
090009450 |
B |
21-Aug-12 |
EI9B11 |
7575 |
W & I 4502 (h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure that two staff did not neglect the needs of 6 clients living in the facility when both staff on duty were observed sleeping on the day shift from 6:00 A.M. to 11:30 A.M. on 3/18/12. Staff did not feed clients breakfast or lunch. Morning medications were not administered. Toileting and personal hygiene was not provided. The clients were not gotten up in their wheelchair to meet recreational and leisure activities. Clients were neglected in bed while the staff were asleep. Additionally, the overnight staff, who witnessed the neglect of clients, did not attempt to provide care, food, medications, and did not tell anyone of the neglect until 3:00 P.M. of the following day, 3/19/12.The clients living in the facility who were the victims of neglect on 3/18/12 from 6:00 A.M. to 11:30 A.M. were the following:A. Client 1 was admitted to the facility on 7/19/11 with diagnoses that included mild mental retardation, dwarfism and cerebral palsy per the Admission Information Sheet. B. Client 2 was admitted to the facility on 7/30/08 with diagnoses that included profound mental retardation, spastic quadriplegia (weakness on four extremities), scoliosis (abnormal curvature of the spine), and legally blind per the Admission Information Sheet. C. Client 3 was admitted to the facility on 7/25/69 with diagnoses that included profound mental retardation, spastic quadriplegia, gastro-jejunostomy tube (feeding tube inserted into the abdominal cavity), and vision impairment per the Admission Information Sheet. D. Client 4 was admitted to the facility on 3/24/72 with diagnoses that included severe mental retardation, epilepsy, left hemiplegia (left sided weakness), and infantile hemiplegia per the Admission Information Sheet. E. Client 5 was admitted to the facility on 9/27/82 with diagnoses that included severe mental retardation, spastic quadriplegia, seizures, and high myopia (pathological nearsightedness) per the Admission Information Sheet. F. Client 6 was admitted to the facility on 2/15/84 with diagnoses that included profound mental retardation, infantile cerebral palsy, seizure disorder, and vision impairment per the Admission Information Sheet.A review of the "Facility Suspected Crime Report Under Elder Justice Act" was conducted on 3/23/12 at 3:35 P.M. The investigative report dated 3/20/12 indicated that direct care staff (DCS) 1 reported that two female facility staff did not provide care for 6 of 6 clients living in the facility on 3/18/12. The two facility staff did not provide care and services that included breakfast, lunch, medications, toileting and personal hygiene to 6 of 6 clients.A review of the "Daily Schedule - Vacation" for clients when home from regular Monday - Friday school or adult day program was conducted. The schedule indicated the following: 6:00 - 9:00 A.M.Morning Personal Grooming (bathing, hygiene, dressing, toileting, communication programs as applicable) Meal Preparation (washing, positioning) Breakfast (drinking, eating, communication programs as applicable) Personal Grooming (washing, toileting as needed) Leisure 9:00 - 11:30 A.M. Active Treatment Options - Therapeutic positioning, Sensory stimulation activities, Socialization and Communication, Recreation and Leisure Activities 11:30 - 1:00 P.M. Meal Preparation (washing, positioning) Lunch (drinking, eating, communication programs as applicable) Personal Grooming (washing, toileting as needed) Leisure of Choice None of the clients' schedule from 6:00 A.M.- 11:30 A.M. was provided by the staff for the clients. The 6 clients remained in bed while the two staff on duty slept.An interview was conducted on 3/23/12 at 3:45 P.M. with the qualified mental retardation professional (QMRP). The QMRP stated, "DCS 1 called me on Monday afternoon to report the two staff for sleeping and for not providing care for the clients on Sunday. According to DCS 1, on 3/18/12, the two staff came to work at 6:00 A.M. When they walked in to the facility, they went in to each client's room and looked. Then they proceeded in the living room. One took her blanket out from her purse and laid on the couch. The other one laid on the recliner. They both went to sleep. All the clients stayed in bed. I have only one client in the house that can talk. Client 1 is interviewable."On 3/23/12 at 4:30 P.M., a joint observation and an interview were conducted with Client 1. Client 1 was observed in wheelchair watching television in his room. Client 1 stated, "No, I did not eat breakfast on Sunday. I was in bed. I did not have any medications. The other clients were also in bed and they did not eat breakfast too. For lunch, I had a bowl of cereal. It was given to me by the tall staff." A phone interview was conducted on 4/5/12 at 5:30 P.M. with DCS 1. DCS 1 stated, "On 3/18/12 after working night shift, I was not able to go home because my ride did not come. I stayed in the facility as I had to work at 2:00 P.M. I was up and I watched television. DCS 2 and DCS 3 came in to work at 6:00 A.M. to 2:00 P.M. DCS 2 and DCS 3 slept from 6:00 A.M. to 11:30 A.M. DCS 2 slept on the couch and DCS 3 slept on the recliner. They did not feed the consumers and they did not give their medications. No breakfast and no lunch. All 6 consumers were in bed. They were not provided care. At 11:30 A.M., DCS 2 and DCS 3 got up. They got the clients up in their wheelchair. Client 1 asked DCS 2 to take him to the toilet. DCS 2 told Client 1 to go to his room. Client 1 was given a bowl of cereal for lunch around 1:00 P.M. The rest of the clients did not eat at all. I was afraid to report these staff. I am new. I was afraid. Yes, I had abuse training and I am a mandated reporter. So, I called the QMRP the following day and reported it to her. "A review of the facility policy and procedure (P/P) entitled, "Client Protections; Abuse Prevention" was conducted on 5/18/12 at 10:30 A.M. The facility P/P indicated, "# IV. Facility Practices: A. The facility through development and implementation of appropriate policies and procedures will protect its clients from mistreatment, neglect and abuse. Clients will not be subjected to abuse by anyone, including but not limited to: facility staff, consultants or volunteers, staff of other agencies serving the individual; family members or legal guardians, friends; other individuals or clients."The facility failed to ensure that 6 of 6 clients were not neglected on 3/18/12, when 2 morning direct care staff slept and did not provide care and services for 5.5 hours. Additionally, a third direct care staff who witnessed the neglect of the clients did not intervene or report it until the afternoon of the next day.A violation of this regulation had a direct or immediate relationship to the health, safety, and or security of these clients. |
| 090000054 |
Fredericka Manor Care Center |
090013189 |
B |
31-Aug-17 |
5U8R11 |
9301 |
F- 323 - The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 9/ 21/17 at 11:00 A.M., an unannounced visit was conducted to investigate a complaint alleging that the physical therapist assistant (PTA) did not locked Resident 1's wheelchair during transfer and Resident I fell.
Resident 1 was a 73 year old resident who was transferred to the facility from the general acute care hospital (GACH) after she had a right hip surgery on XXXXXXX16. Resident 1 was admitted to the facility for a short term rehabilitation service and was planning to go home after she completed her rehabilitation treatment. However, PTA failed to lock her wheelchair during transfer on 9/15/16, as a result, Resident 1 fell and sustained multiple fractures per the hospital's final reports: "1. Nondisplaced anterior left proximal humeral (long bone of the upper arm) greater tuberosity (at the top of the humerus) fracture. 2. Minimally impacted posterior left humeral head/greater tuberosity fracture (bone fracture of left bone of upper arm). 3. T4 (4th thoracic vertebra - spine joint) inferior endplate two-column burst compression fracture (injury to the spine in which the vertebral body is severely compressed. They typically occur from severe trauma, such as a motor vehicle accident or a fall from a height). 4. T3 (3rd thoracic vertebral fracture of the spine joint in which the vertebral body has suffered a crush or wedging injury) superior end plate age- indeterminate wedge compression fracture. 5. Moderate osteopenia (bone loss)..." Resident 1 was transferred back to the GACH on XXXXXXX16.
Based on observation, interview, and record review, the facility failed to ensure that the staff was trained to lock and secure the wheelchair breaks when transferring resident. The PTA did not lock the wheelchair breaks transferring Resident 1 from bed to wheelchair on 9/15/16. As a result, Resident 1 fell off from an unlocked wheelchair and sustained bone fracture of left bone of upper arm. The facility failed to ensure PTA implemented the facility's policy and procedure related to safe transfer and fall prevention program. This failure had the potential to put Resident 1's health and safety at risk.
Resident 1 was admitted to the facility on XXXXXXX16, per the Facility Face Sheet. Resident 1 was known to be high risk for fall according to the admission assessment diagnosis, dated 9/7/16. Per the same record, the resident had diagnoses that included, "1. R (right) hip intertrochanteric fracture s/p (status post) ORIF (open reduction internal fixation- a surgical procedure to fix a severe bone fracture, or break), 2. Mechanical fall resulting in R hip fracture. There was no evidence of documentation or written report that fall risk assessment was performed upon admission for Resident 1. A post fall assessment, dated 9/15/16, indicated "scored 42.00" which identified as "Significant risk for fall."
A review of Resident 1's Minimum Data Set (an assessment tool), dated 9/13/16, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) that scored 13 (on a scale of 00 to 15, 15 being the most cognitively intact). The same MDS assessment on Functional Status for the Activities of Daily Living (ADL) indicated that Resident 1 was a total dependent on transfer which required two (2) or more persons physical assist.
A review of Resident 1's plan of care related to "At risk for Falls", dated 9/6/16, identified the problems which included "history of falls, impaired mobility, poor balance recovery, weakness, s/p (status post) ORIF 9/4/16 secondary to right hip fracture, cerebral vascular accident (CVA - stroke) with left sided paralysis." However, this plan of care did not include the interventions for more than two person physical assistance and the use of breaks during transfer. After the incident occurred on 9/15/16, the LNs added a new intervention of "Assure w/c breaks are on prior to transfers."
A review of Resident 1's Physician Orders, dated 9/7/16, indicated, "...Skilled PT (Physical Therapy) services 6x (times)/wk (week) x 4 wks through 10/5/16 for abnormal posture...for therapeutic exercises, therapeutic activities, & neuromuscular re-education..."
On 9/21/16 at 12:00 P.M., an interview was conducted with the PTA. The PTA stated that on the morning of 9/15/16, the PTA went inside the resident's room, saw the resident with the care giver. The PTA stated that Resident 1 was assisted to get out of bed to perform the transfer training. The PTA tried to put Resident 1 to the wheelchair. The PTA stated that the wheelchair started moving while both hands of Resident 1 were being held. The PTA stated, "She (Resident 1) was going down. I thought I locked it (the brakes of the wheelchair)..." then called CNA (certified nursing assistant) for help. The PTA acknowledged that the brake of the wheelchair had not been locked during Resident 1's transfer to wheelchair. In addition, the PTA transferred Resident 1 by himself without second person/staff's assistance.
On 4/24/17 at 11:50 A.M., a telephone interview was conducted with the care giver (CG). The CG stated that the fall incident had been witnessed inside Resident 1's room. The CG stated that on 9/15/16 around 11:45 A.M. and 12:00 P.M., the PTA came inside the resident's room with a wheelchair, then put the wheelchair near the resident's bed. The CG stated that Resident 1 was seated on the bed, the PTA got the resident up, and tried to put the resident on the wheelchair. The CG stated that the brake of the wheelchair was not locked and the wheelchair started to move. The CG stated that "both the resident and the PTA flew...it was fast, the wheelchair went backward and before Resident 1 landed on the floor, the wheelchair went back to the resident and hit her head." The CG stated that Resident 1 fell flat of the floor, and the PTA ended on top of the resident. The CG acknowledged that the wheelchair brakes had not been locked by the PTA prior to using it.
A review of the Physical Therapy Daily Documentation notes, dated 9/7/16, indicated, "Initial evaluation completed. Treatment initiated. A 73 y/o (year old) female with recent acute hospital stay due to a fall presenting with T hip fracture s/p ORIF, WBAT (weight bearing as tolerated). History of CVA with L (left) hemi (hemiparesis- partial weakness on one side of the body), has a AFO (Ankle foot orthoses- used for contracture management and healing protection for a range of foot and ankle issues that include foot drop) for L (left) foot/ankle to compensate for L equino varus (a foot deformity in which the heel is turned inward and the foot is plantar flexed) contracture. Per patient's care giver, patient required Min (minimum) assist of 1 person for bed mobility and transfers, non-ambulatory. Currently requires Total Asst (assist) Sup<-> sit and Max A to maintain sitting position at edge of bed, tolerated edge of bed sitting x 5 minutes, SPO2 with 2L (liters)/min (minute) O2 (oxygen):98% in supine at rest, de sat to 88% sitting at edge of bed. Will benefit from skilled PT services to improve functional mobility."
A review of licensed nurse (LN) 1's notes, dated on 9/15/16 at 3:52 P.M., indicated, "At 11:45a today alerted by CNA (certified nursing assistant) that resident had a fall with physical therapist...Resident was sitting up on the floor being held from back and head by physical therapist...Resident stated she had pain when back of head and back of neck were touched..."
A review of the facility's policy and procedure (P&P), dated 8/26/16, titled "Therapy Specialists: Safety Training", indicated "F. Observe transferring and lifting techniques. G. Lock wheelchairs when transferring patients..." In addition, the P & P titled "Fall Prevention Program" dated 2/16 indicated, "...1. Assessing fall risk upon admission based on resident's prior level of functioning and their current mental, physical, and medical status..."
On 2/27/17 at 11:50 A.M., the PT Rehabilitation Director was interviewed. He acknowledged that this fall incident could have been prevented, if safe transfer technique was implemented by securing the brakes of wheelchair was implemented.
On 8/29/17 at 3:57 P.M., a telephone interview was conducted with the administrator (ADM). The ADM acknowledged that the fall could have been prevented if the PTA implemented their policy on safe transfer techniques
The facility failed to ensure PTA implemented the facility's policy and procedure related to safe transfer and fall prevention program. As the result, PTA did not lock the wheelchair breaks during transfer of Resident 1 from bed to wheelchair on 9/15/16. In addition, the facility failed to ensure LNs develop interventions in the plan of care/ fall prevention plan to ensure the staff lock wheelchair during transfer with two person physical assist for Resident 1. These failures caused Resident 1's unsafe transfer that resulted to multiple fractures.
A violation of this regulation had a direct or immediate relationship to the health, safety or security of the patient.
1 |
| 010000075 |
Fortuna Rehabilitation & Wellness Center, LP |
110008824 |
B |
15-Oct-12 |
12JO11 |
3663 |
T22 DIV5 CH3 ART5-72541 Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to report an outbreak of gastrointestinal infections with the potential for lack of surveillance and/or infection control and further spread of the illness. The facility had an outbreak of gastrointestinal infections, beginning 11/25/11. By 11/30/11, fifteen (15) residents were affected and neither the California Department of Public Health (CDPH-State Public Health Department) nor the local Public Health Department were notified, within twenty-four hours,During interview, on 12/7/11 at 10:50 a.m., the Administrator stated that the facility had experienced a gastrointestinal illness outbreak that had also affected the community.The facility Medical Director stated, during interview on 12/7/11 at 11 a.m., that the pathogen (cause of disease or illness) causing the outbreak had not been identified. He stated that signs and symptoms included nausea, vomiting, and diarrhea and sometimes fevers. The physician stated that all the residents were treated for their symptoms in the facility.Review of facility documentation, received on 12/7/11 at 11:15 a.m., revealed a total of twenty (20) residents had the symptoms of the gastrointestinal illness: four residents on 11/25/11, another four on 11/26/11, three on 11/27/11, one on 11/28/11, two on 11/29/11, one on 11/30/11, and one on 12/1/11. The outbreak was not reported to the local Public Health Department until 12/1/11, six days after the initial outbreak.On 12/2/11, there was another resident with symptoms of the gastrointestinal illness and on the eighth day of the outbreak, the facility reported the unusual occurrence to the State Public Health agency (CDPH). There was one new case noted on 12/3/11 and two cases were noted on 12/5/11.Review of the facility policy "Communicable Disease Outbreak Management," dated May 2004, revealed: a. An outbreak is defined as in increase in the normal number of cases b. Known or suspected outbreaks will be reported to local, county and state health departments.The facility infection control manual was reviewed, on 12/7/11 at 11:30 a.m., and revealed: a. Outbreaks would be reported immediately to the local public health office.b. Occurrences/outbreaks would be directly reported, within twenty-four (24) hours to the local and State Public Health Departments.During concurrent interviews with the Administrator and the Infection Control Nurse, on 12/7/11 at 1:10 p.m., the Infection Control Nurse stated that more than two cases are considered an outbreak. The Administrator stated that it was her responsibility to report unusual occurrences and she was not aware of either the definition of an outbreak or the twenty-four hour reporting time frame.This facility failure to report a gastrointestinal illness outbreak threatened the welfare, safety, or health of residents. |
| 110000018 |
Fairfield Post-Acute Rehab |
110008977 |
B |
27-Apr-12 |
RW8Q11 |
5483 |
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 failed to carry out orders for oxygen as prescribed by the physician for Resident 1 who had shortness of breath and difficulty maintaining adequate oxygen saturation and was administered half the amount of oxygen that was ordered for more than 19 hours which contributed to the deterioration of her condition.Resident 1 was admitted to the facility on 1/03/12 with diagnoses including type two diabetes, congestive heart failure (a condition in which the heart can no longer pump enough blood to the rest of the body), end-stage renal (kidney) disease and was receiving dialysis treatments three times per week.Review of a chest x-ray report, that was performed on 1/10/12, revealed that she was experiencing moderate right lower lobe pneumonia and was ordered Doxycycline (an antibiotic medication) 100 mg (milligrams) twice daily by mouth and two liters of oxygen per minute by nasal cannula as needed to improve her blood oxygen saturation. Per a Mayo Clinic online article on hypoxemia (low blood oxygen): Normal oxygen saturation readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low.Review of a physician order, that was dated 1/10/12, revealed that Resident 1 was prescribed two liters of oxygen per minute by nasal cannula to be administered as needed for shortness of breath and to keep her blood oxygen saturation above 90 percent.Review of nurses notes, that were dated 1/12/12, revealed that Resident 1 had experienced an unwitnessed fall and was found on the floor in her bathroom at 6:05 a.m.Review of consultation report, that was dated 1/13/12, revealed that she had experienced fractures of four ribs with mild hemothorax (a collection of blood in the space between the chest wall and the lung).Her physician subsequently wrote an order, that was dated 1/12/12 at 4:40 p.m., for her to receive four liters of oxygen per minute by nasal cannula at all times due to shortness of breath and decreased oxygen saturation of her blood.Review of the medication administration record (MAR) revealed that licensed nurses on three separate shifts administered two instead of four liters of oxygen per minute as follows: On 1/12/12 on the evening shift, on 1/12/12 during the night shift, on 1/13/12 during the day shift and on 1/13/12 during the evening shift.Unlicensed Staff B stated during a telephone interview, on 2/16/12 at 2 p.m., that she remembered when she helped Resident 1 to get ready for her eye appointment on 1/13/12 and observed when the licensed nurse dialed the oxygen in at two liters per minute prior to her leaving to see the eye doctor.Review of nurses notes, that were dated 1/13/12, revealed that Resident 1's daughter had accompanied her to the eye appointment and had reported to the facility that Resident 1 had experienced shortness of breath while she was at the appointment.Licensed Staff C stated during an interview, on 1/19/12 at 3:45 p.m., that she had administered two liters of oxygen per minute to Resident 1 on 1/13/12. She stated that she had no knowledge that there had been an order change and had not been told of any changes in Resident 1's oxygen order during the change of shift report.Review of nurses notes, that were dated 1/13/12 revealed that at 12:10 p.m., Resident 1 went to receive physical therapy following an eye appointment.Review of the physical therapist notes that were dated 1/13/12 (no time), revealed that Resident 1 was receiving two liters of oxygen per minute and her blood oxygen saturation readings were at 74 to 76%.Physical Therapist A stated during an interview, on 1/19/12 at 3:30 p.m., that she remembered when she attempted to provide therapy to Resident 1 on 1/13/12 and had checked to make sure that her oxygen dial was set at two liters per minute. Physical Therapist A stated that she was not aware of any changes in Resident 1's oxygen orders.Review of nurses notes, that were dated 1/13/12, revealed that the physical therapist returned Resident 1 to the nursing unit at 12:19 p.m. where her blood oxygen saturation was at 82% while on two liters of oxygen per minute via nasal cannula and she was coughing severely.Resident 1 was transferred to the emergency room on 1/13/12 at 12:22 p.m. where she was evaluated and treated for symptoms including shortness of breath, below normal blood oxygen saturation levels and fluid in her right lung. Review of the emergency room report revealed that her oxygen saturation fluctuated and decreased to as low as 74% and 3% while receiving oxygen.Physician D stated during a telephone interview, on 2/24/12 at 2:45 p.m., that he had not been made aware that the facility had not followed his orders and had only administered half the amount of oxygen that he ordered. He stated that this was causing him concern and that the situation had the potential to have placed undue strain on Resident 1's heart.Review of Resident 1's death report, that was dated 1/16/12, revealed that she suddenly deteriorated in the last 24 hours before her death, was experiencing right-sided chest pain, underwent a right-sided thoracentesis (mechanical extraction of fluid from the lung), developed shock and expired on 1/16/12 at 3:18 p.m.The above violations had direct relationship to the health, safety or security of the Resident. |
| 110000018 |
Fairfield Post-Acute Rehab |
110009253 |
B |
30-May-12 |
Y66O11 |
8675 |
72541 UNUSUAL OCCURENCES Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to notify the Department of an electrical fire at the facility that required the kitchen to close, and failed to provide to the Department documentation of the incident, which had a direct relationship to the health, safety and security of the residents. The Department received two complaints, on 8/25/11, that indicated the facility was serving cold food to the residents because the kitchen had been closed following an electrical fire.During an observation, on 8/26/11, at 10:35 a.m., the ceiling in the kitchen scullery had freshly painted patched areas around the light box, which extended into the ceiling of the main body of the kitchen. The "Rehab Room", used for physical therapy, was located next door to the kitchen. Across the hall from the Rehab Room was a small Rehab Office, next door was a staff break room. During an interview, on 8/26/11 at 3:55 p.m., Staff A stated on 8/9/11, while having lunch in the staff break room, a second staff member came in and asked, "Do you smell something funny?" Staff A stated he checked the toaster in the staff room because it smelled, "...kind of like that." During an interview, on 8/26/11 at 3:25 p.m., Physical Therapist B (PT B)stated there were no patients in the Rehab Room, when Staff A came across the hall to the main Rehab Room. PT B stated there was a faint smell of marshmallows. PT B stated they paged Staff C who checked the ceiling access panel in the hall above the main door to the Rehab Room, but nothing was found. PT B stated the facility Administer in Training E, (AIT E), made the decision to call the fire department. During an interview, on 8/26/11 at 10:35 a.m., Dietary Supervisor D, stated on a Tuesday, (noted as 8/9/11 in the Fire Department Incident Report), about 4:30 in the afternoon, she became aware that staff in the Rehab Room next door to the kitchen smelled an unusual odor coming from the Rehab Room vent. Dietary Supervisor D stated she did not see any smoke in the kitchen as, "the swamp coolers pushed smoke out". Dietary Supervisor D stated she could see smoke in the hallway. Dietary Supervisor D stated the fire department was called; just before the fire department arrived, soot and ash fell from the ceiling vent in the scullery. Dietary Supervisor D stated the fire department evacuated the dietary staff from the kitchen and scullery. Dietary Supervisor D stated new insulation had been installed about four weeks prior to the incident, and, "A conduit wasn't correct". Dietary Supervisor D stated the fire department kept a "fire watch all night", and an "electrical inspector came". Dietary Supervisor D stated dinner had been prepared so dietary staff rolled the food out to a dining room to serve dinner that evening. Dietary Supervisor D stated fire department staff moved the kitchen refrigerators out of the kitchen and "rigged them for electricity". Dietary Supervisor D stated she used the facility emergency menu and food for meals, Tuesday evening through Friday, except for Friday dinner when electricity was restored in the kitchen. Dietary Supervisor D stated most of the meals were sandwiches, but by Wednesday dietary services was able to provide some hot meals or parts of meals, including hot soup and hot drinks. Dietary Supervisor D stated they utilized an outside barbecue for some meal preparation. Dietary Supervisor D stated a "county inspector came Wednesday and took food temperatures". Dietary Supervisor D stated the facility Registered Dietician Consultant came every day during the emergency; Administration, and the Director of Nursing communicated with the residents and families, and she had received only two complaints about the food. During an interview, on 8/26/11 at 11:20 a.m., Resident 1, identified by the facility as interviewable, stated she did not smell smoke or hear the fire trucks on 8/9/11. Resident 1 stated she was wearing head phones when a staff member told her firemen were coming and closed the door to her room. Resident 1 stated she was not frightened because staff reassured her several times. Resident 1 did not remember who told her there was a fire in the kitchen, however stated someone from administration came later and told her about the incident, and that the food would be "different". Resident 1 stated as the days passed, she started to wonder if her family should bring in some food, when the kitchen started up again. During an interview, on 8/29/11 at 12 noon, while sitting in the facility lobby in a wheelchair with oxygen administration equipment running, Resident 2, identified by facility as interviewable, stated he heard a fire alarm on 8/9/11. Resident 2 stated a Certified Nurse Assistant told him there was some smoke from the kitchen, and later someone else told him the food would be cold. During an interview, on 8/26/11 at 3:45 p.m., Certified Nurse Assistant G, (CNA G), stated she had been present in the facility on 8/9/11. CNA G stated she had not smelled or seen smoke, however she had smelled "something". During an interview, on 8/26/11 at 10:20 a.m., Administrator in Training F, (AIT F), stated it was her first full day at the facility. AIT F stated AIT E had been at the facility the day of the fire but was no longer there. AIT F stated she had been told that there had only been the smell of smoke on 8/9/11. Copies of the county inspector and fire department reports, and any facility documentation, were requested from the facility, for review, at approximately 11 a.m. on 8/26/11.During an interview, on 8/26/11 at 12:35 p.m., AIT F could not provide any written information regarding the electrical fire on 8/9/11. AIT F was informed that the facility was required to keep incident report(s) of unusual occurrences in the facility for one year. Copies of county inspector, and fire department reports, and any facility documentation were again requested, to be provided within an hour. During an interview, on 8/26/11 at 1:50 p.m., AIT F again could not provide any facility documentation or copies of inspection reports regarding the fire on 8/9/11. AIT F stated she had no one she could call for assistance in obtaining the reports. The local Fire Department Incident Report was obtained from the fire department, on 9/14/11, and reviewed 9/16/11 and 4/6/12. Review of the Incident Report revealed the following: On 8/9/11, two fire engines responded to a report of a smoke odor at the facility at 16:21, (military time for 4:21 p.m.). The first engine, "advised of an odor of smoke in the kitchen", requested additional units to the facility. Kitchen staff, in response to questions, stated that some of the lights in the area had gone off right before they smelled smoke. The kitchen staff checked the electrical breakers, one of which appeared to be tripped. When kitchen staff reset the breaker, sparks came from a ceiling fixture. The Fire Department opened the ceiling and removed insulation. The Fire Department Incident Report stated, "It appears wire had shorted out and burned a hole in the conduit and burned paper on the sheetrock." The Incident Report further indicated the facility administrator contacted an electrician who arrived to assist with making the area safe. Fire Department personnel contacted the county building department and the county Environmental Health Department. The Fire Department Incident Report indicated that investigation by Fire Department personnel revealed a "lighting retrofit of poor quality", however no flames were seen and there had been no smoke damage to the structure or contents. The facility failed to notify the Department of an electrical fire at the facility that required the kitchen to close, and failed to provide to the Department documentation of the incident, which had a direct relationship to the health, safety and security of the residents. |
| 110000018 |
Fairfield Post-Acute Rehab |
110009374 |
A |
10-Apr-13 |
ZXHR11 |
6546 |
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 failed to revise Resident 1's care plan, after a fall on 7/09/10, with effective interventions to prevent Resident 1 from experiencing a second fall on 8/02/10.Resident 1 was an 80 year-old female admitted to the facility on 6/28/10, following a total right knee replacement.Review of nurses' notes revealed the Resident 1 experienced a fall on 7/09/10 and a second fall on 8/02/10, which resulted in her sustaining a major laceration to the newly operated right knee requiring a second surgery to repair the damage caused by the fall.Review of Resident 1's care plan , dated 6/28/10, entitled "Resident At Risk For Fall", included: "At risk for falls due to 1) attempts independent bathroom time without assist, 2) independent ambulation, transfer attempts away from bed and/or wheelchair and 3) impulsive mobility. Interventions included assist with transfers, and to provide verbal, visual, and hands-on cues PRN (as needed.)"Resident 1's fall risk assessment, dated 6/29/10, indicated a fall risk of 15 and on 7/02/10 was updated to reflect a fall risk of 17. The assessment form indicates a total score of 10 or above represents high risk for falls.Nurses Notes, dated 7/09/10 at 7 p.m., documented that Resident 1 was found by an unlicensed staff, sitting on the bathroom floor. The note indicated that Resident 1 had stated that she had tried to get into her wheelchair by herself and fell.On 7/09/10, after the resident had been found on the bathroom floor, an alarm on Resident 1's wheelchair and bed was added as an intervention to the fall care plan. No new interventions, specific to fall prevention in the bathroom, were addressed. A care plan entitled, "Episodic Fall", also dated 7/9/10, reflected that Resident 1 had been found on the bathroom floor and one approach listed was for a "clip alarm (a pull cord alarm which notifies when a user gets up). The care plan also indicated that staff was to "reinforce use of call light for assistance ". This plan lacked specific interventions for fall prevention in the bathroom.The Minimum Data Set (an assessment tool), completed on 7/11/10, indicated the resident had difficulty walking and a short term memory problem exhibited by forgetfulness and impaired safety awareness. During an interview on 9/22/11 at 9:45 a.m., Unlicensed Staff A stated, that on 8/2/10, at about 2:20 p.m., she heard Resident 1 yelling for help and she assisted Resident 1 to the bathroom via wheelchair. Unlicensed Staff A also stated that she gave Resident 1 the call light to call for assistance when finished in the bathroom. She stated that it was a usual practice to leave Resident 1 alone in the bathroom with the call light. She notified Unlicensed Staff B that Resident 1 was in the bathroom and to watch for her call light. On 9/22/11 at 10:05 a.m., during an interview, Management Staff C stated that, on 8/2/10, Resident 1 was assisted to the bathroom by Unlicensed Staff A, via wheelchair, and that Unlicensed Staff A had instructed Resident 1 to use the call-light when done. Resident 1 had done so in the past. After staff heard a loud noise coming from Resident 1's room and found Resident 1 on the bathroom floor, bleeding from the right knee surgical site.During an interview on 9/22/11 at 10:30 a.m., Licensed Staff D stated, that on 8/02/10 at approximately 2:30 p.m., she was notified, by one of the unlicensed staff that Resident 1 was found on the bathroom floor with blood on her clothing. The blood was from the surgical site on her right knee. Licensed Staff D and Licensed Staff E applied a large gauze dressing and applied pressure to the bleeding area on the resident ' s right knee. Licensed Staff D notified Licensed Staff F, and called 911. Licensed Staff D also notified Resident 1's daughter, who was at the facility visiting Resident 1. During an interview on 9/22/11 at 4:45 p.m., Unlicensed Staff B stated that Unlicensed Staff A told her about Resident 1 being on the toilet, and that they were waiting for the resident to turn on the call-light. Unlicensed Staff G and Unlicensed Staff B went to check on Resident 1 and found her on the floor of the bathroom.An interview was conducted with the Director of Nursing (DON), on 12/22/11 at 4:15 p.m. , regarding measures which were in place to prevent further falls for Resident 1 after the 7/09/10 fall in the bathroom. The DON stated that the Interdisciplinary team recommended a self-release belt (a belt, which a resident can release, designed to aid in reminding a resident not to stand from a wheelchair without staff assistance) in addition to the tab alarm on the wheelchair and on the bed. The DON stated that, in the past, Resident 1 had always used the call light for help. No interventions specific to safety in the bathroom were mentioned.Review of the emergency department notes from the acute care hospital , dated 8/02/10, indicated that Resident 1 had tripped and fallen directly onto the surgical site on her right knee. The note indicated that the surgical site had split open, and that the orthopedic hardware was clearly visible in the wound. The discharge summary from the acute care hospital, on 8/05/10, indicated that Resident 1 had a disruption of the right total knee replacement incision that required surgical procedures; 1. Extensive irrigation and debridement of the right knee joint including skin, subcutaneous tissue fascia, muscle and bone 2. Closure complicated surgical wound dehiscence. Resident 1 had administration of two IV antibiotics and medication to prevent deep vein thrombosis.The facility failed to develop effective interventions, after a fall in the bathroom on 7/09/11, to prevent Resident 1 from experiencing a second fall (also in the bathroom), on 8/02/12. The second fall resulted in Resident 1 sustaining a major laceration to the newly operated right knee and, required Resident 1 to undergo a second surgery to repair the damage caused by the fall.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. |
| 110000018 |
Fairfield Post-Acute Rehab |
110010028 |
B |
10-Oct-13 |
6LQP11 |
6626 |
Health & Safety Code 1429.(a) 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility.Health & Safety Code 1429 (a)(1)(A) 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (1) The citation shall be posted in at least the following locations in the facility: (A) An area accessible and visible to members of the public.Health & Safety Code 1429 (a)(1)(B) (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (1) The citation shall be posted in at least the following locations in the facility: (B) An area used for employee breaks.Health & Safety Code 1429 (a)(1)(C) a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (1) The citation 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.Health & Safety Code 1429 (a)(2)(A) (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size, that includes all of the following information: (A) The full name of the facility, in a clear and easily readable font in at least 28-point type.Health & Safety Code 1429 (a)(2)(B) 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size, that includes all of the following information: (B) The full address of the facility, in a clear and easilyHealth & Safety Code 1429 (a)(2)(C) 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size, that includes all of the following information: (C) Whether the citation is class "AA" or class "A."Health & Safety Code 1429 (b) 1429. (b) Each class "B" citation specified in subdivision (d) of Section 1424 that is issued pursuant to this section and that has become final, or a copy or copies thereof, shall be retained by the licensee at the facility cited until the violation is corrected to the satisfaction of the department. Each citation shall be made promptly available by the licensee for inspection or examination by any member of the public who so requests. In addition, every licensee shall post in a place or places in plain view of the patient or resident in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility, a prominent notice informing those persons that copies of all final uncorrected citations issued by the department to the facility will be made promptly available by the licensee for inspection by any person who so requests.Health & Safety Code 1429 (c) (c) A violation of this section shall constitute a class "B" violation, and shall be subject to a civil penalty in the amount of one thousand dollars ($1,000), as provided in subdivision (e) of Section 1424. Notwithstanding Section 1290, a violation of this section shall not constitute a crime. Fines imposed pursuant to this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2.The facility failed to post a recently-issued "A" Citation, according to the regulations, which had the potential for residents, employees, family members, and the public, to not be aware of facility practices that could impact patient care. Findings: During an observation on 7/23/13 at 10:50 a.m., the posting of a class "A" citation #11-2534-0009374-S, issued on 4/24/13, was absent from any location in the facility. There was no citation posted in the lobby area, the communal areas, such as a dining or activity room, or in the employee break room.During an interview on 7/23/13 at 2:30 p.m., the Assistant Administrator stated that she was not aware of the regulation requirements for the above posting. |
| 110000018 |
Fairfield Post-Acute Rehab |
110010480 |
A |
11-Mar-14 |
2UMO11 |
7817 |
F323 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure the environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for Resident 15 who was identified by the facility to be at high risk for falls, was known to remove her alarm, required staff assistance and a walker when getting out of bed. Resident 15 had entered the unlocked kitchen area, experienced a fall, sustained a fracture of her spine, a deep cut to the head, abrasions and bruising to both lower legs and experienced severe pain. Resident 15 was found alone in the kitchen area and had sustained injuries that required transfer to an acute hospital for medical evaluation and treatment including stitches to her head. This practice had the potential for entrapment, other serious injuries, and death to Resident 15 and other residents who had access to the unlocked kitchen area that was unsupervised and where dangerous equipment and appliances were readily accessible.Review of Resident 15's clinical record revealed that she was admitted to the facility on 2/9/13, with diagnosis including abnormality of gait, and generalized weakness.During review of resident's "Fall risk evaluation" dated 2/9/13, 4/13/13 and 10/9/13, resident had a score of higher than 10 which per facility document a total score of 10 or above represents high risk.Review of resident care plan dated 2/10/13& 10/12/13, indicated "At risk for fall- Frequent falls, altered gait/unsteady" intervention/plans indicated "Provide bathroom time." Resident 15's clinical record did not indicate a bathroom schedule for her.During observation and concurrent interview on 1/7/14, at 8 a.m., Resident 15 was observed sitting up in bed, awake with a nasal cannula applied (a nasal cannula is a device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help). Resident stated, through the translator ADON (Assistant Director of Nursing), that she was walking in the hallway with her walker, she felt dizzy and fell on the day when she was injured. She stated that she experienced "a lot of pain" in her back and was sent to the hospital. She stated that she now did not get out of bed or go to activities because it was too painful to do so. Staff would get her up to shower, which was "very painful" when staff would have to move her to get her out of bed.During an interview on 1/7/14, at 9:05 a.m., MDS (an assessment tool) coordinator stated that Resident 15's last MDS (a discharge MDS) was completed on 12/27/13 when she was transferred to the acute care hospital for evaluation and treatment related to a fall during which she experienced a fracture of her spine and a laceration (a deep cut or tear in skin) to the right side of her head requiring stitches. Resident 15 was re-admitted to the facility on 12/30/13.During an interview on 1/7/14, at 10:15 a.m., Administrative Staff A stated that, per staff report, Resident 15 was looking for the bathroom and instead went to the kitchen, a few doors down from her room, which was where she fell and sustained a head laceration and a fracture. A CNA who went to the kitchen to get ice found Resident 15 on the floor by herself near the steps leading to the dietary office.Observation of the kitchen area, on 1/7/14 at 10:40 a.m., where Resident 15 had fallen on 12/27/13 revealed there was a step that was approximately four inches high, leading to the dietary office where Resident 15 was found on the floor the night of the incident.Equipment and appliances in the kitchen area where confused and wandering residents could injure themselves or get entrapped included: Gas stove burners, sharp knifes, and other sharp utensils. During an interview, on 1/7/14 at 10:20 a.m., Dietary Staff I stated she had been employed at the facility since August 2013 and usually worked the evening shift from 1 p.m. to 9:30 p.m. She stated she had not been told to keep the door to the kitchen locked until recently after a resident wandered into the kitchen during the night and fell. During a subsequent interview, on 1/7/14 at 10:35 a.m., Registered Dietician E stated she was not aware of the facility policy in regards to keeping the door to the kitchen locked at night. During a telephone interview on 1/10/14 at 10:10 a.m., Unlicensed Staff Y stated that the night of the incident (12/27/13), Unlicensed Staff X had called her to let her know that Resident 15 had fallen in the kitchen. Unlicensed Staff Y stated she knew that Resident 15 was not steady on her feet without her walker, had a tab alarm (a tab alarm features a pull-string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver). Unlicensed Staff Y stated that Resident 15 would frequently disconnect the alarm and get out of bed without assistance when she could not wait for her call light to be answered. Unlicensed Staff Y said that Licensed Staff P met her and Unlicensed Staff X as they we were leaving the kitchen and walking Resident 15 back to her room. The facility then called 911 and Resident 15 was sent to the hospital around 4:30 a.m. During a telephone interview on 1/10/14 at 1:05 p.m., Licensed Staff P caring for the resident the night of the incident, stated one of the CNAs called her to the kitchen and she saw that two CNAs were walking Resident 15 back to her room. Resident 15 told her she wanted to use the toilet, became dizzy and fell. Licensed Staff P stated she offered Resident 15 a bed pan, applied oxygen, and called 911. Licensed Staff P also stated Resident 15 had disconnected her tab alarm before getting out of bed by herself "which she has done many times in the past." She said that to be safe, Resident 15 required a walker with one person assisting her at all times. She stated Resident 15 was not using her walker and was by herself when she fell and injured herself. Licensed Staff P further stated she assessed Resident 15 and determined that she had sustained a laceration to the right side of her head and was unable to explain how she got injured.Review of facility policy titled "Fall Prevention Program" (undated), indicated "Following a resident's fall, the licensed nurse will assess the resident for injuries and necessary treatment; if no apparent injuries assist off floor."Review of the acute care hospital admission records, history and physical dated 12/27/13, indicated the admitting diagnosis was "Laceration of occipital region of scalp: Thoracic vertebral fracture: UTI (Urinary tract infection), and bilateral lower extremity abrasions and bruising." Hospital records also indicated that surgical intervention for the compression fracture was not an option due to patient requiring medical management due to her overall condition and medical problems including cardiomegaly (enlarged heart) with congestive heart failure (occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) and coronary artery disease (when the arteries that supply blood to heart muscle become hardened and narrowed). Resident 15 was discharged back to the facility on 12/30/13.These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the resident. |
| 110000018 |
Fairfield Post-Acute Rehab |
110010481 |
A |
28-Mar-14 |
HJ0D11 |
15170 |
F309 ?483.25 Provide Care/Services for Highest Well Being 483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide necessary care and services to maintain the highest practicable level of physical and psychosocial well-being for Resident 14 when the facility failed to ensure that: 1. Licensed Staff recognized, assessed, and monitored Resident 14 for a change of condition when Resident 14 complained of abdominal pain; 2. Staff did not initiate timely Cardio/Pulmonary Resuscitation (a procedure used to restore breathing and heart function) (CPR) consistent with Resident 14's POLST (Physician Order Set for Life-Sustaing Treatment) directive. These failures of not recognizing Resident 14's deteriorating medical condition and delay in initiating CPR resulted in Resident 14 having a Cardio/Pulmonary arrest, unsuccessful resuscitation (restoration of breathing and heart function) and was pronounced dead later that day at an acute care hospital.Resident 14 was admitted to the facility on 1/3/14 for short-term rehabilitation following a surgical repair of a left hip fracture. Review of Admission Assessment (dated 1/3/14) and nurses notes, (dated 1/4/14), indicated Resident 14 was "very with it," cooperative, and able to make her needs known. It was also noted her directive (POLST- Physician Orders for Life-Sustaining Treatment), indicated she wanted to receive full CPR (Cardio/Pulmonary Resuscitation). During an interview on 1/15/14 at 8:20 a.m., Family Member 1 (family of Resident 24) stated he met Resident 14 on 1/7/14, when his mother (Resident 24) was admitted to the facility and was placed in the bed next to Resident 14. Family Member 1 stated Resident 14 was alert, oriented and very pleasant.Family Member 1 stated he and his wife (Family Member 2) decided to take turns staying with Resident 24 (his mother) due to her confusion and dementia. Family Member 1 stated he decided to stay the night (1/7/14) and Family Member 2 would come in the next morning, 1/8/14 at 5:30 a.m. Family Member 1 stated around midnight on 1/8/14, he heard Resident 14 complaining of abdominal pain so he put the call light on for Resident 14. He stated 15 minutes later a CNA (Certified Nursing Assistant) came in and when Resident 14 told the CNA about her abdominal pain the CNA stated she would tell the nurse. Family Member 1 stated later a nurse or a CNA (he didn't remember who) came in as Resident 14 had a bowel movement and needed to be cleaned up. The nurse/CNA told Resident 14 maybe that's why she had a stomach ache. Family Member 1 stated awhile later, between 12 a.m. and 1 a.m., Resident 14 "started vomiting." Resident 14 was given a small basin by a CNA and told Resident 14 she would let the nurse know.Family Member 1 stated Resident 14 kept moaning with abdominal pain, grabbing her stomach all night and he heard her "vomiting" at times. Family Member 1 stated he kept waiting for someone to come to help Resident 14. Family Member 1 stated around 5 a.m., Resident 14 did receive medication for pain.During an interview on 1/15/14 at 9:10 a.m., (and review of a signed, written declaration by Family Member 2), Family Member 2 (for Resident 24) stated she had met Resident 14 on 1/7/14, and found Resident 14 to be very "with it," a sweet person, alert and oriented and seemed very intelligent. Family Member 2 stated when she returned to the facility the next morning (1/8/14) at 5:30 a.m., she found Resident 14 to be a "totally different person." Family Member 2 stated when she asked Resident 14 how she was feeling Resident 14 told her she was having a lot of stomach pain and asked Family Member 2 to help her. Family Member 2 stated she went out in the hall and saw a man wearing scrubs so she asked him to help Resident 14 who was in a lot of pain. He stated he would tell the nurse.Family Member 2 stated from 5:30 a.m. until 7:30 a.m., she notified different staff three times that Resident 14 was in a lot of pain, and needed help. She stated "nothing was done, no medication was given, no staff member or nurse came in." Family Member 2 stated she told Resident 14 that she had notified staff and they were coming. Family Member 2 stated she was trying to provide Resident 14 with "a sense of comfort." Family Member 2 stated Resident 14 continued to moan in pain and was trying to get out of bed. Family Member 2 stated she went out in the hall and even asked "the cleaning lady" to come help. The "cleaning lady" came into the room and put on Resident 14's call light then left the room. Family Member 2 stated a CNA (Certified Nurses Assistant) came in (doesn't remember the exact time) and re-positioned Resident 14 and reminded her not to get out of bed, then left the room. Family Member 2 stated Resident 14 was still moaning in pain. Family Member 2 stated around 7:30 a.m., a CNA came in to "clean up" Resident 14 and during the whole time the CNA was "cleaning her" Resident 14 was moaning and crying out saying she was in pain. Another CNA came in and both CNAs transferred Resident 14 to a wheelchair for breakfast. The CNAs left the room. Family Member 2 stated after the CNAs left the room she heard a gurgling sound from Resident 14 and then there was silence. She stated she peeked around the curtain and saw Resident 14 in the wheelchair with her head down. Family Member 2 stated she went down the hall to the public bathroom and upon returning to the room the CNA was right behind her. Family Member 2 stated she told the CNA that Resident 14 was not okay, and the CNA replied she knew that Resident 14 was in pain. Family Member 2 stated she told the CNA she thought that Resident 14 had passed away. The CNA put on the call light and another CNA came into the room, and they transferred Resident 14 onto the bed and "cleaned her." She stated after the CNAs left the room she looked around the curtain and noted Resident 14 was laying in the bed and was covered with a white sheet. Family Member 2 stated two nurses (did not know their names) then came into the room and were talking for about five minutes. Family Member 2 stated around 8 a.m., she heard a woman (who she thought to be the Registered Nurse for Managed Care not employed by the facility)(PCC T) come to the doorway and asked where the resident was (referring to Resident 14) and was told on the bed. She then asked if CPR had been started, and the response was "No." She also asked if the directive (POLST) had been addressed and again the answer was "No." Family Member 2 stated the PCC T said CPR needed to be started immediately since Resident 14's directive indicated full CPR. Family Member 2 stated one of the nurses (Licensed Staff O) asked PCC T "Do we have to start CPR?" and PCC T stated, "Yes. Now." Family Member 2 stated PCC T was directing the nurses how to do chest compressions, and seemed irritated that they were not doing the chest compressions correctly. Family Member 2 stated it had been "20 minutes" after she had seen Resident 14 slumped in the wheelchair before any CPR was started. She stated when the Paramedics arrived they asked the staff how long they had been doing CPR and were told at least for 10 minutes. Family Member 2 stated "That was not true," and stated she shook her head "No" to one of the Paramedics. Review of the Paramedics flow sheet indicated paramedics initiated an assessment of Resident 14 on 1/8/14 at 8:19 a.m. Review of the Emergency Room notes indicated Resident 14 expired on 1/8/14 at 9:01 a.m. During an interview on 1/16/14 at 3:15 p.m., PCC T stated on 1/8/14 she went to the facility around 7:30 a.m., and was in her usual work space across from Nurses Station 2. She stated around 8 a.m., Licensed Staff O came to her and stated Resident 14 was gone. PCC T stated when she asked Licensed Staff O to clarify what she meant by "gone," Licensed Staff O told her Resident 14 was found unresponsive and had no pulse. PCC T asked Licensed Staff O if the POLST had been checked for code status and Licensed Staff O stated "No." PCC T stated when she checked Resident 14's chart, she noted that Resident 14's POLST stated full code, ( Cardio/Pulmonary Resuscitation). PCC T told Licensed Staff O to call a code, start CPR (Cardio/Pulmonary Resuscitation), and call 911. PCC T stated when she went into Resident 14's room she noted another nurse (did not know her name but stated she was an RN), was not doing chest compressions but was doing the Heimlich procedure (a technique used for removing a foreign body from the trachea or mouth where it is preventing airflow; on an unconscious patient lying supine on the floor, the rescuer exerts a sudden upward pressure on the abdomen; also is referred to as an abdominal thrust maneuver). PCC T stated she had to show the nurse (an RN) how to do chest compressions. PCC T stated when she asked for the Ambu-bag from the crash cart, (a bag-valve mask unit used to provide artificial breaths for a person who can not breathe on their own) she noted there was no mask attached.PCC T stated when the paramedics arrived (around 8:15 a.m.) she left the room. PCC T stated she did not know why Licensed Staff O came to her initially instead of initiating CPR immediately for Resident 14. PCC T stated after observing the two RNs she realized they were not competent with initiating a code blue or delivering CPR correctly. During an interview on 1/30/14 at 6:30 a.m., Unlicensed Staff R stated she cared for Resident 14 on the night shift 11 p.m. on 1/7/14 until 7 a.m., 1/8/14. She stated soon after shift report (around midnight), she had answered Resident 14's call light. Unlicensed Staff R stated Resident 14 complained of a stomach ache and thought she needed to have a bowel movement. Unlicensed Staff R stated she informed Licensed Staff P, who came into the room, asked Resident 14 about her abdominal pain and offered to help her to the bathroom. Resident 14 did not want to get up and asked that Attends (adult briefs) be placed on her. Unlicensed Staff R stated Resident 14 did have two bowel movements, and stated she felt better. Unlicensed Staff R stated awhile later Resident 14 complained of nausea, so she gave Resident 14 a small basin and some tissues. Unlicensed Staff R was not aware that Resident 14 had any vomiting and stated when she checked on Resident 14 later (doesn't remember any times) Resident 14 was sleeping. Unlicensed Staff R stated on her last rounds around 5 a.m., Resident 14 did complain of left arm pain. Unlicensed Staff R told Licensed Nurse P and Licensed Staff P did give Resident 14 Tylenol for her arm pain.During an interview on 1/15/14 at 9:30 a.m., Licensed Staff P stated she was the nurse for Resident 14 on the night shift 11 p.m., 1/7/14, to 7 a.m., 1/8/14. Licensed Staff P stated the CNA, ( Unlicensed Staff R) did tell her Resident 14 was complaining of left arm pain so she gave her Tylenol. She stated that was at 5 a.m., 1/8/14. Licensed Staff P stated she did not receive any report from the CNA of Resident 14 having any other pain during the night, only the one time at 5 a.m.Review of the Medication Administration Record (MAR) confirmed that Licensed Nurse P gave Resident 14 Tylenol 325 mg. 2 tabs at 5 a.m., for 4/10 left arm pain. Review of Resident 14's chart, nurses notes revealed no documentation of assessments or interventions for Resident 14, from 1/7/14, 7:30 p.m., until 1/8/14 at 8 a.m. During an interview on 1/14/14 at 1:45 p.m., Unlicensed Staff Q stated she was assigned to Resident 14 the day shift on 1/8/14. Unlicensed Staff Q stated the only report she received from the night CNA (Unlicensed Staff R) was that Resident 14 was asking for her husband and did try to get out of bed one time. Unlicensed Staff Q stated at 6:15 a.m. on 1/8/14 she answered Resident 14's call light. Resident 14 was asking to speak with her husband. Unlicensed Staff Q told Resident 14 that her husband would be there later. Unlicensed Staff Q stated she "cleaned up" Resident 14 and then she and another CNA transferred Resident 14 to the wheelchair for breakfast. Unlicensed Staff Q stated she left the room to deliver breakfast trays and upon returning to the room with Resident 14's tray she noted Resident 14 was pale and not responsive. Unlicensed Staff Q stated she went to get the nurse and a code was called. During an interview on 1/14/14 at 2:30 p.m., Licensed Staff O stated she worked the day shift on 1/8/14 which began at 7 a.m. She stated when she received shift report from the night nurse there was no mention that Resident 14 had any problems during the night. Licensed Staff O stated at 8 a.m., Unlicensed Staff Q reported to her that Resident 14 was pale and unresponsive. Licensed Staff O stated she went right away to check Resident 14 and found Resident 14 sitting in a wheelchair, pale, without a pulse, and non-responsive. She stated she then called a code blue, started CPR, and called 911. Licensed Staff O stated CPR was initiated 2-3 minutes after Unlicensed Staff Q found Resident 14 unresponsive. Licensed Staff O stated the paramedics arrived shortly after and transferred Resident 14 to the hospital. During an interview on 1/28/14 at 11:30 a.m., Administrative Staff B was asked for the facility's policy and procedure for the resuscitation of an unresponsive resident, including roles and responsibilities of licensed and unlicensed staff. She stated the facility did not have such a policy, but followed the American Heart Association's 2010 Guidelines for CPR, (early recognition of cardiac arrest, immediate CPR can double or triple a victim's chance of survival; there are two steps to "Staying Alive", call 911 and push hard and fast with hands on center of chest, i.e.: chest compressions, a critical component, creates blood flow to the heart.) During an interview on 1/31/14 at 9:10 a.m. Administrative Staff B stated CPR inservices ( training) were conducted on 1/9/14 for licensed nurses on the day and evening shifts following the death of Resident 14. When asked why the licensed nurses on the night shift were not inserviced, Administrative Staff B stated, "There was no need," since it was the day shift that was involved in the incident on 1/8/14.During an interview on 2/4/14 at 11:32 a.m., the Medical Director stated it was "unacceptable" that facility staff did not know the proper technique or procedure for initiating CPR and that he wanted the staff to follow the American Heart Association's Guidelines for CPR, which was early recognition of a cardiac arrest, immediate and proper technique with initiation of chest compressions. When asked if a 10 to 15 minute delay in the initiation of CPR was acceptable, the Medical Director stated it was "not acceptable." These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the resident. |
| 010000022 |
Friends House |
110010984 |
B |
19-Sep-14 |
UK9V11 |
5902 |
F323 ?483.25h-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 regulations by failing to provide or maintain an environment free of accident hazards when hazardous material was used to insulate a gas dryer. The foam board material was combustible and documented as a fire hazard. This had potential for harm to all residents, and resulted in an Immediate Jeopardy (IJ) being called. Management Staff B, and Management Staff I were informed and present when the IJ was called on 5/28/2014 at 5:20 p.m. During observation on 5/27/2014, at 09:30 a.m., a foil covered, foam board material was observed leaning against the ceiling light fixture. This material was observed on 5/27/2014 at 8:30 a.m., 9:30 a.m., 10:30 a.m., and 3:05 p.m.During an interview Staff J on 5/27/2014 at 1:45 p.m., stated the foam board material was used as an insulation to keep the room cool, so that staff folding clothes would not get overheated. During an interview on 5/27/2014 at 2:30 p.m., Management Staff E stated she had received a call from the manufacturer about the foam board material, that the material should be installed behind the wall.During a telephone interview 5/29/2014 at 11:10 a.m., the manufacturer's representative stated that the foam board material was still combustible. Management Staff E provided the following information; The manufacturer's Material Safety Data Sheet for the foam board material, dated 3/2012, page 1, section IV, Fire and Explosion Data, indicated "Unusual Fire or Explosion Hazards: Polyisocyanurate foam is combustible." Additionally, a WARNING in the description pages for the foam board material indicated; "DO NOT leave [material named] exposed. Polyiso foam is an organic material which will burn when exposed to an ignition source of sufficient heat and intensity and may contribute to flames spreading." Facility Safety Program, undated, page 25, under Accident Prevention, indicated; Unsafe conditions should be reported and or corrected. Page 26, under Hazard Communication Program, indicated; All employees will be trained...Training will consist of the physical and health effects of these hazardous chemicals,...and how to read labels and review Safety Data Sheets(SDS), formerly named Material Safety Data Sheets (MSDS). Facility Injury and Illness Prevention Program, dated 10/2012, under Employee Health and Safety Training, indicates; "In addition, [facility named] provides specific instructions to all workers regarding hazards unique to their job assignment, to the extent that such information was not already covered in other trainings...Hazard communication, including training on MSDS, chemical hazards and container labeling" is part of that training. During an observation on 5/28/2014 at 11 a.m. and 4/28/2014 at 4:30 p.m., the foam board material was still around the clothes dryer. The foam board material was 4 by 6 feet each, and surrounded the dryer (ceiling to floor on the left side, top of the dryer to ceiling in front, and covered half way up the right side of the clothes dryer). The foam board material was secured with glue and masking tape. The masking tape did not hold and with any movement the board fell against the metal of the florescent light fixture. The foam board material was degrading and much of the foil had begun to peel. The laundry was directly adjacent to resident room 4, and directly across the hall from residents' rooms 1, 2, and 3.An Immediate Jeopardy was called on 5/28/2014 at 5:20 p.m. for concerns of a potential fire hazard. Management Staff B and Management Staff I were informed and present at the facility when the IJ was called.The foam board material was removed on 5/28/2014 at 5:55 p.m.During an interview on 5/29/14 at 2:55 p.m., Management Staff B stated that she had no knowledge that the material used to insulate the dryer was a fire hazard. She further stated that DSD (Director of Staff Development) does the training of staff in Fire Prevention. During an interview on 5/29/14 at 3:20 p.m., Management Staff A stated that he had no knowledge that the material surrounding the dryer was a fire hazard. When questioned about his oversight in the facility for safety, Management Staff A stated he asks the staff what training they need. In addition, he stated the facility has a Safety Committee and a Risk Management Committee that meets once each month to discuss any safety issues. The facility staff removed the foam board material on 5/28/14 at 5:55 p.m. The laundry, housekeeping, maintenance, and all administrative staff in the skilled nursing facility were in-serviced about not placing objects around the dryer and touching the dryer. A yellow safety line at a 12 inch perimeter was painted on the floor on 5/29/14 to signify a safety zone. Facility staff were interviewed regarding the above mentioned inservice. The survey team accepted and verified that the facility's plan of action was implemented and the IJ was abated on 5/29/2014 at 10:32 a.m. Management staff A, B, and D were informed and present at the facility when the IJ was abated on 5/29/14 at 10:32 a.m.Therefore, the facility violated the regulations by failing to provide or maintain an environment free of accident hazards when hazardous material was used to insulate a gas dryer. The foam board material was combustible and documented as a fire hazard. This had potential for harm to all residents, and resulted in an Immediate Jeopardy (IJ) being called. Management Staff B, and Management Staff I were informed and present when the IJ was called on 5/28/2014 at 5:20 p.m. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 110000018 |
Fairfield Post-Acute Rehab |
110011267 |
B |
01-Apr-15 |
880J11 |
3394 |
A064 A1418.9(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.A065 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 physical abuse to the Department immediately or within 24 hours. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay.The Department received a report of an abuse allegation which was dated 8/13/14. The facility reported Resident 1 had stated that an employee struck her with an open hand across her chest and shoulder and later stated that the employee struck her with her fist. She alleged that the incident occurred while a staff member gave her a shower on 8/08/14 at approximately 10 a.m.Resident 1 was admitted to the facility with the diagnoses of end stage renal disease and generalized weakness. The clinical record's face sheet indicated that her English speaking ability was poor. The MDS (minimum data set, an assessment tool) dated 7/24/14 indicated that Resident 1 was alert and oriented and she was totally dependent on staff assistance for bathing.During an interview on 8/18/14 at 11 a.m., Resident 1 stated that CNA A (certified nursing assistant) pushed her wheelchair out of the bathroom "hard" when she did not want to continue with the shower. Resident 1 stated that CNA A "hit" her on her right shoulder but it did not hurt.During an interview on 8/19/14 at 2:50 p.m., CNA A stated that she did not understand what Resident 1 was saying in a foreign (non-English) language and stated further that she wheeled Resident 1 out of the bathroom and told Resident 1 that she would look for someone who spoke her language.During an interview on 8/20/14 at 11 a.m., the Administrator stated that "she was out of the State" when the incident was reported to her. The Administrator stated the facility reported the allegation to the Department on 8/13/14 after she returned to the facility.The facility provided documentation that the nursing supervisor interviewed Resident 1 about the alleged incident on 8/08/14 and that the alleged perpetrator was suspended pending investigation.The facility policy and procedure that was titled "Reporting Abuse," dated 6/30/05 and revised on 5/8/13, indicated "... Facility will follow mandated reporting requirements by making sure that staff reports any reasonable suspicions of a crime that has occurred against a resident of the facility. The facility must report the incident as follows "....If the alleged or suspected "physical abuse" does not result in "serious bodily injury", Then the mandated reporter shall: 1) Make a telephone report to the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting the physical abuse: 2) Make a written report to the local Ombudsman, CDPH and local law enforcement within 24 hours." The Department's investigation identified that the facility failed to report an allegation of physical abuse to the California Department of Public Health immediately or within 24 hours. This practice resulted in the Department's inability to independently investigate the abuse allegation without delay. |
| 010000022 |
Friends House |
110011273 |
B |
10-Mar-15 |
F74511 |
2986 |
T22 DIV5 CH3 ART3-72315(b) Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility violated the regulation by failing to ensure that one resident (Resident 1) was treated with dignity and respect when the resident was treated roughly and yelled at by three staff members (Unlicensed Staff D, Unlicensed Staff E, and Unlicensed Staff F), resulting in Patient 1 experiencing increased pain and feeling ashamed. Findings: Resident 1, a 60 year old male, was admitted to the facility, from a hospital, on 2/26/13, for rehabilitation services following surgery for repair of a fractured hip.Clinical record review of the "Resident Admission Assessment", dated 2/26/13, documented that Resident 1 was "Oriented" to "Time, Place, Person". During an interview on 3/15/13, at 3 p.m., Resident 1 was asked about the issues he reported related to staff. Resident 1 stated that during the first night in the facility, he awoke and two "nurses" (Unlicensed Staff D and Unlicensed Staff E) were standing by his bed and they were "yelling at me". One of them said, "your bed is all wet and there is pee on the floor. Why didn't you call us. We are going to change you." Resident 1 said the two then lifted him up using a pad that was placed on the bed under him. When he asked what they were doing, they told him to "put your knees up". Resident 1 recalled he was "screaming" with pain but he put his knees up as directed and his right leg (operative leg) "fell off the bed". Resident 1 stated he said "You can't do it this way". Unlicensed Staff D and Unlicensed Staff E responded, "We're not going to do what you say - you're going to do what we say." When asked how these staff behaviors made him feel, Resident 1 stated: "They yelled at me and I felt ashamed. They were mad at me because the urinal got spilled. And when they were turning me, I wanted to tell them how to do it and, when I said, "That's not the right way, they said 'No, you do it our way - we're not doing it your way."Resident 1 added that, "later in the first week in the facility", he put on his call light for help using the bathroom. Unlicensed Staff F came into his room and when he asked for help getting his pants pulled up after using the bathroom, she responded "you did it last week, you can do it again" and when he had several more requests, Unlicensed Staff F kept repeating: "And, And, And." Resident 1 stated he felt "humiliated" by Unlicensed Staff's attitude and words. Therefore, the facility violated the regulation by failing to treat Resident 1 with dignity and respect when the patient was treated roughly and yelled at by three staff members (Unlicensed Staff D, Unlicensed Staff E, and Unlicensed Staff F), resulting in Resident 1 experiencing increased pain and feeling ashamed. The above violations had direct relationship to the health, safety or security of the resident. |
| 010000020 |
Fircrest Convalescent Hospital |
110012069 |
B |
29-Jun-16 |
S0H011 |
4653 |
T22 DIV5 CH3 ART3-72343(b) Dietetic Service-Food Storage (b) All foods or food items not requiring refrigeration shall be stored above the floor, on shelves, racks, dollies or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents or vermin. All packaged food, canned foods, or food items stored shall be kept clean and dry at all times. The facility failed to ensure that food was prepared, stored, and served under sanitary conditions when dry storage room temperatures were consistently above facility specified parameters in an unventilated room. Failure to ensure temperature control in food storage areas may result in growth of foodborne pathogens, in addition to compromising the integrity and/or quality of food. These practices may result in foodborne illness or decreased nutritional intake, which may further compromise the medical status of residents. The standard of practice would be to ensure that dry food storage areas that contained items such as canned goods, baking supplies, grains, and cereals are held safely in dry storage areas. The specified guidelines should be followed: Keep dry storage areas clean with good ventilation to control humidity and prevent the growth of mold and bacteria; store dry foods at 50øF for maximum shelf life. However, 70øF is adequate for dry storage of most products; and store foods away from sources of heat and light, which decrease shelf life (United States Department of Agriculture, 1996). During an observation and concurrent interview with the DSS (Dietary Services Supervisor) and the Maintenance Supervisor on 12/22/15 at 11:10 a.m., ten loaves of bread were in the dry storage room located in the kitchen. The Maintenance Supervisor used his portable thermometer gun to check the temperature in the dry storage room. The thermometer gun indicated the temperature was 81øF, 82ø, and 83øF on three separate readings. He then pointed the thermometer gun into two additional locations in the room and the temperature readings were 78øF and 74øF. When asked if she thought the room felt warm, the DSS stated, "it is." On 2/10/16, at 11:30 a.m., during an initial tour and concurrent interview of the kitchen, the temperature in the dry food storage room was observed at 82 degrees Fahrenheit (øF). Follow up observation on 2/10/16 at 12:15 p.m., noted a temperature of 84øF. The DSS (Dietary Services Supervisor) stated that the temperature could get up to 85 degrees Fahrenheit in the afternoon. The surveyor asked how the facility was addressing the increased food storage temperatures as there appeared to be no air circulation in the room. She replied that while there was a vent in the dry storage area it was part of the general heating system however, the vent was closed since the heater was on and opening the vent would cause the room temperature to increase even further. Follow up observation on 2/11/16 at 8:10 a.m., noted a temperature of 78øF. It was noted that the maximum ambient outdoor temperature for 2/10/16 was recorded as 72øF (National Center for Environmental Information). During a subsequent interview with the Consultant Registered Dietitian (RD) on 2/19/16, at 9:45 a.m., the RD stated that she was aware of the issue surrounding food storage temperatures however; the facility did not consult her to facilitate mitigation of the problem. During a subsequent interview on 2/19/16 at 9:50 a.m., the DSS confirmed that the facility did not utilize the expertise of the RD to provide input on the dry storage temperature issue. A review of the temperature log for the month of February 2016 indicated two other dates: February 4 and February 9, where the temperature was recorded as 80 degrees Fahrenheit. Review of facility document titled, "Dry Food Storage Room Temp Log" indicated from 8/3/15 to 9/6/15, the temperatures in the dry storage room located inside the kitchen ranged from 68øF - 107øF in the morning, and 80øF - 110øF in the afternoons. Eighteen of the temperatures were between 90øF - 98øF, and four temperatures were between 100øF - 110øF. A review of the facility's policy, dated 2014, titled "Storage of Food and Non-Food Supplies" indicated: "The storeroom is clean, well-lighted, and well-ventilated and preferably maintains a temperature of 50 to 75 degrees Fahrenheit." The facility violated the regulation by failing to maintain their dry storage room temperatures within an acceptable range and temperature readings reached up to 110øF. This violation had a direct relationship to the health, safety, or security of patients. |
| 010000075 |
Fortuna Rehabilitation & Wellness Center, LP |
110012282 |
B |
23-Jun-16 |
3KPQ11 |
1674 |
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 violated the regulation by failing to report an allegation of staff to resident physical abuse to the California Department of Public Health (the Department) within 24 hours after a staff member was observed laying across the chest of one resident (Resident 1). This failure had the potential to prevent independent investigation of possible physical abuse, and result in continued abuse of residents. During an interview on 5/10/16 at 12:30 p.m., Administrator stated she was notified on 5/4/16 that CNA A observed CNA B laying across the chest of Resident 1, who was dying, during the previous night shift. Administrator confirmed no report of the event was ever filed with the Department by the facility. Review of a facility policy and procedure titled "Abuse - Reporting & Investigations," dated 11/18/15, revealed, "The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies." Therefore, the facility violated the regulation by failing to report an allegation of staff to resident physical abuse to the California Department of Public Health within 24 hours after a staff member was observed laying across the chest of one resident (Resident 1). The violation of the regulation had a direct relationship to the health, safety or security of residents |
| 010000020 |
Fircrest Convalescent Hospital |
110012498 |
A |
7-Sep-16 |
845R11 |
14964 |
F309 ?483.25 Provide Care/Services for Highest Well Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide the necessary care and services, and follow their policies and procedures for one resident (Resident 21) when Resident 21 experienced a significant change in condition and the physician was not notified in a timely manner. This failure resulted in Resident 21 being transported to the acute care hospital nearly six hours after telling staff she thought she was having another stroke. At the hospital, Resident 21 was diagnosed as having had a cerebrovascular accident (CVA/stroke) of her right basal ganglia (a group of structures in the base of the brain and involved in coordination of movement.) During a review of the clinical record on 4/27/16, Resident 21's face sheet (admission record) indicated Resident 21 was admitted to the facility on 12/30/15 with diagnoses that included: Cerebral infarct (CVA) affecting Resident 21's right dominant side with hemiplegia and hemiparesis (weakness and paralysis to one side of the body), dysarthria (difficult or unclear speech) and dysphagia (difficulty swallowing) following the CVA; and generalized muscle weakness. During a subsequent review of the clinical record on 5/4/16, Resident 21's comprehensive Minimum Data Set (MDS - an assessment tool), Section B, Hearing, Speech and Vision, dated 1/5/16, indicated Resident 21 was able to hear, had adequate vision/wore corrective lenses and had the ability to express wants and was able to be understood. Section C, Cognitive Patterns, indicated a Brief Interview for Mental Status (BIMS) score of "15" (scores of 13-15 denoted intact cognitive functions.) Section G, Functional Status, indicated Resident 21 was not ambulatory (able to walk) and required extensive or total assistance, with two staff members, for transfers (bed to wheelchair, wheelchair to toilet) and personal care. When eating and drinking, Resident 21 required extensive assistance of one person. A subsequent, quarterly, MDS assessment, dated 4/6/16, indicated Resident 21's BIMS score remained intact at 15. Resident 21's transfer ability remained the same, however, Resident 21's ability to eat and drink improved to the point where she was able to eat independently. Review of Resident 21's re-admission MDS, dated 4/23/16 and quarterly MDS, dated 7/6/16, both after her stroke on 4/14/16, indicated she had declined in her ability to feed herself independently to "total dependence" which required staff assistance of one person. During an observation on 4/27/16, at 11:40 a.m., Resident 21 was resting in bed, dressed, sitting upright, and was awake and alert. There was a sign on Resident 21's bulletin board over the head of the bed that stated: "Attention - Make sure all items are on [Resident 21's] Left Side: Bed Control, TV/nurse call control (call bell and TV control are one item), cell phone, make-up bag, glasses." These items were all within Resident 21's reach. Resident 21 was able to demonstrate using the cell phone and the call bell with her left hand. During a subsequent observation and concurrent interview on 7/18/16, at 11:50 a.m., Resident 21 was sitting up in bed, dressed, and had just had her shower. Her two make-up bags filled with accessories, call light, and cell phone were on the left side of her bed, all within reach. When asked if she still used her cell phone for texting communication, Resident 21 shook her head yes and whispered, "Oh, yes." When asked to describe how she felt, on the morning of 4/14/16, when she did not get help after she told staff she felt like she was having a stroke, Resident 21 stated, "Scared...I knew...was having stroke." Resident 21 continued, "My other stroke, (in 2012) I knew [it was a stroke]," and pointed to her right arm and stated, "It's paralyzed." During an interview on 4/27/16, at 11:43 a.m., when asked to describe what happened on 4/14/16, Resident 21 stated, in a slow, quiet voice, she felt her speech and left side of her body weakened. Resident 21 stated, "I knew a stroke was coming." Resident 21 stated a licensed nurse, "Looked at my face and said 'You're ok'." When asked what time the event occurred, Resident 21 stated it was the "morning hours." Resident 21 stated she tried to call (using her personal cell phone) Family Member 22, but there was no answer. Resident 21 explained she was able to speak and communicate by texting on her personal cell phone she kept at her side. Resident 21 stated later that day on 4/14/16, during a subsequent shift (P.M. shift, 3-11 p.m.) that a different licensed nurse "called the doctor and ambulance." Resident 21 stated, at the hospital she had an MRI (magnetic resonance imaging-a medical imaging technique used in radiology) and "I had a stroke." Resident stated, "Stroke killed my mother...runs in my family." During an interview on 4/27/16, at 4:45 p.m., when asked to describe the events of 4/14/16 related to Resident 21, the Director of Nursing (DON) stated a day shift (7 a.m. - 3 p.m.) CNA (certified nurse assistant - Unlicensed Staff G) informed Licensed Staff H that [Resident 21] "was saying she was having a stroke." The DON stated Licensed Staff H went into Resident 21's room, and, said [Resident 21's] face wasn't drooping (a possible sign of a stroke) and she looked ok. The DON stated Licensed Staff H did not inform other licensed staff of Resident 21's reported symptoms, did not document the event or findings, nor did she call Resident 21's physician. It wasn't until the next shift when Licensed Staff F alerted Administrative Staff E that Resident 21 felt she had a stroke. During a telephone interview on 4/28/16, at 9:48 a.m., Family Member 22 stated Resident 21 had a history of strokes and each time Resident 21 "knew it was happening." Family Member 22 stated Resident 21 told Unlicensed Staff G, "around 11 a.m.," she thought she was having a stroke, and Unlicensed Staff G then told Licensed Staff H. Family Member 22 stated that Resident 21 was told by Licensed Staff H that her face wasn't drooping and that she was fine. Family Member 22 had received a cell phone call from Resident 21, on 4/14/16, at 1:49 p.m., however, because of no cell service at her location at that time, Family Member 22 did not receive the call from Resident 21 until 4 p.m. that day. Upon returning the phone call, after 4 p.m., Family Member 22 stated it was difficult to understand Resident 21. Family Member 22 was able to speak with Unlicensed Staff I, who was with Resident 21 at the time, and asked Unlicensed Staff I if Resident 21 said she was having a stroke, at which Unlicensed Staff I responded, "it sounded like it." At that point, Family Member 22 stated she called Resident 21's physician's office and they told her 911 should be called. During a telephone interview on 4/28/16, at 3:50 p.m., Unlicensed Staff G stated she gave Resident 21 a shower on the morning of 4/14/16. After the shower, Resident 21 told Unlicensed Staff G, "I think I'm having a stroke." Unlicensed Staff G informed Licensed Staff H and Licensed Staff H, "did some things, like squeeze my hand, look at my face," to Resident 21. When asked what time the event occurred on 4/14/16, Unlicensed Staff G stated, "Between 10:45 and 11:30 a.m." During a telephone interview on 4/28/16, at 4:10 p.m., Administrative Staff E stated, on 4/14/15, during the late afternoon, Resident 21 was trying to tell Unlicensed Staff I something but it was hard to understand. Unlicensed Staff I then asked Resident 21 to text-message on her cell phone what she was trying to say, however, Resident 21 "couldn't do it." Administrative Staff E stated Unlicensed Staff I went out of Resident 21's room to get help and upon returning, Family Member 22 was on Resident 21's cell phone. Family Member 22 told Unlicensed Staff I she thought Resident 21 was trying to say she was having a stroke. When asked if Resident 21 displayed any symptoms of a stroke, Administrative Staff E stated, Resident 21 "was a little more weak and not speaking well." Administrative Staff E stated Licensed Staff F called Resident 21's physician and obtained orders to transfer the resident to the hospital. When asked how much time elapsed from becoming informed of Resident 21's distress, that late afternoon to the time she was transferred to the hospital, Administrative Staff E stated, "Probably 10 minutes." During a subsequent interview on 4/28/16, at 4:23 p.m., when asked what information was given to him during shift change report (when the licensed staff from the prior shift gives updates on patient's to the oncoming shift), Licensed Staff F stated there was no indication of any changes (in Resident 21's condition) from the day shift nurse. Licensed Staff F stated, "Nothing had been reported about [Resident 21]." Licensed Staff F corroborated Unlicensed Staff I informed him that Resident 21 thought she was having a stroke on 4/14/16 in the late afternoon. Licensed Staff F stated he assessed Resident 21's hand grip strength which was weaker and, "Mainly I was more concerned getting her out ASAP [to the hospital] because [Resident 21] said she was having a stroke." During a review of the facility's physician's orders, Licensed Staff F obtained a telephone order from Resident 21's physician to transfer her to the hospital for further evaluation on 4/14/16 at 1640 (4:40 p.m.) During a telephone interview on 4/29/16, at 4:24 p.m., Licensed Staff H confirmed she was assigned to care for Resident 21 on 4/14/16, day shift. Licensed Staff H stated between 10 and 11 a.m., Unlicensed Staff G told her Resident 21 "was complaining of a stroke." When asked if she told the Director of Nursing (DON) of Resident 21's distress, Licensed Staff H stated, "I did not..." When asked if she documented, in the medical record, any of Resident 21's admissions of feeling she was having a stroke, Licensed Staff H stated, "I did not and that was my mistake." When asked if she called Resident 21's physician, Licensed Staff H stated, "I did not..." Review of Resident 21's medical record/progress notes on 4/27/16, did not indicate any documentation on 4/14/16 by Licensed Staff H. During a telephone interview on 5/2/16, at 3:25 p.m., Unlicensed Staff I confirmed Resident 21 was on her assignment list for the P.M. shift on 4/14/16. Unlicensed Staff I stated Resident 21's call light went on, after 3:30 p.m., and "[Resident 21] was trying to tell me something but I couldn't understand..." Unlicensed Staff I went out of the room to get help, couldn't locate a "nurse" in the immediate area and Resident 21's call light went back on. When Unlicensed Staff I entered the room again, Resident 21 kept "opening and closing" her left hand and "I asked if her hand hurt and she nodded yes." Unlicensed Staff I attempted, again, to find the nurse, but could not and Resident 21 put her call light on a third time. Unlicensed Staff I stated, "This time (upon entering Resident 21's room again) she was on the [cell] phone with [Family Member 22] and I asked if I could speak with [Family Member 22]. Unlicensed Staff I told Family Member 22 that Resident 21 was trying to tell her something and Family Member 22 then stated she thought Resident 21 was "having a stroke." At that point, Unlicensed Staff I was able to alert Licensed Staff F, "and he quickly went in (to Resident 21's room) and he checked her and he called the ambulance right away." When asked the time the event occurred, Unlicensed Staff I stated between 4-4:30 p.m. During a review of the facility's Policy and Procedure titled, "Change in a Resident's Condition or Status," revised April 2014, the Policy Interpretation and Implementation indicated: 1d - The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician...when there has been: A significant change in the resident's physical/emotional/mental condition. 2a - A "significant change" of condition is a decline...in the resident's status that: Will not normally resolve itself without intervention by staff... and 2b - Impacts more than one area of the resident's health status. During a review of the hospital's Emergency Physician's notes, dated 4/14/16, at 17:02 (5:02 p.m.) indicated Resident 21 had weakness and difficulty swallowing and there was a concern for worsening of CVA. Family Member 22 accompanied Resident 21 to the hospital. The emergency physician's notes further indicated, "...if there is any deterioration in the patient's condition, or they are concerned in any way they should contact [Resident 21's] physician earlier..." Results of the MRI of the brain, dated 4/15/16, revealed Resident 21 had an acute (sudden, severe or serious onset) appearing infarct (an area of tissue death from failure of oxygenated blood flow) involving the posterior (rear) aspect of the right basal ganglia. Review of the Discharge Summary from the acute care hospital, dated 4/18/16, indicated Resident 21 required resumption of physical, occupational, and speech therapy evaluations and treatment, in addition to dysphagia (difficulty swallowing) evaluation and treatment. Recognition of stroke and calling 9-1-1 will determine how quickly someone will receive help and treatment. Getting to a hospital rapidly will more likely lead to a better recovery. Note the time of the first symptom. This information is important and can affect treatment decisions. (National Stroke Association) Two million brain cells die every minute during a stroke, increasing the risk of permanent brain damage, disability or death. Recognizing symptom's and acting FAST (FAST is an acronym used as a mnemonic to help detect and enhance responsiveness to victim needs. The acronym stands for Facial drooping, Arm weakness, Speech difficulties and Time) to get medical attention can save a life and limit disability. - www.stroke.org Therefore, the facility failed to ensure the necessary care and services were provided to attain the highest practicable physical, mental, and psycho-social well-being for Resident 21, identified by the facility as having had a history of strokes, when Resident 21 experienced a significant change in condition and the physician was not notified in a timely manner. This failure resulted in Resident 21 being transported to the acute care hospital nearly six hours after telling staff she thought she was having another stroke. At the hospital, Resident 21 was diagnosed as having had a cerebrovascular accident (CVA/stroke) of her right basal ganglia (a group of structures in the base of the brain and involved in coordination of movement.) This failure presented either imminent danger that serious harm would result or a substantial probability that serious harm or death would result. |
| 010000020 |
Fircrest Convalescent Hospital |
110012499 |
A |
7-Sep-16 |
845R11 |
13720 |
F224 ?483.13(c) Mistreatment/Neglect/Misappropriation The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow its policy and procedure titled,"Preventing Resident Abuse," when the facility did not identify areas of neglect for 3 of 17 sampled resident's (Resident 8, 15, and 16) and 1 unsampled resident's (Resident 25) whose call lights were not answered in a timely manner, which led to: 1. Resident 25 being left sitting on the bathroom toilet for a significant time period, while trying to summon staff to help her, and her physically impaired roommate (Resident 16) walked with walker out to the hallway yelling for help. 2. Resident 8 and 25 soiled themselves because they had to wait a prolonged period of time to receive help to the bathroom. This failure made Resident 8 feel "bad" and Resident 25 feel "embarrassed." The practice had the potential for the development of skin breakdown and infections, and caused psycho-social harm when the residents were presented with an environment whereby they were left in human waste, and likely to have felt helpless and disrespected. 3. Resident 15, who was blind and a left leg amputee, fell after attempting to go to bathroom on his own because no one would help him to the bathroom after being told three times by way of intercom someone would be there to assist him. This had the potential to cause serious injury and death, and the practice caused psycho-social harm to Resident 15 when he became teary eyed and stated the situation made him feel "bad" and "worthless." 1. During an interview on 7/19/16 at 10:00 a.m., Resident 16 stated she tried to help Resident 25 who was left in the bathroom calling for help. Resident 16, who was physically impaired, stated she had to force herself to help Resident 25. Resident 16 stated it made her feel helpless because no one was coming to help Resident 25, and Resident 16 did not feel safe helping Resident 25. Resident 25 stated she was dependent on people to help her to the bathroom. During an interview on 7/21/16 at 9:30 a.m. and 7/25/16 at 5 p.m., Resident 16, whose Minimum Data Set (MDS) comprehensive assessment, dated 6/20/16, indicated a BIM (Brief Interview of Mental Status) of 15 (resident's mental understanding and 15 being the highest), stated a week ago Thursday (July 14, 2016) between 3-5 p.m., Resident 25 was assisted to bathroom by Unlicensed Staff DD, but was left in bathroom for "a long time" to the point Resident 25 was "panicked" and knocking on the door for help. Resident 16 stated she walked to the bathroom using walker and opened the bathroom door to check on Resident 25. Resident 16 then walked out to the hallway to see if there was any staff nearby to help Resident 25. Resident 16 stated she saw Licensed Staff P and Licensed Staff Z down at the nurses' station, so she called out, "Please people she needs help." Resident 16 stated she recalled calling out several times, but neither Licensed Staff P nor Licensed Staff Z responded to Resident 16's call for help. During the same interview, Resident 16 was asked if she ever had to wait for her call light to be answered. Resident 16 stated the facility was short staffed. Sometimes staff would answer the call light at the nurse's station by way of intercom, turn the call light off, and state they would be right down. "The staff member never shows up, they forget about you." During a record review, Resident 16's "Care Plan" dated 6/16/16 indicated, Resident 16 had impaired mobility, decreased strength and endurance, decreased balance and coordination, and gait (walking) issues. During an interview on 7/22/16 at 2:55 p.m., Resident 25 stated she was assisted to bathroom, but was left there. Resident 25 stated she pulled the call light for help, but no one came to help her, so she started to "scream for help." Resident 25 stated she was not supposed to try and help herself back to bed due to the possibility of falling. Resident 25 stated her roommate (Resident 16) tried to get her help. Resident 25 stated, "I thought I was going to die," my heart was racing. Resident 25 stated she was hyperventilating to the point she felt she needed to see a physician. Resident 25 stated she had been transferred to the hospital a few weeks ago due to having experienced a stroke. During a record review, Resident 25's "Care Plan" dated 6/7/16 indicated, Resident 25 had an unsteady gait, increased risk for falls because of muscle weakness and given Ativan for anxiety, needed assistance to bathroom, and needed frequent safety checks. Side effects of Ativan are dizziness, fatigue, weakness, confusion, and unsteadiness (Mosby's Nursing Drug Reference 2011). During an interview on 7/22/16 at 4:35 p.m., Licensed Staff P stated he never went to assist Resident 25, whose bathroom call light was on. Licensed Staff P stated he called the CNA to help assist Resident 25 back to bed. Licensed Staff P stated he did give Resident 25 Ativan 0.5 mg (for anxiety) to help calm her down and a Tums (heartburn relief) for her stomach once she was assisted back to bed. During an interview on 7/22/16 at 5:20 p.m., Unlicensed Staff DD stated he did assist Resident 25 to the bathroom and did wait in hallway for her to put on her bathroom call light. Unlicensed Staff DD stated Licensed Staff Z called him to assist her with another resident who had fallen. Unlicensed Staff DD informed Licensed Staff P that Resident 25 was still in bathroom and he had to leave to assist Licensed Staff Z with an emergency involving another resident. Unlicensed Staff DD stated Licensed Staff P said to him, "okay." Unlicensed Staff DD stated Resident 25's bathroom call light was going off 30-45 minutes, but he could not leave the other resident who had just fallen. During an interview on 7/22/16 at 4:00 p.m. and 5:20 p.m., Director of Nursing (DON) stated Licensed Staff P did not assist Resident 25, who was calling for help in the bathroom. DON stated Licensed Staff P, who had been available to assist Resident 25, informed the DON it was not part of his job description to assist a resident off the toilet. During an interview on 7/25/16 at 2:15 p.m., when Unlicensed Staff JJ was asked who was responsible for answering call lights, Unlicensed Staff JJ stated all nursing staff should answer residents' call lights, but most the time nurses won't answer the call lights. They wait for the certified nursing assistant (CNA) to answer the call light. During an interview on 7/25/16 at 3:05 p.m., Licensed Staff Z stated she helped Resident 25 back to bed, but did not know how long Resident 25 had been waiting in the bathroom. When asked whose responsibility was it to answer the residents' call light, Licensed Staff Z stated it was the "nurses" and the "CNAs" responsibility to answer the residents' call light. During an interview on 7/26/16 at 8:30 a.m., Licensed Staff LL stated she started the "Resident Abuse Investigation Report Form" on 7/15/16 (California Department of Public Health, Licensing and Certification Division received the "Resident Investigation Report Form" on 7/25/16), after Licensed Staff LL was informed by the night nurse about Resident 25 being left on the toilet for a significant period of time on the evening of 7/14/16 due to no one would answer Resident 25's call light. Licensed Staff LL stated Licensed Staff P told her it was not his job to answer call lights, it was the CNAs job. Licensed Staff LL stated Licensed Staff P has often stated it was not his job to answer call lights. Licensed Staff LL stated Resident 25 was still very upset the morning of 7/15/16, and refused her breakfast. During a review of the facility policy and procedure titled, "Charge Nurse" (dated 2003) indicated nurses must be a supportive team member, contribute to and be an example of team work and team concept. It also indicated nurses must function independently and have flexibility, personal integrity, and ability to work effectively with residents, personnel, and support agencies. During a review of the facility policy and procedure titled, "Answering the Call Light" (Revised September 2003) indicated resident's call light should be answered as soon as possible. 2. During an interview on 7/22/16 at 2:55 p.m., Resident 25 stated she has had to wait one to two hours for a staff member to answer her call light causing her to wet her pants. Resident 25 stated it made her feel very embarrassed when she wet her pants. During an interview on 7/21/16 at 8:35 a.m., Resident 8, whose MDS quarterly assessment, dated 4/7/16, indicated a BIM of 15, stated there were no CNAs in the afternoon shift (3p.m. to 11p.m.) available to assist him to the toilet. Resident 8 stated he did not receive help to go to the bathroom. During an interview on 7/21/16 at 3:50 p.m., translated by Unlicensed Staff KK, Resident 8 stated he felt "sad" when it took a staff member a significant period of time to answer his call light, especially when he needed to have a bowel movement. Resident 8 stated if staff did not help him to the bathroom in a timely manner, the urge to have a bowel movement passed and he became constipated. During an interview on 7/25/16 at 4 p.m., translated by Administrative Staff T, Resident 8 stated he called for assistance to go to the bathroom, but no one came. Resident 8 stated he had an accident on the bed as a result. Resident 8 stated he felt "bad" wetting the bed. 3. During an interview on 7/22/16 at 4:12 p.m., translated by Unsampled Resident 31, Resident 15, who had his left leg amputated, stated he fell on the floor on 7/11/16 at 5 p.m. Resident 15 stated he pushed the call light for assistance to go to the bathroom three to four times. Resident 15 stated the staff responded to each call stating somebody would come to help him, but no one came. Resident 15 stated he tried to get up but fell on the floor and hit his head that led to a head wound. Resident 15 stated the incident made him "feel bad' and "worthless." Resident 15 stated he was used to doing things alone when he had both legs. Resident 15 eyes were teary after the statement. During an interview on 7/25/16, at 8:36 a.m., Unlicensed Staff BB stated Resident 15 needed one-person assist to use the toilet. During an interview on 7/25/16 at 3:36 p.m. (translated by Administrative Staff T), Resident 15 stated he used the call light but no one responded. Resident 15 tried to go to the bathroom using his walker and left leg prosthesis but fell (the same incident from the prior interview). During a review of the clinical record, the Admission Record indicated Resident 15 was blind in both eyes and had a left leg below the knee amputation. During a review of the clinical record, the MDS, a standardized complete assessment, dated 6/17/16, indicated Resident 15 had BIMS score of 15. MDS indicated Resident 15 was not steady and only able to stabilize with staff assistance when walking, turning around, moving on and off toilet. MDS indicated Resident 15 needed extensive assistance and one-person assist with toilet use and walking. During a review of the clinical record for Resident 15, the Nurses Progress Note dated 7/11/16, indicated Resident 15 had an unwitnessed fall. During a review of the clinical record for Resident 15, the Care Plan for "Mobility Limitations/Safety Risks" dated 6/28/16, indicated an intervention of "assess and provide assistance as required to keep Resident 15 safe and meet his needs," because Resident 15 was a fall risk. During a review of the clinical record for Resident 15, the Medication Administration Record for the of month July, indicated Resident 15 was receiving Coumadin, an anticoagulant (a blood thinner) medication that can cause major or fatal bleeding (Bristol-Myers Squibb, pharmaceutical company maker of Coumadin). Resident 15's hitting his head as a result of the fall put the resident at high risk for subdural hematoma (bleeding between outside the brain and under the skull). According to author Richard Meagher, "Subdural hematoma occurs not only in patients with severe head injury but also in patients with less severe head injuries, particularly those who are elderly or who are receiving anticoagulants (Meager, R. J. (2015, January 8). Subdural Hematoma. Retrieved August 02, 2016, from http://emedicine.medscape.com/article/1137207-overview). Therefore, the facility failed to follow the facility ' s policy and procedure that prohibited neglect when Resident 8, 15, 16, and 25 ' s call light was not answered in a timely manner resulting in: 1. Resident 25 being left sitting on the bathroom toilet for a significant time period, while trying to summon staff to help her and caused her to feel she was going to " die, " and her physically impaired roommate (Resident 16) walked with walker out to the hallway yelling for help and caused her to feel " helpless, scared, and unsafe, " 2. Resident 8 and 25 soiled themselves because they had to wait a prolonged period of time to receive help to the bathroom, which caused Resident 8 to feel " bad " and Resident 25 to feel " embarrassed, " and 3. Resident 15, who was blind and a left leg amputee, fell after attempting to go to bathroom on his own because no one would help him to the bathroom after being told three times by way of intercom someone would be there to assist him, which caused Resident 15 to become teary eyed and feel " bad " and " worthless. " These presented either imminent danger that death or serious harm would result, substantial probability that death or serious harm would result, and/or psycho-social harm would result. |
| 010000020 |
Fircrest Convalescent Hospital |
110012518 |
B |
21-Sep-16 |
J5KT11 |
2436 |
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 incident of resident neglect, which occurred on July 14, 2016 between 3-5 p.m., in a timely manner when Licensed Staff P was alleged to have refused to assist Resident 25 off the toilet which resulted her to be left sitting on the toilet for a significant time period, endangering her and her roommate who, at risk to her own safety, attempted to summon staff to help her. This practice endangered Resident 25's safety if she had tried to get off the toilet by herself, which could have led to her falling and fatally injuring herself. Resident 25 stated she felt she was going to "die." The delay in reporting to the Department did not allow for a prompt investigation by the agency. During an interview on 7/22/16 at 4:35 p.m., Licensed Staff P stated he never went to assist Resident 25, whose bathroom call light was on. During an interview on 7/22/16 at 4:00 p.m. and 5:20 p.m., Director of Nursing (DON) stated she had just started the investigation regarding Resident 25 being left on the toilet for a significant time period. DON stated Licensed Staff P did not assist Resident 25, who was calling for help in the bathroom. DON stated Licensed Staff P, who had been available to assist Resident 25, informed the DON it was not part of his job description to assist a resident off the toilet. During a review of the facility's Resident Abuse Investigation Report Form on Resident 25, indicated the facility did not fax document to the State licensing/certification agency within 24 hours. The incident occurred on 7/14/16 and the document was not received until 7/25/16 (eleven days later). During a review of the facility policy and procedure titled, "Reporting Abuse to State Agencies and Other Entities/Individuals" (undated), indicated the facility needed to report the suspected incident of abuse either by way of verbal or written notice to the State licensing/certification agency within 24 hours. Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic B violation. |
| 010000020 |
Fircrest Convalescent Hospital |
110012613 |
B |
18-Oct-16 |
845R12 |
4222 |
? 483.13 (c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATN The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policies and procedures that prohibit the mistreatment of residents when Unlicensed Staff OO used abusive language toward Resident 29. This failure caused Resident 29 psychosocial harm when the mistreatment made her feel "terrible", "sad", made her cry and she did not eat her usual portion of her meal. A confidential report that was supplied to the Department, dated 8/7/16, indicated at 8 a.m., in the dayroom/dining room, Unlicensed Staff PP witnessed Unlicensed Staff OO stating to Resident 29 "You run around and can't sit still, no wonder your daughter doesn't want you." Unlicensed Staff OO also came to Unlicensed Staff PP and stated "I hate that woman and told her that is why her daughter does not love her". During a concurrent observation and interview on 9/13/16, at 12:05 p.m., Resident 29 walked in her room. When asked about what happened in the dining room approximately two months ago, Resident 29 stated when Resident 29 tried to help her "friend" [another resident], in the dining room, Unlicensed Staff OO yelled at her "...Don't do it. That's why your daughter doesn't want you and doesn't love you." Resident 29 stated Unlicensed Staff OO was so rude and made Resident 29 feel "terrible". Resident 29 stated the incident "saddened" her and she still felt terrible. The 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 6/1/16 and 9/1/16, indicated Resident 29's Brief Interview for Mental Status scores were 13 - 15, which indicated Resident 29 was cognitively intact. During an interview on 9/13/16, at 12:15 p.m., Unlicensed Staff PP stated on 8/7/16, at breakfast in the dining room, she heard Unlicensed Staff OO arguing with Resident 29 about the napkins for the dining table. Unlicensed Staff PP stated she heard Unlicensed Staff OO talked to Resident 29 in a "mean tone" "Because you don't listen, that's why your daughter doesn't want you and doesn't love you." Unlicensed Staff PP stated Unlicensed Staff OO also told Unlicensed Staff PP, "I hate that woman. She didn't listen. That's why I told her [Resident 29] no wonder your daughter don't want you and don't love you." Unlicensed Staff PP stated Resident 29 ate only approximately 25 percent of the meal and left the dining room. She stated Resident 29 usually ate 75 to 100 percent of her meals. Unlicensed Staff PP stated Resident 29 went back to her room and told Unlicensed Staff PP again what Unlicensed Staff OO had said to her (Resident 29). Unlicensed Staff PP stated Resident 29 cried for about three minutes. Unlicensed Staff PP stated at lunch, Resident 29 was quiet and sat at the dining room window and looked at outside through the window, which was not Resident 29's routine. The facility's Resident Abuse Investigation Report Form dated 8/12/16, indicated "...Determined that verbal abuse likely occurred. CNA [Unlicensed Staff OO] terminated..." The facility's policy and procedure titled "Preventing Resident Abuse," undated, indicated "Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse." The facility's policy and procedure titled "Resident Rights," revised April 2007, indicated "Employees shall treat all residents with kindness, respect, and dignity." Therefore, the facility failed to implement their policies and procedures that prohibit the mistreatment of residents when Unlicensed Staff OO used abusive language toward Resident 29. This failure caused Resident 29 psychosocial harm when the mistreatment made her feel "terrible", "sad", made her cry and she did not eat her usual portion of her meal. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 010000020 |
Fircrest Convalescent Hospital |
110012614 |
A |
18-Jan-17 |
845R12 |
12424 |
F309 ?483.25 Provide Care/services For Highest Well Being
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to follow the physician's diet order, facility's policy and procedure, and "Dysphagia (difficulty swallowing) Feeding Instructions" when one Resident 21's) food was not cut up into small bite size pieces. Resident 21 did not receive adequate monitoring and assistance during meals which caused Resident 21 to choke on a piece of meat while eating lunch. These failures resulted in Resident 21 being transported by ambulance to an acute care hospital. At the hospital, Resident 21 was intubated (insertion of a breathing tube into the trachea for mechanical ventilation) because of acute hypoxemia (low level of oxygen in the blood) caused by a chunk of meat measuring 1.18 x 1.18 inches lodged in Resident 21's epiglottis area (a flap of tissue at the base of the tongue that keeps food from going into the trachea or windpipe during swallowing). This caused serious physical injury and potential for death.
The physician's "Admission History and Physical" dated 4/19/16, indicated Resident 21 had been readmitted to the facility from an acute care facility following another stroke. Resident 21's diagnosis prior to her being admitted to the acute care facility included several strokes with post-stroke symptoms including dysphagia (difficulty swallowing). A new symptom since Resident 21's latest stroke was increased dysphagia.
Resident 21's Quarterly Minimum Data Set (MDS - a clinical assessment process that provides a non-comprehensive assessment of the resident's functional capabilities between comprehensive assessments and helps ensure staff monitor critical health problems) dated 7/6/16, Section G, Functional Status, indicated Resident 21 was not able to eat and drink on her own and required one person physical assist. Section K, Swallowing/Nutrition Status, indicated Resident 21 needed to be on a mechanically altered diet (required change in texture of food or liquids, such as pureed food and thickened liquids).
Resident 21's "Speech Therapy Plan of Care Evaluation" dated 8/26/16, indicated: 1) Resident 21's swallowing impairment was moderate (50-75%), 2) Resident 21 had difficulty masticating (chewing) foods, and Resident 21 was: 3) on a Regular textured diet, small bites; nectar thick liquids, 4) on aspiration precautions (choking) with "Max" caregiver assistance with denture care, and 5) discharged from speech therapy (ST) to restorative nursing assistance (RNA) program under ST's directions/supervision for speech and swallow rehabilitation 3 times per week for 3 months.
During a clinical record review and interviews on 9/14/16 at 3:30 p.m. and 9/16/16 at 4:15 p.m., Resident 21's "Order Summary Report" dated 9/1/16, indicated Resident 21's diet was a Regular Diet, Nectar Consistency, and Small Bites. Resident 21's "Diet Card" for 9/5/16, indicated she was on a Regular, Small Bites, and Nectar Consistency and special instructions indicated foods were to be cut up. Dietary Supervisor stated Resident 21's lunch tray on 9/5/16 consisted of barbeque baby back ribs and a vegetable medley. Dietary Supervisor stated the PM cook plated Resident 21's food and Dietary Supervisor cut up Resident 21's baby back ribs no larger than 1 inch in diameter, which was a bite size piece of food.
Resident 21's "Care Plan" dated 6/9/16, indicated staff was to focus on Resident 21's dysphagia, full dentures, and assistance per speech therapist guidelines. Resident 21's goals indicated no aspiration, choking, and least restricted diet. Resident 21's interventions indicated nectar thick liquids, but thin liquids when up in wheel chair, oral/denture per protocol, and required set up assistance at meal time.
During concurrent record review and interview on 9/14/16 at 11:10 a.m., ST stated one of the reasons Resident 21 was living at the facility was because she needed assistance with her meals and supervision with thin liquids. ST stated she thought the staff was aware of a small bite size being no more than a teaspoon. ST pointed out specific "dysphagia feeding instructions" (both in English and in Spanish), which were posted over Resident 21's bed for staff to follow. "Dysphagia Feeding Instruction" dated 5/15/16, indicated Resident 21: 1) was to have a Regular Diet, Small Bites, Nectar-Thick Liquids, and Use Straw, 2) needed to be encouraged to take small bites and slow intake before taking more food, and 3) needed to be assisted with denture adhesive before all meals. Other signs posted over Resident 21's bed indicated several measures for strict aspiration precautions, such as: 1) thin liquids when up in wheel chair and 2) take one sip of liquid at a time.
During an interview on 9/14/16 at 2:05 p.m., Registered Dietician (RD) stated the company she is contracted with and whose diet guidelines the facility followed had no guidelines specific to "bite size," but there was a diet specific to "cut up foods (one inch or less)," which they were going by. RD stated all food should have been cut up into one inch pieces or less for Resident 21, even her roll.
The facility policy and procedure titled, "Continuum of Food Textures" dated 2013, "Cut Up" means, "to cut into bite size pieces approximately 3/4 to 1 inch squares/pieces." Usually items like meat loaf, baked fish or moist chicken are cut up."
During an interview on 9/15/16 at 3:16 p.m., Physician AAA stated he thought Resident 21 was on chopped foods. Physician AAA questioned the "Bite Size" diet due to people have different bites. Physician AAA stated Resident 21 did code (heart stopped beating as in cardiac arrest) in the emergency room (ER) on 9/5/16, and Resident 21 will be having a PEG tube (Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia). Physician AAA stated Resident 21's food should have been cut up into small pieces for her because of Resident 21's paralysis (upper right extremity due to stroke); Resident 21 could not cut up her food. Physician AAA stated this incident showed Resident 21 was not safe to eat independently.
During an interview on 9/13/16 at 1:15 p.m. and on 9/14/16 at 10:05 a.m., when asked to describe what happened on 9/5/16 during Resident 21's lunch time, Unlicensed Staff BB stated Resident 21 had turned on her call light. Unlicensed Staff BB answered Resident 21's call light per intercom and then went down to Resident 21's room because he could not understand her. Unlicensed Staff BB stated Resident 21 was up in wheel chair, was alone, the meal tray was in front of her, and Resident 21's upper or lower denture (did not know which one) was placed on the dinner roll bag. Unlicensed Staff BB stated Resident 21 was holding her throat. Unlicensed Staff BB stated he asked Resident 21 if she was choking, and Resident 21 nodded her head up and down, which indicated "Yes." Unlicensed Staff BB stated he asked Resident 21 if she was "Okay," and Resident 21 shook her head back and forth, which indicated "No." Unlicensed Staff BB stated Licensed Staff YY was passing by Resident 21's room, so he called her to help. Unlicensed Staff BB stated Licensed Staff YY did the Heimlich maneuver (quick upward abdominal thrusts force the diaphragm upward suddenly, making the chest cavity smaller. This has the effect of rapidly compressing the lungs and forcing air out. The rush of air out will force out whatever is causing the person to choke), but nothing came up. Unlicensed Staff BB stated he then did the Heimlich maneuver, but nothing came up. Unlicensed Staff BB stated Resident 21's food was cut up.
During an interview on 9/13/16 at 12:35 p.m. and 9/14/16 at 2:30 p.m., when asked to describe what happened on 9/5/16 during Resident 21's lunch time, Licensed Staff YY stated Unlicensed Staff BB called her by way of intercom because Resident 21 needed help. Licensed Staff YY stated when she entered Resident 21's room Resident 21 was up in wheel chair. Resident 21 looked like she was choking and Resident 21's skin color was blue tinged (can be caused by something stuck in the airway. Reference: https://medlineplus.gov/ency/article/003215.htm). Licensed Staff YY stated she first checked Resident 21's mouth and then proceeded to do the Heimlich maneuver, but nothing came up. Licensed Staff YY stated, Administrative Staff Q was called to help while Licensed Staff YY called 911. Licensed Staff YY stated the meat on Resident 21's lunch tray was cut up into different sizes (not as small as a dime, but not as big as a quarter). Licensed Staff YY stated she thought there was a standard for "bite size." Licensed Staff YY stated there was a piece of roll on Resident 21's tray, but Licensed Staff YY could not tell if it had been cut up. Licensed Staff YY stated there was a denture on Resident 21's tray, but she did not know if Resident 21's dentures were loose and the denture had fallen out while Resident 21 was eating or if Resident 21 took the denture out. Licensed Staff YY stated she did not assist the residents with their meals and/or feed the residents; the certified nursing assistance (CNA) fed the residents.
During an interview on 9/14/16 at 4:15 p.m., Unlicensed Staff DDD stated he was aware of the "Dysphagia Feeding Instructions" over Resident 21's bed. Unlicensed Staff DDD stated he would cut up Resident 21's food into smaller pieces if she asked him to. Unlicensed Staff DDD stated, "Resident 21 would eat independently." Unlicensed Staff DDD stated he was not aware of any issues with Resident 21's dentures. Unlicensed Staff DDD stated he never checked to see if Resident 21's dentures needed more adhesive.
During concurrent interviews on 9/15/16 at 3:50 p.m., ST stated Resident 21 needed food that was soft and cut up into bite size pieces ranging from 1/2 inch to 1 inch; anything larger would not be safe. ST stated Resident 21 could feed self if her food was cut up into bite size pieces. DON also agreed bite size pieces ranged from 1/2 inch to 1 inch, and anything larger would not be safe for Resident 21. ST stated Resident 21's dentures did not fit right and staff needed to make sure adhesive was applied to Resident 21's dentures before she ate.
The acute care hospital "Critical Care/ICU (Intensive Care Unit) Progress Note dated 9/6/16, indicated Resident 21 was intubated on 9/5/16 in an "emergent manner because of acute hypoxemia respiratory failure; at intubation a 3 cm x 3 cm (1.18 in x 1.18 in) of steak was found lodged in Resident 21's epiglottis area..." Resident 21 had two episodes of sustained cardiopulmonary resuscitation (CPR): consists of the use of chest compressions and artificial ventilation to maintain blood circulation and breathing) while in the emergency room. Resident 21 failed being weaned of ventilator on 9/6/16. The report indicated Resident 21 was going to be difficult to wean of the ventilator because of Resident 21's "marked weakness having bilateral strokes with severe right sided total hemiplegia (paralysis of one side of the body) and moderate left side hemiplegia."
Therefore, the facility failed to follow the physician's diet order, facility's policy and procedure titled, "Continuum of Food Textures" dated 2013, for "Cut Up" (to cut into bite size pieces approximately 3/4 to 1 inch squares/pieces), and "Dysphagia Feeding Instructions" when Resident 21's food was not cut up into small bite size pieces on 9/5/16 and failed to provide adequate monitoring and assistance which caused Resident 21 to choke on a piece of meat while eating lunch. This failure resulted in Resident 21 being transported by ambulance to an acute care hospital. At the hospital, Resident 21 was intubated because of acute hypoxemia caused by a chunk of meat measuring 1.18 x 1.18 inches lodged in Resident 21's epiglottis area, and admitted to the Intensive Care Unit (ICU). This presented either imminent danger that death or serious harm would result, substantial probability that death or serious harm would result. |
| 010000585 |
FIFTY-O-ONE PARKHURST |
110012865 |
B |
18-Jan-17 |
CWW911 |
5877 |
T22 DIV5 CH8.5 ART3-76876(b) (b) Medications and treatments shall be administered as prescribed and shall be recorded in the unit client record. The name, title of the person administering the medication or treatment, the date, time and dosage of the medication administered shall be recorded. Initials may be used provided the signature of the person administering the medication or treatment is recorded on the medication or treatment record. The facility failed to follow a physician's verbal telephone order for one client (Client 1), as prescribed, when: 1. The physician ordered Ferrous Sulfate (an iron supplement) 325 milligrams (mg), orally, twice a day, for anemia. 2. The facility purchased Elemental Iron 65 mg (iron supplement, equivalent to 325 mg of Ferrous sulfate), and administered five tablets, on three separate occasions, before discovering one tablet of Elemental Iron 65 was equal to one tablet of Ferrous Sulfate 325 mg. Client 1 is a 59 year old, mildly intellectually disabled male, with a diagnosis including Gastroesophageal Reflux Disease (GERD), and scoliosis. GERD, also called acid reflux, is a long term condition where stomach contents come back up into the esophagus. Scoliosis is a sideway curvature of the spine, which affects posture and proper digestion function, contributing to GERD. Client 1 is wheelchair bound, and lives in a home with four other clients. Client 1 is totally dependent upon staff for medication administration, and assistance with all activities of daily living. A review of an incident report, dated 4/9/16, indicated the facility purchased Elemental Iron 65 mg. for Client 1, on 4/8/16. The incident report indicated facility staff administered five tablets of 65 mg on three separate occasions, before discovering their medication error. During an interview on 4/18/16 at 3:30 p.m., Client 1's family member stated Client 1's GERD and scoliosis had created an ulceration on Client 1's esophagus (tube connecting the mouth to the stomach). Client 1's family member stated the ulceration had bled and caused anemia, for which the physician ordered an iron supplement. Client 1's family member stated Client 1 experienced a little constipation after receiving an overdose of iron supplement. During an interview on 4/18/16 at 4:20 a.m., Nurse Consultant stated he received a telephone call from Management B, at approximately 8 p.m., on 4/8/16, during which Management B stated the following: A. Client 1's physician prescribed a new order of Ferrous Sulfate 325 milligrams (mg), orally, twice a day, for anemia. B. He (Management B) had a difficult time finding Ferrous Sulfate and had purchased an over the counter Elemental Iron 65 mg. C. He (Management B) divided 65 into 325, and determined five tablets of Elemental Iron 65 was equivalent to one tablet of Ferrous Sulfate 325 mg. D. He (Management B) administered five tablets of Elemental Iron 65 to Client 1, prior to calling Nurse Consultant. Nurse Consultant stated he did not correct Management B, and should have looked the supplement up immediately, rather than waiting until the following day. During a record review on 4/18/16 at 4:30 p.m., the physician's telephone order for Client 1, dated 4/8/16, indicated the following: 325 mg Ferrous Sulfate BID (twice a day). The Medication Administration Record (MAR) for Client 1 indicated the following: Ferrous Sulfate 65 mg, give 5 tabs BID, at 7 a.m. and 5 tablets 10 p.m., with Vitamin C. The MAR indicated staff had administered two doses (10 tablets) of Elemental Iron on 4/8/16, and one dose (5 tablets) on the morning of 4/9/16. A review of the Elemental Iron bottle on 4/18/16 at 4:40 p.m., indicated it was a high potency iron, given as a dietary supplement, and serving size should be one tablet. The back label, under "Supplement Facts," indicated Iron 65 mg was equivalent to 361% of daily value. The label "Warning," indicated that accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under six. During an interview on 4/18/16 at 4:49 p.m., Management B stated Client 1's physician order had arrived at the facility late on 4/8/16, and he administered the five tablets of Elemental Iron at about 5 p.m., and a second dose of 5 tablets at 10 p.m., because Client 1's physician wanted Client 1 to get an iron supplement as soon as possible. A review of the "National Institutes of Health. Dietary Supplement Fact Sheet: Iron." Retrieved from: March 8, 2012, indicated that Ferrous Sulfate has 20% of elemental iron (325 mg of Ferrous Sulfate is equivalent to 65 mg of Elemental iron). The review further indicated "...acute intakes of more than 20 mg/kg iron from supplements or medicines can lead to gastric upset, constipation, nausea, abdominal pain, vomiting, and faintness, especially if food is not taken at the same time. Taking supplements containing 25 mg elemental iron or more can also reduce zinc absorption and plasma zinc concentrations. In severe cases (e.g., one-time ingestion of 60 mg/kg), overdoses of iron can lead to multisystem organ failure, coma, convulsions, and even death. The facility's policy, "Medication Error Procedure," defined medication error as including "...administration of a dose not prescribed." Therefore, the facility failed to follow a physician's verbal telephone order for one client (Client 1), as prescribed, when: 1. The physician ordered Ferrous Sulfate (an iron supplement) 325 milligrams (mg), orally, twice a day, for anemia. 2. The facility purchased Elemental Iron 65 mg (iron supplement, equivalent to 325 mg of Ferrous sulfate), and administered five tablets, on three separate occasions, before discovering one tablet of Elemental Iron 65 was equal to one tablet of Ferrous Sulfate 325 mg. This violation had a direct or immediate relationship to the health, safety, or security of Client 1. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170006840 |
A |
19-Apr-12 |
IOD511 |
12789 |
T22 DIV5 CH8 ART4-76525(a)(20) Clients' Rights (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During the investigation of an unusual occurrence the following was revealed: The facility did not comply with the above regulation when it neglected to provide sufficient supervision to protect Client 1 from homicide while residing in the facility's locked Adolescent Residence 529.Clinical record review revealed Client 1 was a 16 year-old female admitted to the facility on 1/22/09 after numerous failed community placements. She had a history of aggression including threatening staff and private citizens with a knife. She had an unsteady gait and had been undergoing physical therapy three times a week to improve balance, strength, and endurance. Clinical record review for Client 2 revealed she was a 16 year-old female who had been originally admitted to the facility in 2006. She had experienced behavioral difficulties that required psychiatric hospitalizations since she was eight years old. It was documented that she had episodes of intense anger and had attacked peers and staff. On 12/2/08, while on an outing in the community with her court appointed special advocate she disappeared into the local community. She threw a brick through the window of a house to break in and steal a butcher knife. She then entered another house and threatened a female resident with the knife. She had good gross and fine motor skills. She ambulated with a steady gait, had full range of motion of all extremities, could manipulate objects without difficulty and was able to ride a two wheel bike. She had objective "#1 Verbal/Written Threats to Harm Others will decrease to 1 time per month for any 6 months by 12/30/09." Staff Member-L was no longer employed by the facility however, she was interviewed by the Special Investigations unit with her interview was documented in the OPS Investigation Disposition Report. Staff Member L was the acting unit supervisor at the time of the incident. The report specified that Staff member-L reported, "...there are policies on the unit that require the clients are physically checked every 15 minutes. The checks are to be documented on the Q15 report. After the clients are put to bed there is to be a staff member positioned in the girls' hallway to monitor the clients." She had also stated that it was common practice for staff members to leave the unit two or three minutes early if properly relieved, but not a full 15 minutes prior to the end of the shift. She believed all the staff members were aware of the shift expectations."Nursing procedure: 7.11 Revised Date: 06/08," regarding shift change report specified that, "If residents are not ambulatory or in full view at the time of report, the on-coming Group Leader and the off-going Group Leader shall make rounds and observe all individuals in the group." The PM shift always ended at 11:00 PM and the Nocturnal (NOC) shift began at 10:45 allowing for a 15 minute overlap for shift change report.On 2/22/09, the census on Residence 529 was five clients and each of the three shifts had five staff members assigned.Review of the Investigation Disposition Report conducted by the Office of Protective Services (OPS) revealed that on the evening of 2/22/09, Staff Member-A stated that she arrived at Residence 529 at approximately 2240 hours (10:40PM. She said at approximately 2250 hours (10:50PM), she went to assist Client 1's roommate no one was monitoring the girl's hallway and the door to the hallway was closed. When she reached their room she found Client 1 unresponsive and she ran to the nurse's station to tell Staff Member-B to call in a medical emergency. The actual time recorded on the code blue documentation sheet of the initial emergency call was 2257 (10:57 PM). The facility incident report specified that Client 1 was found unresponsive lying on her back on the floor of her bedroom. She had three blankets placed on her and appeared to be bleeding from the mouth. There was a t-shirt partially inserted in her mouth and paper inserted in both nostrils. There was also what appeared to be hand lotion covering both eyes.When Staff Member-B entered Client 1's bedroom he began CPR (cardiopulmonary resuscitation) Client 1 was transferred to a local Emergency Room where she was treated and subsequently transferred to a hospital that specialized in pediatrics. It was there that Client 1 expired on 2/23/09 at 5:38 AM. The autopsy report listed the cause of death as anoxic encephalopathy (lack of oxygen to the brain) due to airway obstruction by foreign objects. The manner was listed as Homicide. The autopsy report also specified, "A collection of 7 to 8 superficial puncture wounds is noted on the right mid anterior thoracic wall/right upper medial breast region... Subsequent dissection and exploration reveals a 0.7 cm length of apparent pencil lead embedded within the fatty tissues of the right anterior thoracic wall/breast." When OPS Special Investigator-D, working overtime as a patrol officer, responded to the residence on 2-22-09 at 2257 (10:57 PM), Client 2 told him that she had given a note to Staff Member-E allegedly written by Client 1 that said she, Client 1, wanted to commit suicide but Staff Member-E had torn it up. Staff Member-E subsequently told the OPS investigator that she never received such a note from Client 2. Client 2's involvement in Client 1's homicide was suspected by the facility and she was placed on constant one to one observation.On 2/26/09 Client 2 told a story of how another peer had assaulted Client 1. Then on 3/2/09 at 12:00 PM, she had a conversation with a staff member that was documented in her Interdisciplinary Notes. She stated, "I don't feel bad for what I did." When asked what she was talking about she said, "On Sunday night." Staff encouraged her to speak with her attorney about it. But she continued. She said she took her pillow with her to Client 1's bedroom and asked if she could come in and Client 1 said yes. Client 2 said she looked down the hall and saw the hall door was closed and the staff member was knitting outside the door. She stated that she went onto Client 1's room and sat on her bed. She said I have a present for you then put the pillow on Client 1's face and held it there for a long time. She then said she got Client 1's radio cord and put it around her neck and choked her with it. She said following that she went to her own room and got a plastic bag then returned and put over Client 1's face and made it really tight. She then said Client 1 wasn't breathing. Client 2 said she again went to her room and this time got a pencil that she scratched and stabbed Client 1's chest with. She said she then put paper in Client 1's nose and pushed it up with the pencil. She then put a shirt in Client 1's mouth and lotion on her eyes. Following this she covered Client 1 with blankets. Client 1's only roommate got up and asked if Client 1 was sleeping. Client 2 said she told her, "yes" Client 2 said she then heard someone open the door to the girls' hallway. Client 2 said she hid in the room and when a staff member came in the room she began calling for help and left the room. Client 2 said at that time she went to her own room and then to the bathroom. On 3/4/09, Client 2 was taken into custody by the local police department. The court subsequently made a commitment order to send Client 2 to a secure treatment area of a developmental center when she was deemed incompetent to stand trial.Staff Member-F was no longer employed by the facility however, he was interviewed by the Special Investigations unit with his interview was documented in the OPS Investigation Disposition Report. He was the PM shift lead person on the 2/22/09. He had five staff members working the PM shift that day. The other working staff members were Staff Members-C, G, I and K. Staff Member-C had been assigned to monitor the girls' hallway. Staff Member-I had left early at 9:30 PM because he had worked a double shift. When Staff Members-A and B arrived at approximately 10:40 PM, Staff Member-G asked if he could leave because he had worked a 16 hour shift the night before. Staff Member-F told him that he could and he did. When Staff Member-H arrived at around 10:45 PM, Staff Member-C asked if she could leave and Facility Staff Member-F told her she could and she did. Staff Member-F said he left at 10:47 PM, even though he falsified his time as staying until 11:00 PM. The OPS Investigation documented that Staff Member-F stated that staff are always with the clients during the day so 15 minute rounds are not performed until the clients go to their rooms at 9:00 PM. He said it was at the time that staff members sat at the entrance of the boys' and girls' hallways to monitor the clients. He said if the hallway monitors have to do paperwork someone relieves them. When the 15 minute checks were done, the staff member was to get up and actually go look in the rooms. He said the hallway doors were to always remain open. Staff Member-F said rounds were not typically made with the relieving NOC (nocturnal) shift SPT (Senior Psychiatric Technician), because a verbal report was given. He stated that he did know it was policy for the PM shift SPT to complete change of shift rounds with the NOC shift SPT. He also stated that is was a common practice for the PM shift to leave 15 minutes prior to the end of the shift. Staff Member-C was no longer employed by the facility however she was interviewed by the Special Investigations unit and her interview was documented in the OPS Investigation Disposition Report. She said that on 2/22/09 after the girls went to bed, she positioned herself by the open door of the girls' hallway and did her charting. After she completed her charting she admitted that she was knitting. She stated that she checked the clients every 15 minutes from 9:00 PM until 10:30 PM. She said that at 10:30 PM, all the girls were in their beds but were awake. The Q15 sheet indicated that she had checked the clients at 10:45 PM, but she admitted that she did not actually check the girls at 10:45 PM. It was documented that she could not provide a reason for falsifying the Q15 sheet on 2/22/09, and said "it was a mistake." She said she left the unit around 10:45 PM, even though she falsified her time as staying until 11:00 PM.Staff Member-B was interviewed on 7/19/11 at 4:30 PM. He stated that he came to work at approximately 10:40 PM on 2/22/09. The door to the girls' hallway was closed, which was not normal, and Staff Member-C was standing by the medication/chart room, waiting for the oncoming shift. He stated that the girls' hallway could not be visualized from Staff Member-C's vantage point. He said he went to the nurses' station to sign in and shortly thereafter Staff Member-A came in and said she needed help.Staff Member-A was interviewed on 9/29/11 at 11:24 PM. She said she arrived for the NOC shift on 2/22/09 at approximately 10:45 PM shortly after Staff Member-B had arrived. She stated that when she arrived she saw Staff Member-C was standing by the chart room. She said the girl's hallway could not be visually monitored from that area. She also stated that the door to the girl's hallway was closed. She said she went to the nurses' station to sign in and read memos (memorandums). She stated that she did not conduct rounds with Staff Member-F as was facility policy. She said very often the PM shift members would leave early and she usually conducted rounds by herself. After she was done in the nurses' station she said she went straight to Client 1's room to see if her roommate needed assistance. That is when she found Client 1 unresponsive on the floor of her bedroom.When Staff Member-A was asked how a closed hallway door impacted the ability to hear the clients down the hallway, she said, that to her, it was a very substantial noise reduction.On 7/12/11 at 11:50 AM, observation of the girls' hallway door on Residence 529, revealed it was a solid two inches thick with a metal plate up to the door knob on the bedroom hallway side. The upper portion of the door had wire reinforced glass which was also covered with a sheet of plexi-glass on both sides. It was also observed that while standing at the medication/chart room the girls' hallway could not be visualized.Therefore the facility's neglect to provide supervision to prevent or even be aware of Client 2's physical attack on Client 1 presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result or a substantial probability that death or serious physical harm to Client 1 would result. |
| 170001770 |
FAIRVIEW DEVELOPMENTAL CENTER D/P SNF |
170008980 |
A |
29-Apr-14 |
I2D911 |
7474 |
483.25(h) ACCIDENTSThe facility must ensure that (1) the resident environment remains as free of accident hazards as is possible; and (2) each resident receives adequate supervision and assistance devices to prevent accidents. An investigation was conducted on 10/27/11 as the result of a facility self-reported incident. The results showed that the facility: 1. Failed to investigate, for causal factors, a previous fall on 7/15/11, during which Resident 1 hit her head on the floor; 2. Failed to review and revise the plan of care following that fall and develop new interventions to prevent further falls; 3. Failed to implement the written care plan so that Resident 1 received adequate supervision to prevent falls; and 4. Failed to identify possible or likely causes of Resident 1?s 9/28/11, as specified by facility policy and procedure. Resident 1 was 21 years old with diagnoses that included Charge Syndrome (a chromosomal disorder), aggression, self-injurious behaviors, gastrostomy tube for swallowing difficulties, and tracheostomy tube for breathing difficulties.The ?Nursing Fracture/Fall Risk Assessment? for Resident 1, dated 6/1/11, documented the resident was at risk for falls. The ?PM&R [Physical Medicine and Rehabilitation] Gait Evaluation,? dated 12/16/10, recommended that Resident 1 walk with hand-held assistance. The Minimum Data Set (MDS), dated 6/21/11, documented that Resident 1 required one-person physical assist with transfers between surfaces, including to/from a wheelchair, and one-person physical assist when walking in a room.The MDS Focus Summary, dated 6/28/11, identified Resident 1?s gait as unsteady. The ?Care Area? of ?Falls? was triggered due to Resident 1?s ?unsteadiness in balance and transition activities? and specified that she required the assistance of one staff ?to stabilize her during activities requiring balance and transition including moving from a sitting to a standing position . . . and moving from surface to surface.? The PM&R recommendation of hand-held assistance was incorporated in this Summary. The Individual Program Plan (IPP), dated 6/28/11, specified that Resident 1 required the assistance of one staff when moving from a sitting to a standing position, walking, turning around, getting off and on the toilet, and moving from surface to surface ?to ensure she remains free of injury.? In addition, the PM&R recommendation, from 12/16/10, of hand-held assistance was included in the IPP. Health Care Objectives and Plans, No. P13-1, Joint Disorder, dated 6/28/11, specified ?Hand held assist with transfer.? Health Care Objectives and Plans, No. P16-4, Abnormalities of Gait/Unsteady Gait, dated 8/2/11, restated the MDS requirement from 6/21/11 of physical assistance with all transfers. On 7/15/11, Resident 1 was attending a daily on-campus activity program, staffed by Developmental Center employees who were responsible for the implementing all aspects of Resident 1?s plan of care during attendance at the activity program. Resident 1 was ambulating with assistance of staff, fell, and hit the back of her head on the floor. Nursing Procedure Number: 10.11, Falls Management, specified, ?Within 24 hours of a fall, the residence staff will begin efforts to identify possible or likely causes of the incident.? The procedure further required staff to ?evaluate the chain of events or circumstances preceding a recent fall? and the ?IDT [Interdisciplinary Team] will identify interventions to reduce the risk of falls.? There was no documentation that the nursing facility investigated the circumstances surrounding this fall. There was no documented evidence that residence staff began to identify possible or likely causes of the fall, or that the staff evaluated the chain of events or circumstances preceding the fall or that the IDT identified interventions to reduce the risk of falls, as specified in Nursing Procedure Number 10.11.On 2/6/12 at 3:20 PM, Staff Member C stated that the facility did not investigate falls if no injury was identified at the time of the fall and stated no post-fall investigation or report was done following the fall on 7/15/11. There was no evidence that Health Care Objectives and Plans P13-1 and 16-4 had been reviewed and revised following the fall on 7/15/11. No new interventions to prevent further falls were added to Resident 1?s plan of care.On 9/28/11, Resident 1 was again attending the daily on-campus activity program staffed by Developmental Center employees who were responsible for implementing all aspects of Resident 1?s plan of care during attendance at the activity program. According to facility documentation, at 10:20 AM, Resident 1 got up from her wheelchair, turned around, lost her balance, and fell to the floor. Resident 1 hit the back of her head on the floor. There was no documentation that the nursing facility investigated the circumstances surrounding this fall until 9/30/11. There was no documented evidence that, within 24 hours, residence staff began to identify possible or likely causes of the fall or that staff evaluated the chain of events or circumstances preceding the fall or that the IDT identified interventions to reduce the risk of falls, as specified in Nursing Procedure Number 10.11.Two days after the fall, on 9/30/11, Resident 1 was sent to the emergency room of a local hospital when she was identified as lethargic with prolonged expiratory phase. Resident 1 was admitted to the intensive care unit on 9/30/11 and died on 10/3/11. The autopsy report listed the cause of death as blunt head trauma with skull fractures and bleeding in the brain. Staff Member C confirmed that no investigation of the fall was initiated until after Resident 1 had a change of condition on 9/30/11. During an interview on 2/6/12 at 11:25 AM, Staff Member A, who was responsible for the care of Resident 1 at the time of the incident on 9/28/11, stated she was standing near the resident at the time Resident 1 attempted to transfer from her wheelchair to a padded chair in the classroom. Staff Member A stated Resident 1 got out of her wheelchair, took a couple of steps toward the padded chair which was about five feet away, turned, and fell straight backwards, hitting the back of her head on the floor. Staff Member A stated she was not touching or holding on to any part of Resident 1 during the attempted transfer from her wheelchair to the padded chair.During an interview on 2/7/12 at 8:50 AM, supervising Staff Member B confirmed that one-person physical assist and hand-holding during transfers and ambulation were interventions specified in Resident 1?s plan of care to prevent falls. Staff Member B further stated that all staff involved in the care of Resident 1, including Staff Member A was aware of the interventions required in the plan of care.The facility?s failure to investigate the causal factors, review and revise Resident 1?s plan of care, develop new interventions to prevent further falls after Resident 1?s 7/15/11 fall, in which Resident 1 hit her head on the floor, then failed to provide adequate supervision to prevent falls by failing to implement the written care plan in effect and the facility?s failure to begin efforts to identify possible or likely causes of the 9/28/11 fall as specified by the facility? policy and procedures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170009179 |
B |
27-Feb-14 |
R9F611 |
4360 |
76525 (a) (20) right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During the investigation of an unusual occurrence the following was revealed: The facility did not comply with the above regulation when it neglected to provide adequate supervision to prevent Client 2 from kicking Client 1 in the ribs resulting in harm, fractures to right 10th and 11th ribs. Clinical record review for Client 1 revealed that he had diagnoses that included anxiety and impulse control disorder. He had a history of aggressive harm to others, was intrusive and would make derogatory comments about and use profanity with others. Clinical record review for Client 2 revealed that he also had an impulse control disorder, psychosis not otherwise specified and a history of aggressive harm to others. He had open Individual program objectives to reduce the behaviors of hitting and kicking others. During August of 2011 he had kicked others seven times. He had hit others 13 times in August of 2011, two times in September 2011 and four times during November 2011. Client 1 had been complaining of pain to his right side. X-ray examination conducted on 11/18/11 at 10:40 AM, revealed that he had fractures of his 10th and 11th ribs on the right side. When asked about the origin of these injuries, Client 1 stated that on the prior Monday morning of 11/15/11, another client had kicked him while in the group area. He described the client only as tall and dark. Later that afternoon he pointed out Client 2 as the peer who had kicked him on his right side. He said he didn't report it sooner because he was afraid. It was documented that same afternoon that facility staff asked Client 2 if he had hit or kicked Client 1. He initially denied doing it, however he later came to staff and admitted that he did kicked Client 1 on the previous Monday. When asked where he kicked him, he said on the right side. He said Client 1 had called him a "nigger" and he got mad and kicked him. Review of an office of protective services investigation report dated 2/28/12 revealed that Client 2 stated he remembered physically assaulting Client 1 in the Group room R43. Client 2 said that Client 1 accused him of taking his soda. Client 2 stated he denied taking the soda and Client 1 called him a "nigger". Client 2 said he then kicked Client 1 on the legs and stomach area. He told the officer that no one saw him kick Client 1.On 4/29/12 during interview with a Supervisory Staff Member 1, she stated that Client 1 and 2 were assigned to different groups. She was not sure in which group the altercation took place. She acknowledged that there was two staff members assigned to each group.In response to being questioned as to why the assault had not been witnessed by staff, she stated that perhaps both staff members were helping other clients. However, she stated that a staff member should have been in the group area.On 4/18/12, Staff Member 2, who was the PM group leader on the day of the assault, was interviewed. She said that she didn't hear any altercation that day. She said that afternoon Client 1 had come to her and said Client 2 had kicked him. She said she didn't know if the attack had occurred in the morning or afternoon. She said one person usually stays with the group and that they are not supposed to leave the group unattended.On 5/5/12, Staff Member 3, who was the AM group leader on the day of the assault, was interviewed. He stated that usually one staff member will stay in the group area if the other staff member goes to help other clients. He said that on the day in question, he didn't remember where he was or why there was no staff member in the group area at the time of the incident.Facility policy "5.5 CLIENT'S SAFETY 5.5.3 SUPERVISION OF CLIENTS" specified under Direct Care Staff Responsibilities, "Ensure that adequate supervision is provided whenever leaving clients, keeping in mind the health, physical and behavioral issues for each client". Therefore the facility neglected to provide adequate supervision for the clients in group room R43 resulting in Client 1 sustaining fractures to his right 10th and 11th ribs after an unwitnessed physical assault by Client 2.The above violation had a direct or immediate relationship to the health, safety, or security of Clients. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170009189 |
A |
07-Apr-14 |
JJOE11 |
3045 |
76525 (a)(7) Free from physical harm An investigation was initiated on 3/9/12 as a result of a facility self-reported incident. The facility failed to protect Client 2 from harm when Client 1 beat Client 2 to the point Client 2 required hospitalization for skull and facial fracture and bleeding in the brain.Client 1's Interdisciplinary (ID) notes contain documentation of three client to staff aggressive acts over the preceding 6 months and two aggressive acts against peers. These aggressive acts included hitting and kicking. On 2/14/12, staff documented in the ID Notes that Client 1 pulled another client to the ground and kicked him in the face. On 2/26/12, staff documented in the ID Notes that Client 1 had an altercation with another client and the other client was unable to bear weight on his leg following the incident. The Individual Program Plan (IPP) "Desired Outcome and Milestone" behavior plan B2-2 for kicking others was initiated on 10/31/10. Client 1's medical record failed to contain documentation that Client 1's behavior plan had been either reviewed or revised since 10/31/10.The facility was unable to provide documentation that Client 1's behavior plans have been reviewed and/or revised following these violent aggressive acts.On 3/3/12 at 12:30 PM, Staff Member 2 observed Client 2 face up on the floor with Client 1 stomping on him.Medical record review revealed that Client 2 required cardiopulmonary resuscitation to restore breathing and heart action. He was taken to an emergency room with two skull fractures, a nasal fracture, and subdural/subarachnoid hematomas [bleeding in the brain.] Statistically, this type of bleeding into the brain can cause a 60-80% mortality rate if left untreated.During an interview on 3/28/13 at 10:20 AM, Staff Member 2 stated that he was mopping in the hallway near the dining room, looked down a side hall, and was about 6 or 7 feet away from the two clients. He stated when Client 1 saw him, Client 1 backed away. Staff Member 2 then called for Staff Member 1. During an interview on 3/22/13 at 10:30 AM, Staff Member 1 stated that on 3/3/12 at 12:30 PM, he was in the station chart room when he heard someone calling his name. When he ran out, Staff Member 2 told him that Client 1 was "beating up" Client 2. No other staff members were in the area. Staff Member 1 observed Client 2 face up on the floor in the hallway with his face full of blood, unresponsive with no breathing, no heart rate, and his eyes rolled back in his head. Staff Member 1 stated that emergency measures were initiated and Client 2 was taken to a hospital. He stated that he observed Client 1 in his room, still agitated, with blood on the bottom and inner side of his shoe. He stated Client 1 was assigned a one-to-one staff member to supervise him. Therefore, the facility: 1. failed to ensure Client 2 was free from harm; 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. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170009362 |
B |
27-Feb-14 |
GP6O11 |
3915 |
76525 (a) (20) right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During the investigation of an unusual occurrence initiated on 6/5/12, the following was revealed: The facility failed to comply with the above regulation when it neglected to provide adequate interventions to prevent Client 2 from hitting Client 1 in the face causing harm, right orbital (eye socket bones) and nasal bone fractures. Clinical record review for Client 1 revealed that he had diagnoses that includedschizoaffective disorder and impulse control disorder with a history of aggressive harm to others.Clinical record review for Client 2 revealed he also had a diagnosis of impulse control disorder and a. history of aggressive harm to others. On 2/6/12, Client 1 entered Client 2's room and proceeded to go through his property. Client 2 responded by wrapping an electrical cord around his fist and physically assaulting Client 1. Client 1 sustained abrasions to his head, face and neck. He also sustained 2 bites to his upper left arm.It was documented that following the incident, Client 2 said, "He won't leave me alone and I am sick of it. He tried to take my stuff."Facility records indicated that Client 1 was known to have an unusual fascination with Client 2 and Client 2 had asked him to leave him alone on many occasions. Prior to this incident, Client 1 had grabbed Client 2 inappropriately with a defensive response by Client 2. Following the 2/6/12, a special conference was held on 2/9/12. The action plan included that staff were to ensure that there were no "chance" meetings between the clients, "until issue resolved by increasing visual checks for both clients". Facility record review revealed that on 4/28/12, staff heard a commotion in the east wing of the residence where both clients' bedrooms were located. Client 1 was found on the floor. He stated that Client 2 had hit him in the face. Client 1 complained of dizziness and began to vomit. He was transported to an outside acute care hospital where he was found to have a right orbital fracture and nasal fracture that required surgical intervention. Client 2 stated that Client 1 came into his bedroom and grabbed his genitals and that is when he hit Client 1. Client 1's roommates confirmed that was what happened. On 6/5/12 at 11:15 AM, the Unit Supervisor 1 who was in charge of the residence during the 2/6/12 incident was interviewed. She said she that while she was still in charge of the unit the "issue" between the two clients was never resolved. When Unit Supervisor 1 was asked how the history of negative interactions between Client 1 and Client 2 was communicated to Unit Supervisor 2 when she took over the unit, she stated that it was covered in their morning program management meetings. She was unsure if Unit Supervisor 2 was present in a meeting about Client 1 and 2. She stated that she did not have a face to face takeover meeting with Unit Supervisor 2.On 6/5/12, supervisory staff for the Residence during the 4/28/12 incident was interviewed. She stated that during the 2/6/12 incident she was not on the residence and was not fully aware of the incident. When asked if there is ever a meeting between the oncoming and off going unit supervisors, supervisory staff stated she had never had such a take-over meeting. She said she wasn't aware of the 2/9/12 special conference action plan that included that staff was to ensure there were no "chance" meetings between the clients, "until issue resolved by increasing visual checks for both clients".Therefore the facility neglected to implement adequate interventions to prevent Client 2 from physically assaulting Client 1 which resulted in harm to Client 1, a fractured right orbit and a fractured nasal bone.The above violation had a direct or immediate relationship to the health, safety, or security of Clients. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170010230 |
A |
2-Sep-16 |
Q7DL11 |
12332 |
REGULATION VIOLATION: 76525 CLIENTS' RIGHTS (a)Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights. (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure that Client 1 was free from neglect and harm when the facility failed to: (a) promptly identify injuries of unknown origin; (b) ensure Client 1 was assessed and treated for injuries following a witnessed fall; (c) ensure that Client 1's protective helmet was free of defects to prevent head injuries; and (d) provide adequate supervision to prevent injuries to Client 1 when Client 1's injuries had increased in number and severity. These facility failures resulted in severe injuries of unknown origin to Client 1. These injuries included a right rib fracture, left frontal parietal scalp hematoma (top left side of the scalp, swelling caused by a collection of blood from broken blood vessels), a fractured cervical (neck) spine and paralysis. Review of the clinical record on 7/22/13, noted that Client 1 had resided at the facility since May of 1999. Client 1's diagnoses included severe intellectual disability and epilepsy with episodes of grand mal seizures. The client wore a protective helmet (with extra inside padding) while she was awake and a soft helmet when she was asleep. Client 1 ambulated and had full use of all her extremities. She had a history of falls when walking or standing. Client 1 made her needs known by using single words and short sentences. It was noted in the clinical record that the client was on general supervision (staff were to know her whereabouts and make periodic checks at least every 15 minutes) and enhanced supervision only during showers. Review of the clinical record noted the following events, which occurred within a one-month period from 6/16/13 through 7/19/13: 6/16/13 at 8:10 PM Interdisciplinary Notes (IDN): During bathing, staff noticed a 10 cm (centimeter) x 12 cm area of yellowish to light purple discoloration on the client's upper left arm. (Yellowish to light purple skin discoloration indicated that the bruise had been present for several days.) 6/16/13 at 9:30 PM IDN: cause of the discoloration unknown. 6/18/13 Emerging Risk Review (ERR): Review of incident (identification of the upper arm bruise) attended by Unit Supervisor, Social Worker, RN Health Services Specialist, Psychiatric Technician, and the Individual Program Coordinator, noted that "thorough skin assessments" were not done during showering which could have possibly identified the bruise on an earlier date. On 7/1/13 Client 1 had a seizure on the way to school and fell to the ground. The IDN dated 7/1/13 at 2:50 PM specified "No injuries. Seen by the physician." However, review of the documentation in the Physician Progress notes failed to note that the physician had examined the client. Licensed Staff A (witness to the fall on 7-1-13), stated during an interview on 8/2/13 at 1:20 PM, regarding the incident on 7/1/13, that the client had a seizure and fell "pretty hard" on the sidewalk. She stated that the client put both hands out to brace herself and fell on her left side. She stated that after a few minutes she and the client started to walk back to the unit. They walked a few feet and then a passing facility bus picked them up. Licensed Staff A stated that the client was not injured. Following the 7/1/13 fall, increased supervision and additional measures to prevent similar incidents were not developed for Client 1. During review of the physician's progress notes and concurrent interview with Client 1's residence physician (Physician A) on 8/27/13 at 10:30 AM, regarding the fall on 7/1/13, Physician A stated that she did not remember the incident and did not make a note for that day. She stated that she relies on the staff to inform her of these incidents. Physicians' Progress note on 7/10/13 at 1:00 PM specified, "Staff reported that client had pain in her left shoulder with limitation in movement." Licensed Staff B stated during an interview on 8/7/13 at 2:25 PM, that on 7/10/13, the client was only able to raise her arm up half way and did so when examined by Physician A. Licensed Staff B stated that the client told her that she did not know why her shoulder was hurting. Licensed Staff B stated that the client only complained for one day. However, there was no documentation that the licensed staff subsequently assessed the client to determine if she still had limited range of motion of the left arm. On 7/14/13 at 3:45 PM, IDN specified that during showering, the client was noticed with a discoloration behind her left ear down the nape of her neck to the start of her shoulder. There were various stages of discoloration in a 7 cm X 4 cm area, yellowish, 1cm X 3 cm dark purple and a 1 cm X 1.5 purple. Licensed Staff C, who discovered the discolorations behind the client's left ear and on neck on 7/14/13, stated during an interview on 8/9/13 at 12:50 p.m., that the yellowish discoloration was on the scalp area by the left ear and the two purplish areas were on the left side of the neck; however, one of the purplish areas was closer to the client's shoulder. There was no increase in Client 1's supervision subsequent to the discovery of these injuries. Although the origin of the head and neck injuries could not be determined, Physicians' Progress Note on 7/14/13 at 5:00 PM specified that the contusion fading at the neck and scalp area may have been related to the tight fitting helmet. During an interview with the Assistant Technology Specialist on 8/9/13 at 9:50 AM, he stated that he repairs and makes durable medical equipment such as helmets. He stated that upon examining the Client 1's helmet on 7/15/13, there was a lot of hair that had adhered to the removable inner lining and on the inside of the helmet. He stated that approximately 2/3rds of the inner lining was worn and cracked. He also said that he found a 2 inch crack on the right front of the helmet. He showed a similar hard helmet and the location of the crack which he stated had separated. He stated that he discarded the original helmet due to the crack. He stated that staff used to send the inner lining to his department for replacement when there was a defect, but it has been sometime since he had received one. The Unit Supervisor stated during an interview on 8/9/13 at 11:00 AM, that residence staffs were not checking the condition of the client's helmet daily prior to putting the helmet on Client 1. Review of the policy, Nursing Procedure Number 10.02, Revised 04/13. Helmet Usage, Procedure 1, noted that helmets were to be inspected prior to each use to ensure that they were clean and in good repair. Staff were to check for defects or damage such as tears in the inner lining, worn areas, etc. It was noted that if any defect was found the helmet was not to be used. The IDN on 7/17/13 at 7:15 AM specified that Client 1 refused to get out of bed. Related to back pain and that the physician was notified. During an interview with Licensed Staff C on 8/9/13 at 12:50 PM, she stated that the client complained of back pain at least a week before 7/17/13. She stated that she told the medication nurse on two occasions; however, she checked the MAR (medication administration record) and did not see the entries. When asked why she did not document the client's symptoms in the IDN, she stated that she thought the medication nurse would have done it. Physicians' progress note on 7/17/13 at 9:00 AM specified that the client complained of back pain, but range of motion in both legs and arms were complete without pain. It also specified "No bruise on body." X-rays ordered of cervical spine, lumbar spine, thoracic, chest and hip. At 3:00 PM, all x-rays were noted to be negative for fracture. Review of the 7/17/13 X-ray report of the cervical spine, noted that the x-ray was a limited study of the cervical spine showing C1 - C3 due to client habitus (appearance/physique). (The cervical spine consists of C1 - C7). It was noted that no fracture of C1 - C3, but if symptoms persisted, a CT scan was suggested. The x-ray report was read on 7/19/13 and transcribed on 7/22/13. On the afternoon and evening of 7/17/13, Client 1 continued to complain of back pain and refused to move her legs. On 7/17/13 at 10:20 PM, the physician on call was notified of the Client's condition. On 7/18/13 at 12:10 AM, the on call physician's assessment revealed that Client 1 had poor knee reflexes and lower extremity weakness. He also noticed two purplish discolorations to the client's left lower back. He ordered Client 1 to be transferred to an outside acute care hospital to rule out spinal injury. Review of the policy, Client Protections, General Event Reporting, 5.5.5 Attachment A, Issue 25-6/13. Injuries of unknown origin (source not observed by any person and injury suspicious because of the location of the injury). Residence Staff failed to timely identify the injuries of unknown origin on Client 1's back. The on call physician discovered the bruises to Client 1's lower back. On 7/18/13 at 5:45 AM, Client 1 returned from the outside acute care hospital. The acute care hospital discharge note dated 7/18/13 at 3:14 a.m., noted that the lumbar spine (low back) x-ray and pelvis x-rays were negative for fractures. Client 1 remained on general supervision (staff were to know her whereabouts and provide visual checks at least every 15 minutes). Review of the IDNs for 7/18/13 showed Client 1 received pain medication for back pain as follows: 0700: Ibuprofen 400 mg (milligrams). 0830: Ibuprofen not effective Given Acetaminophen with codeine #3. 1000: Acetaminophen with codeine not effective. MD informed. New order given Tizanidine HCL 4 mg (medication used to treat muscle spasms caused by certain conditions (such as multiple sclerosis, spinal cord injury). 1800 (6 PM): Ibuprofen 400 mg at 1730 (5:30 p.m.). At 1900 (7:00 PM) mildly effective. 2200 (10:00 PM): ...No complaint of pain. IDNs for 7/19/13 show the following: 0630: ...No complaint of back pain during the night. 1000: ...No complaint of back pain. Lying on back. Refused to be moved. 7/19/13 at 10:00 AM, Physicians' Progress Notes: Client's condition has not changed. Client refuses to get up and does not move extremities much. Referred to the outside acute care hospital for follow up. On 7/19/13, the client was admitted to an outside acute care hospital. Review of the acute care hospital clinical record revealed she had a bruise on the neck, a rib fracture of unknown length of time, a hematoma (blood clot) under the scalp in the parietal area, paralysis of the lower extremities and a fracture of the cervical (neck) spine. The cervical fractures were at C4 & C5 (areas that were not previously examined on 7/17/13). The acute care hospital record specified that the client underwent surgery on 7/19/13 for the cervical fractures and had a postoperative diagnosis of quadriplegia (paralysis of arms and legs) with a tracheostomy (opening into the trachea) with oxygen administration. On 8/8/13, Client 1 was transferred to a transitional care hospital where Client 1 expired on 9/5/13. Therefore the facility failed to ensure that Client 1 was free from neglect and harm when the facility failed to: (a) promptly identify injuries of unknown origin; (b) ensure Client 1 was assessed and treated for injuries following a witnessed fall; (c) ensure that Client 1's protective helmet was free of defects to prevent head injuries; and (d) provide adequate supervision to prevent injuries to Client 1. These failures resulted in severe injuries of unknown origin to Client 1. These injuries included a right rib fracture, left frontal parietal scalp hematoma (top left side of the scalp, swelling caused by a collection of blood from broken blood vessels), a fractured cervical (neck) spine and paralysis. These facility failures presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170010289 |
B |
07-Apr-14 |
0QV311 |
2596 |
76525 (a) (20) Right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility's neglect of Client 1 to prevent Client 1 from swallowing inedible items placed Client 1 at risk of serious injury or death from unnecessary surgery to remove the inedible items Client 1's swallowed from Client 1's gastrointestinal tract.Review of Client 1's clinical record revealed that Client 1 had an extensive history of swallowing inedible objects (PICA). Foreign objects she had swallowed in the past included key rings, batteries, screws, paperclips, soda can tops, metal bicycle parts, tacks and zippers. Many of these incidents required that Client 1 be hospitalized for EGD procedures (esophagogastroduodenoscopy) for the removal of the foreign objects. This procedure consisted of inserting a long flexible tube with a camera and a retrieving device into the GI tract to remove objects lodged in the esophagus, stomach or duodenum. This procedure is performed when a foreign object is unable to pass through the GI tract or is likely to perforate the GI tract. Client 1 was on an enhanced supervision which required an assigned staff member to be in constant line of sight of the client during all waking hours. During the night, 15 minute checks were to be performed by staff when she was in bed. Client 1 had a strong history of hiding objects on her person, in her bed linens or near her bed and would swallow them after she was in bed. Periodically, a denial of rights was put in place that consisted of AM and PM shift rooms searches for items she could swallow. A body search would be performed on the AM and PM shifts if required. Client 1 did not have a denial of rights in place on 7/7/12. On 7/7/12, Client 1 reported to staff that she had swallowed batteries and a zipper. An x-ray examination performed that day, revealed the presence of multiple foreign bodies in her GI (gastrointestinal) tract. Subsequent x-ray exam on 7/8/12 and 7/11/12 showed the foreign objects were not moving along her GI tract. The radiologist made the opinion that the objects were not likely to pass on their own.On 7/17/12 at an outside acute care hospital, EGD removal of Client 1's GI foreign objects was unsuccessful. Consequently, an exploratory laparotomy was performed. Six batteries and two paperclips were surgically removed from her stomach, small bowel and colon. Her surgical wound required 43 surgical staples for closure.The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170010290 |
B |
02-Apr-14 |
RTS311 |
3596 |
483.440(d)(1) Facility Practices (1) As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.An investigation was begun on 2/27/13 as a result of a facility reported incident. The investigation showed the facility failed to: 1. ensure that Client 1 received continuous active treatment consisting of needed interventions for safety awareness and 2. failed to implement recommendations for safety awareness training. The clinical record for Client 1 indicated that he had a history of chronic compression fractures of his back. The Individual Program Plan (IPP), dated 4/18/12, indicated that Client 1 walked with a steady gait with good balance. The IPP documented that Client 1 was able to participate in conversational speech. The Safety Awareness section documented that the client did everything in a hurry, including walking and, "He does not always know how to avoid environmental hazards such as wet floors, spills ..."The Interdisciplinary Team (IDT) recommended implementing training to enhance the client's safety awareness skills. The Approaches and Strategies, dated 4/18/12, documented that Client 1 "walks with his head down and needs to be encouraged to keep his head up and watch where he is going." The Approaches and Strategies further specified, "Optimal techniques for skill acquisition include verbal instruction..." Facility documentation indicated that, on 5/24/12, Client 1 was in the dining room on his residence. The housekeeper had mopped up spilled liquid from the floor and had placed warning signs around the wet area of the floor at the exit of the dining room. At 7:50 AM, Client 1 was leaving the dining room. Staff Member 1, the dining room coordinator, noted the wet floor and "walked with caution" past the area. She then looked back to see Client 1 slip and fall in the wet section of the floor. Client 1 was transferred to the emergency room at an acute care hospital where he was treated for a fracture of the twelfth thoracic vertebra (broken lower back). Upon return from the hospital, Client 1 required pain medication 42 times during the next month. He still complained of pain of a severity of 9 on a scale of 1 to 10 on 6/11/12, two and a half weeks after the injury. Client 1 was also required to wear a back brace at all times for several months. During an interview on 6/13/13 at 3:00 PM, Client 1 stated that he remembered the fall and that it hurt. During an interview on 6/13/13 at 3:15 PM, Staff Member 1 stated the client was exiting the dining room and she was going to give him money for the day. The housekeeper had mopped and placed warning signs on the floor. When asked, Staff Member 1 stated no one warned Client 1 or provided safety training about the wet floor before he slipped and fell.During an interview on 6/13/13 at 3:30 PM, more than a year after the injury, Staff member 2 stated, "I don't think he's [Client 1] back to the level he was before." Therefore, the facility failed to provide continuous active treatment consisting of needed interventions for safety awareness to a client with poor safety awareness and failed to implement recommendations by the IDT for training to enhance the client's safety awareness skills. The client suffered a fall and fracture. The above had a direct or immediate relationship to the health, safety, or security of clients. |
| 170001770 |
FAIRVIEW DEVELOPMENTAL CENTER D/P SNF |
170010359 |
B |
07-Apr-14 |
IZG711 |
4515 |
F323 483.25 (h) Accidents The facility must ensure that:(1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to: 1. Ensure that Resident 1 was provided the correct assistive devices to prevent accidents when the resident, while being transported via a mechanized transfer lift instead of a wheelchair, fell from the sling, which gave way, resulting in a head laceration that required several staples to close the head wound. 2. Follow the plan of care for Resident 1 as stated in his assessment plan which indicated that the resident required a minimum of 2 plus staff to physically assist during transfers.On 11/13/13 at 8 AM, during a recertification survey, Resident 1 was observed in his room receiving medication via gastrostomy tube. Further observation of the resident revealed a scar on top of his head in the frontal area.Review of the clinical record for Resident 1 on the same day revealed that Resident 1 was admitted to the facility with diagnoses including seizure disorder and abnormal gait.On 8/16/13 at approximately 6:50 AM, the resident was transported by one staff from his bed room through the residence hallway to the bathroom by means of a mechanized transfer lift on a sling. Per the Manufacturer's recommendations, the mechanized lift was designed only for stationary transfer from bed to wheelchair, wheelchair to bath, etc. and not to be used for translocation. Resident 1 fell in the hallway from the mechanized lift to the floor on his right shoulder when the sling gave way from the lift. The top of his head hit the metal chassis of the mechanized lift. Resident 1 sustained a 2.0 cm (centimeters) by 0.2 cm laceration on top of his head with some bleeding. Resident 1 also sustained injury with a bruise measuring 12 cm by 15 cm on his right shoulder, redness to the left collar bone measuring 1 cm by 0.2 cm and redness to neck area measuring 0.1 cm by 0.2 cm. The clinical record also revealed that while being assessed in the hallway of the unit after the fall, Resident 1 vomited a small amount of bile. Vomiting is a symptom of concussion. Resident 1 was transferred to the acute hospital for further evaluation and treatment. The resident received four staples to the laceration on his head. During interview on 11/14/13 at 10:15 AM, licensed staff stated that on the morning of 8/16/13 he was assisting Resident 1 with his personal grooming when he transported him by means of the mechanized lift from his bedroom to the bathroom. When asked the number of staff required to transfer Resident 1 licensed staff stated that he was not sure. He usually transferred him alone.A review of the Minimal Data Set (MDS- an assessment tool) on 11/13/13 and dated January 17, 2013, was conducted. It indicated Resident 1 required 2 plus persons to physically assist during transfer. When asked how residents requiring assistance with transfers are transported from one location on the unit to another, licensed staff stated it was by wheelchair and not on a mechanized lift with a sling. Licensed staff further acknowledged that the mechanized lift was only utilized in transferring residents from bed to wheelchair and vice versa. During interview on 11/15/13 with the Unit Supervisor, (US) she acknowledged that mechanized lifts are only used for transferring residents from bed to wheelchair or from wheelchair to bath. The US also acknowledged that the resident should not have been moved from the bed through the hallway to the bathroom in the mechanized lift. This was confirmed by review, on 11/15/13, of the manufacturer's recommendations that indicated that the mechanized lift must only be used for transfers from bed to wheelchair, wheelchair to bath, etc. and not used for translocation. The facility failed to ensure that Resident 1 was provided the correct assistive devices to prevent accidents when the resident, while being transported via a mechanized transfer lift instead of a wheelchair, fell from the sling, which gave way, resulting in a head laceration that required several staples to close the head wound. The facility failed to follow the plan of care for Resident 1 as stated in his assessment plan which indicated that the resident required a minimum of 2 plus staff to physically assist during transfers.The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170011345 |
A |
05-Aug-15 |
VVLF11 |
6347 |
T-22 76525 (a) (20) right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to recognize Client 1's known antecedent behaviors and intervene to prevent harm to Client 1. Client 1 was allowed to bang his head on a wall of his residence fracturing his neck and causing partial paralysis of his limbs. An unannounced visit was made to the facility on 3/4/15 to investigate an entity reported incident. Clinical record review on 3/4/15 revealed Client 1 had a well-known self-abusive behavior of banging his head on hard surfaces when he was upset or frustrated. This behavior was so extensive that an individual program plan objective had been developed on 5/30/14 as follows, "[Client 1] will decrease hitting his head (Against Hard Surfaces) 0 times for 5 consecutive months within a one year time frame by 5/30/15." Behavioral antecedents included: perservation (continual attention) on a calendar, loud vocalizations, hitting his hands hard and pacing rapidly. This objective specified when antecedent behaviors were present, staff were to calmly but firmly sign to him to stop and ask him to engage in alternate activities. If this was ineffective Client 1 was to be encouraged to go to a calmer environment and "engage in deep breathing or other relaxation activities." If this was also ineffective staff were to ask Client 1 to "focus on the following (this has been found effective), "[Client 1] focus on these thoughts i.e. Patience, Love, Joy, Happy, Good, Perfect, Peace, Mom, etc." This objective also included, "Five point Restraint/Mobile Restraint Chair - not to exceed 45 minutes per application." Client 1 had severe hearing loss and used sign language as his primary method of communication. On 3/4/15, review of the facility's general event report revealed that on 2/13/15, Client 1 had been agitated most of that morning. He had been pointing to the calendar and thought he was going on a home visit with his mother which was actually scheduled for the following day. Client 1 was still agitated when he left the dining room accompanied by Psychiatric Technician (PT 2) after lunch. He was making loud vocalizations and hit his hand on the wall of the hallway on his way to the group room. At approximately 12:58 PM he banged his head on the wall of the group room sustaining a laceration of his forehead and PT 2 assisted him to sit in a chair. Soon after he sat in the chair, it was documented that he slumped to one side and staff were unable to get a blood pressure reading so they called Code 77 (used to summon a medical emergency team which included physicians) at approximately 1:07 PM. Paramedics were called and they provided transportation to an outside acute care hospital, where it was determined he fractured C (cervical) 6 and C7. He also had a C1 fracture of indeterminate age and significant stenosis (narrowing of the spinal column) of C3, C4 and C5. He developed central cord syndrome (an incomplete spinal cord injury with arm and leg weakness). On 2/19/15, Client 1 underwent surgery that involved C3, C4, C5 and C6 laminectomy (removal of the back part of the spine) and mechanical fusion (vertebrae held together with metal components). He returned to his home facility on 2/25/15. On a transfer summary dated 2/27/15 a facility physician, specified Client 1 had "gross movement of his arms and flaccid paralysis [muscle weakness related to nerve damage] of his leg." It specified that he was to be transferred to a skilled nursing rehabilitation facility. During interview with MD 5 on 3/11/15 at 10:45 AM, he stated that it was determined that Client 1 could benefit from specialized physical rehabilitation. He was transferred to a rehabilitation facility on 2/27/15. He expired at that facility on 3/1/15 at 12:56 AM. On 3/5/15 at 10:35 AM during an interview with PT 2, he stated on 2/13/15 Client 1 had been agitated because he believed he was going on a home visit that day; however it was actually scheduled for the following day. PT 2 said, "I'm not an expert in sign language but I tried to tell him his visit was the following day." PT 2 said he also verbally stated "tomorrow" to Client 1. PT 2 said he wasn't sure if Client 1 could read lips, but stated, "I believe that he could read lips to a certain extent." PT 2 couldn't say for sure that Client 1 understood he was to go on his home visit the following day. PT 2 said he knew Client 1 was agitated that day so when he left the dining room after his lunch, he followed him and saw him hit the wall with his hand. When he reached the group room he was yelling and pacing. Client 1 had his back partially to the wall when he turned and ran his head into the wall. PT 2 said he went up behind him so he wouldn't fall backward and helped him to a chair. That is when he said Client 1, "held his head to one side and wasn't himself." PT 2 said he had seen Client 1 bang his head before but still, "was himself." He stated he had never seen Client 1 hit his head this hard, and this time he, "wasn't himself." PT 2 said he called for help and PT 3 responded and attempted to take Client 1's vital signs but, "she couldn't get a good blood pressure." PT 2 said they called an emergency code.On 5/4/15 at 11:32 AM, an additional interview was conducted with PT 2. PT 2 confirmed that he told Client 1 to "just calm down" and tried to communicate that he was to go on a home visit the following day. He stated that there was not a staff member working on the residence that day who was proficient enough in sign language to effectively communicate and ensure Client 1 knew his home visit was to be the following day.On 3/5/15 at 1:10 PM, during an interview with PT 3, she stated that she knew Client 1 was agitated because he kept pointing at the calendar that day. Pointing at the calendar was an antecedent for banging his head.Therefore the facility failed to recognize the client's known antecedent behaviors and intervene to prevent harm to Client 1. Client 1 was allowed to bang his head on a wall of his residence fracturing his neck and causing partial paralysis of his limbs. This violation presented either imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170011482 |
A |
14-Dec-15 |
LVFW11 |
12527 |
T-22 DIV 5 CH 8 ART 476525(a)(20) Clients' Rights (a) Each Client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights:(20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. Findings: The facility failed to ensure Client A remained free from harm when Client B took a butter knife from the dining room and stabbed Client A. Client A suffered pain and sustained multiple deep lacerations on the left side of his facial area, requiring sutures.An unannounced visit was made to the facility on 5/4/15 to investigate a complaint regarding an incident that occurred on 4/30/15 where Client B attacked and stabbed Client A. Client A suffered pain and multiple deep lacerations on the left side of his facial area.On 5/4/15 a review of Client A's clinical record was conducted. Client A was a 31 year old male admitted to the facility on 12/27/00 with diagnoses that included moderate intellectual disability, autistic disorder (a neurological and developmental disorder characterized by lack of social awareness, communication difficulties and restricted, repetitive behaviors). Client A had limited expressive vocabulary but could understand simple and familiar verbal requests and instructions. He also communicated through self-injurious behaviors and aggression toward others.Client A's Individual Program Plan (IPP) dated 3/25/15 indicated that he had general supervision on and off the residence. The IPP also indicated, "[Client A's name] has access to the following areas with staff supervision within the residence; group rooms, visitor room..." It was documented in the IPP that the IDT (Interdisciplinary Team) determined that he needed supervised access to all areas on campus and in the community due to behavioral barriers and lack of safety awareness. The Physician's Progress Notes dated 4/30/15 at 5:15 p.m., indicated that Client A was examined for lacerations to his left ear due to being stabbed with a butter knife by Client B. The community hospital consultation report dated 4/30/15 indicated Client A suffered a total of nine penetrating lacerations (three around the left ear, three on the left lateral cheek area, and three on the left side of the scalp) in addition to several superficial abrasions throughout the left side of the face and scalp. All nine penetrating wounds were approximately one centimeter in length and penetrated at least one to two centimeters deep with active bleeding and deep hematoma (bruise) collections. Client A required moderate sedation to repair the lacerations with the use of sutures. On 5/4/15 a review of Client B's clinical record was conducted. Client B was a 28 year old male admitted to the facility on 11/29/05 with diagnoses that included moderate intellectual disability, unspecified schizophrenia ( a brain disorder in which people interpret reality abnormally), aggression by harming self and others. He has good expressive and receptive communication skills, and is able to make his wants and needs known verbally.Client B's IPP dated 10/4/12 indicated he had open behavior plans for hitting others, throwing/banging/slamming objects, statements of suicidal ideations, statements regarding experiencing auditory hallucinations, and making sexually inappropriate statements. Client B was receiving therapy and pharmacological treatment. He has a long history of unsafe and aggressive behavior towards self and a history of using objects as weapons. His IPP dated 10/4/12, 10/3/13, and 10/9/14 indicated that he had general supervision in all settings; which was defined as "Clients with general supervision have assigned staff who maintain a visual observation or make periodic checks/contacts in order to provide assistance or guidance, as needed, while individual engages in day activities."Client B's IPP also indicated that although he had general supervision, the IDT agreed and documented that he was not safe to have independent access on or off of the facility grounds, due to stress factors that could impact safety awareness and the risk of self-injurious behaviors.On 5/4/15 at 11:30 a.m., a review of the facility's "Management Summary - General Event Report (GER) by Event Date" was conducted. The review indicated that Client B had been involved in multiple aggressive behaviors against his peers from 11/25/14 through 4/30/15. There were seven incidents documented where Client B was the aggressor and one incident where on 12/23/14, Client B claimed he had stabbed Client A, which the facility determined was a false claim, as there was no evidence this had occurred.On 5/4/15 at 10:49 a.m., an interview with the DOD (Director of Dietetics) was conducted. She stated that there was no specific policy on silverware prior to the incident. She stated that bread knives in the dining room were made out of metal and that plastic ware was only used on "to go" containers for clients unable to eat in the dining room. She stated that the dining room area is always open and clients can access it 24 hours a day.On 5/4/15 at 12:05 p.m., an observation was conducted in the dining room of Residence 21. The dining room was observed with two doors in the front that were open. There was a silver table that had silverware (forks, spoons, and butter knives) in a caddy on top of the table.On 5/4/15 at 12:27 p.m., an interview with SPT 1 (Senior Psychiatric Technician 1) was conducted. SPT 1 stated she was working as an acting supervisor on 4/30/15 in Residence 21. She stated PT 3 told her Client B stabbed Client A about eight times while in the group room and there were no witnesses to the incident. SPT 1 interviewed Client B who told her that he walked in to the dining room area when he came back from school and saw Client A in the group room. Client B grabbed the butter knife from the dining room area at approximately 2:45 p.m. and walked back in to the group room where he stabbed Client A. Client B told SPT 1 he did not like Client A, and that was why he stabbed him. SPT 1 stated Client B hears voices and has a history of aggression, hitting people, and throwing furniture.During a follow-up interview with SPT 1 on 5/18/15 at 2:45 p.m., she stated Client B had an incident in the classroom on 4/30/15 prior to stabbing Client A. Client B was upset and walked out of the classroom because he wanted to see a female client's feet. Client B was brought back to Residence 21. Although he was presenting an unusual behavior at that time, his level of supervision remained the same.On 5/4/15 at 12:55 p.m., an interview with SPT 2 (Senior Psychiatric Technician 2) was conducted. He stated that he brought Client B back inside the Residence at around 2:30 p.m. Client B went inside his room in a calm, but talkative manner. SPT 2 went inside the nurse's station at 2:40 p.m. He stated a change of shift began between 2:40 p.m. and 2:45 p.m. Staff would be in a huddle (meeting) and that the huddle ended at around 3:05 p.m. He stated that Client B could have had the opportunity to obtain the silverware (knife) at that time. He stated that all doors to the dining room are open all the time. He also stated that both Clients A and B were on general supervision; where staff needed to know where the clients were all the time and a visual check was performed every 30 minutes. He stated that no clients are allowed to have a knife in their possession or in their bedroom. SPT 2 stated that he heard a yell and responded in the group room. He saw two staff (PT 2 and PT 3) inside the group room. He instructed the staff to stay with Client A so he could notify others. He walked passed Client B's room at around 3:15 p.m. and observed him standing inside his room. Client B told him, "I did it." He walked inside the room and asked Client B, "Did what?" Client B replied, "I stabbed Bubba." SPT 2 stated that he saw a butter knife with a streak of blood on top of the bed inside Client B's room. He then directed PT 2 to stay with Client B.During a follow-up interview with the SPT 2 on 5/18/15 at 7:42 p.m.,He stated that he was not aware Client A was on the unit and he did not know which staff was watching him at that time. He stated that he knew Client B had walked out of the classroom, but was not aware of the reason why. He stated the staff from the classroom did not notify him that Client B was upset when he left the classroom.SPT 2 was asked if the staff was supposed to report the prior incident in the classroom, before Client B returned to the Residence, he stated, "It should have been reported." When SPT 2 was asked if he would have known about the incident, would he have placed Client B on increased or enhanced supervision? SPT 2 stated, "I'll make sure that there's staff around him, if it was communicated to me. Even if he goes in his room, he'll have somebody to frequently check on him, that's his support."On 5/5/15 at 11:40 a.m., an interview was conducted with the RP (Residence Psychologist), who has treated Client B since 2015. She stated that Client B has schizophrenia with mood disorder. He has delusions, paranoia, and auditory hallucinations, telling him to hurt people. Pharmacological treatment and behavioral counseling have been provided to Client B. She also stated that he has a history of aggressions.On 5/5/15 at 12:40 p.m., an interview with Client B was conducted. He stated that he stabbed Client A eight times on the left ear area. He stated, "I wanted to kill him, but like him." He stated that he was in his room and went to the dining room where he passed by Client A in the group room. He grabbed a knife that was on the table next to the door, placed it inside his pocket, and proceeded to the group room where Client A was sitting and listening to his music. He stated that he started stabbing Client A on the left side of his ear area. He stated that Client A defended himself by blocking the attack, but he was still able to stab him. He stated that no one, either staff or other clients, saw him go to the dining room and go back to the group room to stab Client A. He stated that he went back to his room after he stabbed Client A and stood inside his room. Client B also stated that he was arrested before by the local police department for possession of a knife because he wanted to stab someone, while residing in East Los Angeles.On 5/6/15 at 9:36 a.m., an interview with PT 2 (Psychiatric Technician 2) was conducted. She stated that she was in the nurse's station at 2:30 p.m. on 4/30/15 for the huddle. After the huddle at around 3:05 p.m., she walked with PT 3 to the group area. When they got there, she saw Client A banging his head on the arm rest with blood coming from the left side of his head. She yelled for help and SPT 2 and PT 1 responded. She stated that when she was in the group area, there was no one there, except Client A. Both she and PT 3 started assessing and treating Client A. She observed several cuts located on the left side of Client A's head and thought that it was from banging his head.On 5/18/15 at 5:10 p.m., a review of the facility's P&P (Policy and Procedure) titled "Reporting Alleged Mistreatment of Clients", with a revised date of 2/21/14 was conducted. The review indicated, "Policy - The fundamental responsibility of every employee is to ensure the safety and well-being of individuals who live at the Center. Any form of neglect or abuse is expressly prohibited...1. Definitions:...1.8 Neglect - The negligent failure of any person having the care or custody of an elder or dependent adult to exercise the degree of care that reasonable person in a like position would exercise, treatment or maltreatment of a person, which indicates harm or threatened harm to an individual's health or welfare, failure to provide goods or services necessary to avoid physical or psychological harm..." Therefore the facility failed to prevent harm to Client A when Client B took a butter knife from the dining room and used it to stab Client A multiple times in the face while he sat in a group room. Client A sustained nine deep lacerations to his face resulting in pain and required sutures.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. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170011537 |
A |
30-Sep-15 |
QC0D11 |
7876 |
REGULATION VIOLATION:483.420(d)(1) (d) Standard: Staff treatment of clients.W149 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.The facility violated the above mentioned regulations when it failed to maintain the safety of one of five clients being transported to school (Client 1) when he jumped over the seat of the van in which he was riding and exited via the rear door as the van was still moving and sustained injuries. Client 1 was to have had one to one supervision anytime he was being trans located off of his residence. This failure meant Client 1 was not being closely monitored and sustained a head injury and a laceration to the back of his head, as well as bruising and abrasions and had the potential for Client 1 to have sustained more serious injuries and even death. Findings: Client 1 is a 19 year old male. Client 1 was admitted to the facility with diagnoses including Impulse Control Disorder, Post-Traumatic Stress Disorder, Mild Intellectual Disability (IQ of 50-70), Bipolar I Disorder, and Autism.An abbreviated survey to investigate an Entity Reported Incident was initiated on 3/2/2015, at 10:40 AM. The facility reported Client 1 was being transported to school the morning of 2/3/2015. The initial report stated Client 1 was engaging in self-injurious behavior and had sustained a laceration to the back of the head and an abrasion to his lower back. He was transported to a local hospital.A review of the General Event Reports involving Client 1 on 2/2/015 was reviewed. The injury summary is as follows: (Client 1) became upset when riding in the van on the way to school, a peer (Client 2) became upset and broke out a window of the van. (Client 1) unbuckled his seatbelt, jumped over the seat to the back of the van, jumped out of the moving van hitting the ground. (Client 1) sustained injury to the back of his head with a moderate amount of bleeding of a lacerated area and his right hip/back area has a significant abrasion with bleeding. At the hospital, Client 1 received six staples to the laceration on his head. Review on 3/2/2015 revealed Senior Psychiatric Technician (SPT) 1 and Psychiatric Technician (PT) 1 were in the van with Client 1 at 9 AM in route to school. SPT 1 was driving the van and PT 1 was sitting next to Client 1 in the van. Client 2 was sitting directly in front of PT 1 next to the sliding door of the van. PT 1 was trying to redirect Client 2 when he kicked out the window. This is when Client 1 removed his seatbelt, jumped over the seat and exited the moving van. When the van stopped, PT 1 exited the van and stayed with Client 1 until help arrived. Chief of Plant operations was driving behind the van and called for assistance. PT 2 was walking to the school with clients when the event occurred and witnessed it.During continued review of the GER, Physician 1 arrived on scene at 9:16 AM and noted abrasions to the back and a laceration to Client 1's head. He was transported to a local hospital via ambulance and paramedics for further evaluation. Client 1 received six staples to the laceration on the back of his head. A review of Client 1's clinical record was conducted on 3/2/2015. A late Interdisciplinary note (IDN) for 2/3/2015, at 3:40 PM, PT 1 documented Client 1 was attempting to jump over the seat in the van. PT 1 tried to stop Client 1, but he made it over and opened and exited out of the van which was travelling between 10-15 miles per hour.A review of Client 1's Individual Program Plan (IPP) narrative was conducted on 3/2/2015. An IPP Annual Conference conducted on 10/30/2014 revealed the Interdisciplinary Team (IDT) agreed with the following level of supervision for Client 1: "...Off Residence (on campus) 1:1 (one staff member to one client)." Under the heading of, "Access/Safety Awareness", it is documented, "(Client 1) has the opportunity to access campus and community with supervision (1:1 due to high Absent Without Leave (AWOL)."During further review of Client 1's Individual Program Plan (IPP) challenging behaviors for Client 1 included attempts/actual jumping on cars and attempts to AWOL. A milestone for Client 1is noted will stay with the group during translocation to any destination on or off campus.Situational antecedents for some of Client 1's behaviors were identified such as being exposed to an anxiety arousing situation, when he is trans locating/transitioning from one location to another, and when Client 1 is exposed to an over stimulating environment (e.g. peer agitation,...).A review of the Office of Protective Services (OPS) report dated 3/11/2015 was conducted. Background information lists Client 1 as being on 1:1 supervision while off of the residence.An interview was conducted with the Unit Supervisor (US) 1 on 6/3/2015, at 12:05 PM. The US 1 was asked what she recalled about the incident involving Client 1 on 2/3/2015. She stated 4 or 5 clients were in the van including Clients 1 and 2, and they were on their way to their school program. Client 2 was calm at that time, but when he gets into the van Client 2 often gets agitated. She stated she responded when emergency assistance was requested. She stated, "The 2 (Client's 1 and 2) have a history of causing agitation for each other." An interview with SPT 1 was conducted on 6/3/2015, at 12:25 PM. SPT 1 stated that he was driving the van. SPT 1 stated Client 2 was agitated when he entered the van and sat just inside the door. He stated the incident of Client 2 kicking out the door window and Client 1 climbing over the seat and going out the back door happened very fast.An interview with PT 1 was conducted on 6/9/2015, at 10:36 AM. She was asked about the incident involving Client's 1 and 2 on the morning of 2/3/2015. She stated she was in the van to take clients to school. She was in the van sitting next to Client 1. Client 2 entered the van and was at first calm. As they left the unit, Client 2 began to get agitated. PT 1 and SPT 1 were trying to keep Client 2 calm, but once they were on Shelley Circle Client 2 kicked out the window on the sliding door. SPT 1 and PT 1 were trying to keep Client 2 safe when Client 1 went over the back seat and out the back of the moving van. PT 1 was asked what level of supervision Client 1 was on at the time of the incident. PT 1 stated, "He was on enhanced supervision at that time." A review of the facility's policy manual in regards to Client's Safety, 5.5, undated, One to One supervision is described as, "The staff person assigned to provide one to one supervision is expected to be physically with the client at all times...redirect appropriately to avoid injury and intervene immediately to protect the client from harm to self or others." A review of the facility's policy for Reporting Alleged Mistreatment of Clients, number 1-06-01, undated, under the heading 1.8 Neglect states: "The negligent failure of any person having the care or custody of an elder or a dependent adult to exercise that degree of care that reasonable person in a like position would exercise,...failure to provide goods or services necessary to avoid physical or psychological harm." Therefore the facility failed to maintain the safety of one of five clients being transported to school (Client 1) when he jumped over the seat of a van and exited via the rear door as the van was still moving. The facility failed to closely monitor and supervise Client 1 while being transported leading to the Client sustaining severe head injury and laceration to the back of his head as well as abrasions to his back and neck area. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170011538 |
B |
12-Nov-15 |
PVEX11 |
6088 |
REGULATION VIOLATION T-22 76345(a)(5)(A) Support Services - Nursing Services Facilities shall provide nursing services in accordance with the needs of the clients for the purpose of: Control of communicable diseases and infections through: Identification and assessment. The facility failed to identify and treat an abscess to Client 1's buttock until it had become large. Client 1 required transfer to the acute care unit and intravenous antibiotics to treat the abscess.Findings: During an investigation of an entity reported incident conducted on 3/26/2015, the General Event Reports (GER) for 8/23/2014 was reviewed. It was submitted by Physician 1 and detailed his concerns about a "huge red mass on (Client 1's) (l) (left) buttock." Physician 1 assessed Client 1 after he was called to evaluate the mass that had been observed by Psychiatric Technician (PT) 1. Physician 1 assessed the client along with the Health Services Specialist (HSS) 1. The mass was oval in shape and measured 6 cm by 9 cm. The center of the mass was 4 cm by 6 cm with an intact center measuring 1 cm round and the skin was intact. The mass was swollen, warm and tender to touch. Client 1 had a temperature of 101.3 Fahrenheit.The diagnosis of cellulitis/abscess was made. During further review of the GER, HSS 1 documented Client 1 was transferred to Residence 209 for "IV (intravenous) antibiotic tx." During further review of the GER, Physician 1 documented "The lesion is located on the L (left) buttock within the diaper area. Also noted a diaper rash on the groins." Temperature at that time was 100.4 F. During a review of the GER, the Program Assistant documented Physician 1 directed Senior Psychiatric Technician (SPT) 1 to initiate a GER for neglect. SPT 1 informed Physician 1 that he had to initiate the GER per facility policy.During a review of Client 1's clinical record, conducted on 3/27/2015, the interdisciplinary notes indicated Client 1 is able to participate in activities of daily living (ADLs) but needs assistance. An interdisciplinary note, dated 8/23/14, at 8:15 AM documented Client 1 was being assisted to the bathroom by PT 2 to change his wet pants. PT 2 observed a "round redness with pimple like on the center to his (left) hip/buttock area."The Approaches and Strategies for Client 1 requires supervised access on the residence: includes "bathtub rooms." Client 1 needs general supervision during bathing as well as assistance in all areas of the bathing process." A review of the facility's Nursing Procedure Number: 7.01, Bathing, Various, dated revised, 09/12, under section IV Shower, number 8 states, "...Observe skin condition and color during cleaning to assess skin integrity." On 5/12/15 during a review of the Office of Protective Services (OPS) report, dated 12/23/2014, staff member PT 3 admitted he did not conduct a head to toe body assessment when assisting Client 1 with his shower on 8/22/2014. During an interview, conducted on 5/12/2015, at 2:45 PM, Psychiatric Technician Assistant (PTA) 1 was asked about observing skin condition of clients during showers. PTA 1 stated, skin checks "should be done every shift." PTA 1 further stated, "if the client is dependent (on staff assistance) for ADL's, it should be more thorough." An interview, conducted on 5/13/2015, at 9:45 AM, with Physician 1, he was asked what he could recall from Client 1's case. Physician 1 stated, "He (Client 1) had a large cellulitis on his buttocks." Physician 1 stated it would take about a week to develop an abscess of that size. Physician 1 was then asked if the area was in a location that would be hard to see and he stated, "No! It was easy to see the area." He also stated he "relies heavily on staff to monitor this kind of thing." He stated, "They should have seen it sooner." An interview, conducted on 5/13/2015, at 11:25 AM, with PT 2, she was asked about what she observed on 8/23/2014 with Client 1. She stated, "Early in the day he needed to be cleaned and was taken to the shower." She stated she observed the area of redness and reported it. She was asked if the area of redness was in an area that would be difficult to see. PT 2 stated, "No, it was very easy to see and very large." PT 2 was then asked about what the facility policy stated about observing skin condition of clients and she stated, "We must always observe skin condition of clients and report any changes." An interview was conducted on 5/19/2015, at 12:10 PM with PT 3. He was asked if he remembered assisting Client 1 with a shower on the evening of 8/22/2014. He stated "Yes" he did assist with Client 1's shower that evening. PT 3 was asked if Client 1 needed any assistance with bathing/showering. He stated that Client 1 only needed stand by assistance. He was then asked if he noticed any changes in Client 1's skin condition and he stated "No. I saw nothing." During a review of interdisciplinary notes, dated 8/23/2014, at 12 PM, Client 1 arrived at the facility's acute care unit at 10:43 AM. Physician 1 gave orders for Client 1 to have an intravenous line started and saline lock. It is documented that Client 1 was trying to pull out the intravenous line. Physician 1 gave orders for four point soft restraints to be used to prevent Client 1 from removing the line. Client 1 was also placed on 1:1 supervision for safety.During a review of physician progress notes, a note dated 8/27/2014 reflects results of a blood culture as being positive for Staph beta hemolytic, indicating Client 1's infection may have spread from the buttock location into the blood stream, a condition called sepsis which can be life threatening. Client 1 was on the acute care unit for five days with soft restraints ordered to prevent him from pulling out his intravenous line. The result was the facility failed to identify and treat an abscess to Client 1's buttock until it had become large. Client 1 required transfer to the acute care unit and intravenous antibiotics to treat the abscess. This violation had a direct or immediate relationship to the health, safety, and security of the patient. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170012215 |
A |
2-Sep-16 |
WKOB11 |
8114 |
REGULATION VIOLATION: 76525. Clients' Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect Based on observation, interview, and record review, the facility failed to protect Client 1 from harm when he was bitten by his roommate, (Client 2). This failure to ensure Client 1 was protected resulted in Client 1 sustaining a 4 centimeter (cm) by 4cm bite with skin missing and the possible need for a skin graft. Client 1 is a 36 year old male who was admitted to the facility on 12/10/1996. Client 1 is non-verbal and communicates his needs using a communication book. Client 1 has diagnoses including profound intellectual disability and impulse control disorder. On 4/4/16 a review of the General Event Report (GER) was conducted and indicated that on 2/23/16 at 10:50 PM; staff members were doing final rounds for the evening shift. Psychiatric Technician (PT) 1 entered Client 1's room with Senior Psychiatric Technician (SPT) 1 from the oncoming night shift. PT 1 observed Client 1, "lying in bed with a fresh bite to (Client 1's) right forearm 4 cm X 4 cm. Small amount of blood on his (Client 1's) shirt and a couple of drops on the floor." Client 2, who was Client 1's roommate was observed by PT 1 sitting up in bed staring at staff. There were no other clients in the room. Client 1 appeared to be sleeping, not crying or in any distress. During continued review of the GER, it indicated Client 1 was on generalized level of supervision which is defined as being checked every 15 minutes. The last time Client 1 was documented as being seen was at 10:30 PM by Psychiatric Technician Aid (PTA) 1 and Client 1 was free of injury at that time. Client 2 is a 30 year old male who was admitted to the facility on 11/30/11. Client 2 is also non-verbal and communicates his needs using facial expression and a communication book. Client 2's diagnoses include severe intellectual disability. Client 2 has an open behavior plan (a plan to replace maladaptive behaviors with appropriate ones) in his Individual Program Plan (IPP) for biting others. Further review of the GER indicated the physician (Physician 1) on call was notified of the injury and assessed both Client 1 and Client 2. Physician 1 assessed Client 1 and ordered him to be sent to the local acute hospital for further evaluation. Physician 1's report included in the GER stated, "(Client 1) had a 4X4 CM patch of skin missing from his right inner forearm. Underlying tissue exposed. (Client 1) unresponsive to questioning... (Client 1) sent to emergency room. Etiology unknown. Could have been caused by a human bite." Review of the clinical record for Client 1 was conducted on 4/5/16. A physician's progress note for 2/24/16 indicated Client 1 was bitten by a peer to his right forearm with loss of tissue to the fascia (a thin sheath of fibrous tissue enclosing a muscle or other organ). Upon return from the acute care hospital on 2/24/16, Client 1 was placed on the facility's acute care unit. Review of the acute care clinical record for Client 1 was conducted. The Emergency Department history and physical, dated 2/24/2016 at 1:18 am, indicated, "Right medial (side closest to the body) forearm 6 cm (centimeter) round skin and subq (subcutaneous) fat missing consistent with human bite." A nurse's note, dated 2/24/2016 at 2:04 am, indicated, "Wound is located on RFA (right forearm) and is down to muscle." Review of the clinical record for Client 2 was conducted on 4/5/16. In the Interdisciplinary Notes (IDN) it was documented Client (2) bit Client (1). IPP objectives are noted for actual and attempted behavior of biting others. At least two other instances of biting others is documented in the clinical record over the past 6 months for Client 2. An observation of Client 1 on the facility's acute care unit was conducted on 4/6/16 at 8:30 AM. Physician 2 and staff were present and photos of the wound were taken. It was 43 days since the injury. Client 1 had a 1:1 sitter at bedside. The old dressing was removed and Client 1 was trying to touch the wound. The wound was smaller, around 2X3 cm with the skin still missing. Physician 2 stated in a concurrent interview that the wound was being treated as a full thickness pressure ulcer and was healing well. Physician 2 also stated when Client 1 was in the emergency room, the physician there was considering a skin graft since the wound was so deep. An interview was conducted with the Unit Supervisor (US) 1 on 4/6/16 at 10:15 AM. US 1 stated he was covering for the residence's usual US, US 2 at the time of the incident. US 1 stated at the time of the incident, no one saw or heard anything. The injury was found during change of shift rounds. US 1 stated Client 1 was on general supervision and verified this means the client must be observed every 15 minutes. US 1 verified 20 minutes had passed between 10:30 pm and 10:50 pm when staff did shift rounds and visually observed Client 1 with the bite. An observation was conducted of Client 1 and Client 2's shared bedroom on 4/6/16 at 11:15 AM. There were two beds in the room separated by 2 large closet cabinets and lockers. There are low walls between the client rooms adjacent to Client 1's room. Client 1 was in the first bed by the door and Client 2 was on the other side of the closets and lockers. A concurrent interview was conducted with US 2 while on the residence. US 2 states there is staff in the room next to Client 1's room on the evening and night shifts to hear anything unusual that happens on that wing of the unit unless they are providing care. A telephonic interview was conducted on 4/13/16 at 1:30 PM with the investigator from the Office of Protective Services (OPS) for the facility. The investigator was asked if any photos of the wound were taken and he stated after Client 1 returned from the hospital they were taken, but there was a dressing on the site. The investigator was asked if he knew the dimensions of the wound and he stated 4 x 4cm but no measurement of the depth was taken. The investigator stated Physician 1 was in a sleeping room right across from Client 1's room and he responded immediately. Physician 1 assessed both Client 1 and Client 2. There was no injury to Client 2's mouth or trace tissue or blood. The investigator then stated he checked the shared room and found a smear of blood on the blanket on Client 2's bed near his head. An interview was conducted with US 2 on 5/4/16 at 11:45 PM. US 2 was asked if Client 2 has always had the behavior of biting others. US 2 stated yes, but the type of biting Client 2 engaged in was usually directed toward staff, not toward other clients. US 2 was asked when Client 1 and Client 2 were placed as roommates. US 2 stated she started on the unit in 2014 and they had been roommates since at least that time. US 2 was asked if she thought it was acceptable to have a non-verbal client in with a known biter and US 2 stated Client 2 is usually only aggressive towards staff. US 2 was asked when Client 1 returned to his regular residence and she stated it was 4/20/16 and Client 1 was having a difficult time adjusting to life back on the residence. Therefore, the facility failed to protect Client 1 from actual harm when he was bitten by his roommate who had known behaviors of biting others. This facility failure resulted in Client 1 sustaining a 4 cm by 4 cm bite (skin missing to the fascia) and an acute care hospital visit for treatment with the possibility of developing an infection and a skin graft. Client 1 was also removed from his usual routine at his residence for nearly 2 months. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170012246 |
B |
03-Jun-16 |
CP0N11 |
3661 |
REGULATION VIOLATION: W149 483.420 Condition of participation: Client Protections. (a) Standard: Protection of clients' rights. The facility must ensure the rights of all clients. Therefore, the facility must-... (d) Standard: Staff treatment of clients. (1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. (i) Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment The facility failed to protect Client 1 from abuse when it was reported that a staff member, Psychiatric Technician Aid (PTA 1), was observed slapping and kicking Client 1 on the night shift. This failure had the potential to cause Client 1 emotional anguish, increased inappropriate behavior, and humiliation. FINDINGS: Client 1 is a 42 year old male who was admitted to the facility on XXXXXXX, with diagnoses including moderate intellectual disability, anxiety disorder, and autistic disorder. An unannounced visit was made on 10/14/15 to investigate an allegation by PT1. PT 1 had observed the abuse of Client 1 on 8/30/2015 by PTA 1. The allegation was reported to the Unit Supervisor (US) on 9/1/2015 at 2:50 PM. The US then reported the allegation of abuse to the operator for the facility. A review of the General Event Report (GER), dated 9/1/15, indicated PT1 had observed PTA1 being rough with Client 1 and slapping him. PT1 reported that on 8/30/2015 Client 1 was having behavior issues. PTA1 slapped Iso Gel (an alcohol based hand rub used for hand hygiene) on Client 1's face and then slapped him. When this incident was reported to the US by PT1, the US told PT1 this was abuse and PT1 had failed to report it. PT1 was removed from client contact. PTA 1 was also removed from client contact. An interview with the Unit Supervisor (US) was conducted on 11/9/2015 at 1:10 PM. The US stated she received a telephone call from PT1 on 9/1/2015 in the afternoon. The US stated PT1 asked her if she was aware of what was going on during the night shift. US stated PT1 told her Client 1 PTA1 was slapping Client 1's face with Iso gel, then took Client 1's shirt and wiped it off. The US asked PT1 to write up a statement about the incident and that was when the US found out PTA1 had also kicked Client 1. PT1 stated PT2 was present and observed what occurred. PT2 and PTA1 were interviewed by the US and denied any abuse occurred. A written statement by PT1 was reviewed, dated 9/2/15, regarding the night shift ending 8/30/15. Client 1 was having behavior issues and staff was trying to calm him down. PTA1 put on an exam glove and put Iso gel all over Client 1's face and then slapped Client 1 on the cheeks and yelled at him, "Is that what you want?" Client 1 yelled, "No!' while PTA 1 was wiping Client 1's face with his shirt. Client 1 was crawling on the floor and tried to hit PTA1 and PTA1 kicked Client 1 in the upper thigh. PT2 was present and gestured at PTA1 to stop what he was doing. An interview was conducted on 1/28/2015 at 11:40 AM with PT1. PT1 was asked about the events that occurred on the night shift from 8/29 into 8/30/2015. PT1 stated the incident occurred on the night shift that began on 8/29/2015 and ended on the morning of 8/30/2015. PT1 also stated she reported the incident to the US on 9/1/2015 and she was aware this was considered late reporting. Therefore, the facility failed to protect Client 1 from abuse. This failure had the potential to cause Client 1 emotional anguish, increased inappropriate behavior, and humiliation. This abuse had a direct or immediate relationship to the health, safety, or security of clients. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170012247 |
A |
03-Jun-16 |
ZGOD11 |
7434 |
REGULATION VIOLATION: F411 483.420 Condition of participation: Client protections (a) Standard: Protection of clients' rights. The facility must ensure the rights of all clients. Therefore, the facility must-... (d) Standard: Staff treatment of clients. (1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. (i) Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment FINDINGS: The facility failed to protect Client 1 from potential serious harm when the client, who had known pica (ingestion of inedible items) behavior, was in the possession of and ingested sewing needles. Client 1 had to be taken to the acute care hospital for an endoscopy (a tube is passed into the stomach through the mouth and visualization, photos, and removal of objects can be done) procedure, performed under sedation. Not all of the needle pieces were able to be removed. Client 1 was admitted on XXXXXXX with diagnoses that included mild intellectual disability, Bipolar Disorder, and Dysthymic Disorder (a form of depression) Childhood onset type. Client 1 also had other known behavioral issues including engaging in pica. On 2/9/2016, a review of the General Event Report (GER-the facility investigative report), dated 1/31/16, related to an incidence of pica behavior for Client 1 was conducted. On 1/31/2016 during the early morning, Client 1 woke up and asked Psychiatric Technician Aid (PTA) 1 to turn off the television. PTA 1 was providing 1:1 supervision for Client 1 per her program plan. At that time PTA 2 entered the room to provide PTA 1 a restroom break. When PTA 1 returned, Client 1 was looking for a movie she wanted to watch because she could not sleep. The movie was selected and PTA 2 left the room. Client 1 asked to use the restroom. PTA 1 took Client 1 to the restroom and stayed with her. After returning to the room, Client 1 sat down and started to drink a soda from a can she had in her room, then Client 1 started to cough. Client 1 told PTA 1 she was okay. Client 1 asked to speak to PTA 2. PTA 2 entered the room and Client 1 started crying and told PTA 2, "I just swallowed a needle." PTA 1 asked Client 1 when she swallowed the needle and Client 1 replied, "Just right now." The Charge person was notified of the incident at 2:20 AM. Further review of the GER indicated the Health Services Specialist and Physician on duty were notified and assessed Client 1. An x-ray of Client 1's abdomen was completed and indicated long, slim objects in the abdomen. Client 1 was transferred to a local acute hospital where an endoscopy (visualization via a tube through the mouth and into the stomach-items and biopsies can also be completed) was performed. Five pieces of metal were removed, but two could not be removed. It appeared several of the needles Client 1 ingested were broken pieces, but some were whole. A review of the clinical record was conducted for Client 1. In the Individual Program Plan (IPP) for Client 1, dated 8/13/2015, baseline/current status information in regards to pica behavior indicated Client 1 has had seven attempts to ingest inedible items and eight actual ingestions of inedible objects from January 2015 to January 2016. During continued review of the clinical record, a Special Conference was held on 1/19/16 in regards to an incident earlier in the month where Client 1 physically assaulted a staff member. Client 1's level of supervision was revised to 1:1 supervision during waking hours and 2:1 supervision during the night shift. Another Special Conference was held on 1/26/16 indicated under the recap of the Interdisciplinary (ID) team discussion that the level of supervision will remain unchanged. An interview was conducted on 2/10/2016 at 7:30 AM with the Unit Supervisor (US). The US was asked about Client 1's rights at the time of the occurrence. The US stated Client 1 is very aggressive and was moved to a wing of the residence by herself. After she was moved, Client 1 was allowed to have her personal possessions back. Client 1 had previously had a Denial of Rights for her pica behaviors. The US was asked about the needles and how Client 1 was in possession of them. The US stated she was unable to determine how Client 1 obtained them. Client 1 had told the US she bought them from the store. A photograph of the slim container that the needles had been in was observed. It was a round plastic container Client 1 had in with her DVD's and PTA 2 found more needles in the drawer. An interview was conducted with PTA 1 on 2/10/2016 at 7:55 AM. PTA 1 stated she had worked with Client 1 before the incident. When PTA 1 arrived to provide 1:1 care for Client 1 at 10:45 PM, on 1/30/16, Client 1 was watching a movie in her room. At 1:30 AM on 1/31/16, Client 1 asked PTA 1 to turn off her television. PTA 2 came in after that to provide PTA 1 a break. When PTA 1 returned, Client 1 was looking at her DVD's for a movie to watch. Client 1 asked to use the restroom and PT1 took Client 1 to the restroom and stayed in the room with her, per Client 1's program plan. On returning to the room, Client 1 drank some soda from a can and coughed a little. Client 1 wanted to speak to PTA 2 so PTA 1 asked him to return to the room. Client 1 told PTA 2 about the needles she had swallowed. PTA 1 had no idea how Client 1 obtained the needles and stated she must have had them in her hand when she drank the soda. An interview was conducted on 2/10/2016 at 8:15 AM with PTA 2. He was asked what he remembered about the occurrence. PTA 2 stated he relieved PTA 1 for a break. PTA 2 does not recall when, but does remember being asked to return to the room to talk to Client 1. Client 1 told PT2 she swallowed a needle. PT2 was not clear about when Client 1 swallowed the needles but believes the needles were in the drawer containing the DVD's. A review of the facility's policy regarding Client's Safety 5.5, Supervision of Clients, 5.5.3, dated 11/11, and was conducted on 2/10/2016. The policy stated the staff person assigned to provide one to one supervision is expected to be physically present with the client at all times. Staff will encourage and assist the client to participate in their planned activities, redirect appropriately to avoid injury, and intervene immediately to protect the client from harm to self or others. An interview was conducted with Client 1's Individual Program Coordinator (IPC) on 5/ 12 /16 at 2 pm. The IPC was asked what Client 1's milestones for pica behavior were at the time of the incident. The IPC stated Client 1 had 2 milestones in place at that time-B-1-3 was for attempted ingestion of inedible items and B-1-4 was for actual ingestion of inedible items. The IPC was asked about antecedent behaviors for pica behavior and the IPC verified one of Client 1's behaviors is being unable to sleep. Therefore, the facility's failure to maintain Client 1's stated supervision level resulted in Client 1 engaging in the pica behavior of swallowing needles and not ensuring Client 1 did not incur injury and potential serious harm. Client 1 had to undergo an endoscopy with sedation for removal of some but not all of the needle pieces were removed. This facility failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 170001769 |
FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD |
170012305 |
B |
03-Jun-16 |
CP0N11 |
3695 |
REGULATION VIOLATION: H & S 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to immediately report an observation of abuse to Client 1 when Psychiatric Technician Aid (PTA 1) was observed slapping and kicking Client 1 on the night shift. The facility staff who observed this abuse failed to report this abuse to the State Agency immediately or within 24 hours. This failure caused a delay in investigation and had the potential for further abuse of clients. FINDINGS: Client 1 is a 42 year old male who was admitted to the facility on XXXXXXX, with diagnoses including moderate intellectual disability, anxiety disorder, and autistic disorder. An unannounced visit was made on 10/14/15 to investigate an allegation of abuse made by Psychiatric Technician (PT) 1. PT 1 reported that a staff member of the facility, Psychiatric Technician Aide 1 (PTA 1) was observed abusing Client 1 on 8/29 to 8/30/2015 during the night shift. The allegation was reported to the Unit Supervisor (US) on 9/1/2015 at 2:50 PM. The US then reported the allegation of abuse to the operator for the facility. The facility reported the abuse to California Department of Public Health on 9/2/2015 at 1:50 PM A review of the General Event Report (GER), dated 9/1/15, indicated PT1 had observed PTA1 being rough with Client 1 and slapping him. PT1 reported that on 8/30/2015 Client 1 was having behavior issues. PTA1 slapped Iso Gel (an alcohol based hand rub used for hand hygiene) on Client 1's face and then slapped him. When this incident was reported to the US by PT1, the US told PT1 this was abuse and PT1 had failed to report it immediately. On 9/1/15 PT1 was removed from client contact. PTA 1 was also removed from client contact. An interview with the Unit Supervisor (US) was conducted on 11/9/2015 at 1:10 PM. The US stated she received a telephone call from PT1 on 9/1/2015 in the afternoon. The US stated PT1 asked her if she was aware of what was going on during the night shift. US stated PT1 told her PTA1 was slapping Client 1's face with Iso gel, then took Client 1's shirt and wiped it off. The US asked PT1 to write up a statement about the incident and that was when the US found out PTA1 had also kicked Client 1. PT1 also stated PT2 was present and observed what occurred. PT2 and PTA1 denied any abuse occurred when they were interviewed by the US. A written statement by PT1 was reviewed. According to PT 1's statement, on the night shift beginning on 8/29/15, Client 1 was having behavior issues and staff was trying to calm him down. PTA1 put on an exam glove and put Iso gel all over Client 1's face and then slapped Client 1 on the cheeks and yelled at him, "Is that what you want?" Client 1 yelled, "No!' while PTA 1 was wiping Client 1's face with his shirt. Client 1 was crawling on the floor and tried to hit PTA1 and PTA1 kicked Client 1 in the upper thigh. PT2 was present and gestured at PTA1 to stop what he was doing. An interview was conducted on 1/28/2015 at 11:40 AM with PT1. PT1 was asked about the events that occurred on 8/30/2015. PT1 stated the incident occurred on Saturday 8/29/2015 to 8/30/2015 in the morning during the night shift. PT1 also stated she reported the incident to the US on 9/1/2015 and she was aware this was considered late reporting. Therefore, the facility staff's failure to immediately report the witnessed abuse or within the 24 hour timeframe, placed clients at risk of further abuse by PTA 1. |
| 240001155 |
Fifteenth Street House |
240012589 |
A |
22-Sep-16 |
D2KT11 |
9415 |
REGULATION VIOLATION 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. FINDINGS: The facility failed to provide sufficient safeguards and supervision to protect Client A from injuring herself and others when Client A arrived at the Day Program with an explosive behavior and aggression evidenced by hitting her hands on tables, desks, walls, file cabinet and throwing objects such as a paper hole punch and binders. This failure resulted in Client A sustaining an injury that required a transfer to a hospital where Client A received a diagnosis of a fracture (broken bone) on the left hand and had the potential for other clients and the day program staff to receive injuries. A review of the clinical record for Client A, reflected Client A was admitted on June 10, 2013 with diagnoses which included: hyperopia (a vision condition in which distant objects can be seen clearly, but close ones do not come into proper focus), Bipolar Disorder (causes extreme mood swings that includes emotional highs and lows), profound hearing loss (difficulty hearing and understanding, even with amplification), and severe intellectual disability (considerable delays in development, understands, but little ability to communicate, needs supervision in social situations). During a review of an Incident Report dated February 10, 2016 at 9:36 AM, indicated, "What was determined to be the cause of the incident [Client A's name] acting out at a day program couldn't get her way. Hitting herself. Behavioral plan: [Client A's name] still inflicts herself with pain. Placement for behavior home has been on place for sixty days still looking." During an observation at the Day Program on March 8, 2016 at 12:00 PM, Client A was observed playing ball in the courtyard with other Clients. She had a cast on her left hand. During an interview with the Program Administrator (PA), on March 8, 2016 at 12:01 PM, the PA stated, "(name of client, Client A) had suffered a broken left hand because she was upset, she had a different staff taking care of her." During a phone interview with the Registered Nurse (RN), on May 11, 2016 at 4:47 PM, she stated the client was never on a one to one observation at the house or the day program. During a phone interview with the Program Administrator (PA), on May 12, 2016 at 4:45 PM, she stated, "My office door remained open when (name of client, Client A) entered my office. We couldn't restrain her so we just let her go and protected the other clients from her because she was uncontrollable." During a phone interview with the Direct Support Profession (DSP), on May 18, 2016 at 8:41 AM, she stated, "We can't restrain her (Client A) when she is out of control. I can't do anything about it. I have to let her have her fit." During a review of the Clinical Record for Client A, the "Support Notes", dated January 10, 2016, (dated incorrectly, the incident occurred on February 10, 2016) indicated, [Client A's name] arrived at the day program very upset. She refused to join the staff she was assigned to. She immediately began screaming and crying. She refused to go in her assigned area and instead went to other rooms asking staff to join their group. Each time staff attempted to redirect [Client A's name] out of the room, she would attempt to hit staff and anyone in her reach. She would also throw items (her lunch, and shoes). She repeatedly went into the office and became upset when the staff would attempt to redirect her to join her group. She began hitting the walls and desk, attempting to hit staff, and threw items that included a hole puncher, a binder, staples, post-it holder, and the staffs purse. [Client A's name] repeated this cycle multiple times and went to the board where groups are made and hit it repeatedly with her hands and threw everything off the board about three times. [Client A's name] was physically abusive towards her peers. Client sat in her chair and continued to scream and cry the remainder of the time she was at program. She had episodes of pulling her hair, hitting her head, face with her hand, and hitting the wall. Staff noticed [Client A's name] had a big blue bump on her right hand and another bump on her right forearm." During a review of the clinical record for Client A, the goals and objectives dated, October 14, 2015 indicated, "Behaviors still present due to (Client A's) not getting her way, can be manipulative, always want to apologize after the fact, well aware of what she is doing." During a review of the clinical record for Client A, the summary of behavioral objectives assessment of behavior (addressing aggression), dated October 30, 2015 indicated, "Before outings talk with [Client A's name] privately and rehearse expected behavior, keep her hands in her pockets, look at items but do not touch, stay at the side of a staff person. If [Client A's name] starts to move away from her assigned area her staff should catch up with her and urge her to a quiet area by walking within an arm's length or a little more of her and using your body, gestures, and words to indicate to where you need her to walk. If she goes off course you may need to shift your position to urge her back to the area you want her to approach. If she goes off course, offer her the wheelchair." A review of Client A's "Goals/Objectives/Plans" addressing Decrease Self Injurious Behavior, dated April 16, 2015, under Plan Step 6. Steps to be taken when behavior occurs (in order of use): 1. When (name of client, Client A) hits or pinches herself, immediately use the verbal and signed prompt "Stop (name of client), No Hitting" or "No Pinching" in a very firm tone of voice, paired with the signed prompt. 2. If she responds and stops, praise her for stopping and re-engage her in an activity that requires the use of her hands. 3. Talk to (name of client), ask her what is wrong, and talk to her about better ways of handling her agitation besides hitting or pinching herself. Make sure she is attending to you at this time. 4. If (name of client) does not respond, but continues to hit or to pinch herself, repeat the verbal and signed prompts and pair it with the physical prompt of brief duration (3-5 seconds) of guiding her hands to her sides, but do not hold them............ 7. Repeat steps as necessary until the hitting and pinching stop. Documentation underneath the section "Steps to be taken" indicated, "Prior to this plan, positive reinforcement was ineffective in decreasing this behavior." The IDT (Interdisciplinary Team), BMT (Behavior Management Team) and HRC (Human Rights Committee) approve this plan. During further review of the clinical record for Client A, a Report of Consultation dated February 15, 2016 indicated, "Was seen by ....(name of physician) on February 11, 2016 and the findings were Left fifth metacarpal fracture (a break on the neck of the fifth metacarpal caused by punching a hard object)." During an interview with the Facility Manager (FA), on March 8, 2016 at 10:50 AM, she stated the day program facility called them to pick up Client A because she destroyed the PA's office and tried to hit staff. The physician ordered an x-ray (images taken of the structure inside the body, in particular the bones) and the left hand was broken. During a phone interview with the Qualified Intellectual Disabilities Professional (QIDP), on May 18, 2016 at 9:46 AM, when asked about Client A's behavior in the home, she stated, she (Client A) had her moments of aggression and was self-abusive by hitting herself. During a phone interview with the Qualified Intellectual Disabilities Professional on July 21, 2016 at 8:21 AM, she stated, Client A has a history of being kicked out from several day programs due to her outbursts. I was called from her day program twice regarding her outburst from not getting her way. A review of the facility policy and procedure entitled, "Consumer Rights", dated August 15, 2012, indicated, "To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect." A review of the facility policy entitled, "Individual conduct", undated, indicated, "Individuals with specific challenging behaviors have ISPs which contain plans for intervening and managing their behaviors. Individuals are to be encouraged to display appropriate and adaptive behaviors using positive reinforcement techniques." Because the facility did not have an effective plan in place to intervene and manage Client A's behavior, Client A's aggressive outburst resulted in self injury and placed other clients and staff at risk for injury. This violation had a substantial probability of death or serious physical harm to patients. |
| 240001155 |
Fifteenth Street House |
240012591 |
A |
22-Sep-16 |
0ZF611 |
7310 |
REGULATION VIOLATION Welfare & Institution Code, 4502 - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. FINDINGS: The facility failed to provide sufficient safeguards and supervision to protect Client A from injuring herself and others when Client A threw a knife, attacked staff, and hit Clients B and C. This failure resulted in Client A hitting herself and Clients B and C. The facility transferred Client C to urgent care because Client A hit Client C on the chest and head. The facility dialed the emergency department and Client A was handcuffed by the police department and placed on a 5150 (Involuntary psychiatric hold when a person, as a result of a mental health disorder, is a danger to self and others). A review of Client A's clinical record, indicated Client A was admitted on June 10, 2013 with a diagnoses of hyperopia (a vision condition in which distant objects can be seen clearly, but close ones do not come into proper focus), Bipolar Disorder (causes extreme mood swings that includes emotional highs and lows), profound hearing loss (difficulty hearing and understanding, even with amplification), and severe intellectual disability (considerable delays in development, understands, but little ability to communicate, needs supervision in social situations). A review of the Qualified Intellectual Disabilities Professional (QIDP) notes, dated March 22, 2016 at 8:20 AM, indicated: Received a call from the Facility Manager (FM) that [Client A?s name] started hitting herself and demanding to be moved, she went after another client. The Facility Manager attempted to protect the other client from Client A and in the process, [Client A?s name] hit the FM causing the FM to fall down to the floor, and hurt her knee. [Client A?s name] was kept home from day program today due to continued escalating behaviors, Inland Regional Center was contacted 2 times asking for assistance to move her (Client A) to a temporary place, before she seriously harms herself and others around her, no calls returned today. During a review of the Qualified Intellectual Disabilities Professional (QIDP) notes, dated March 23, 2016 at 7:15 AM, indicated: "Got a call that [Client A?s name] threw a knife and attacked staff and hit two consumers, police was called upon my arrival Fire Department, Paramedics and Upland Police were all here, [Client A?s name] was writing notes stating, she wants to move and can she stay at the hospital until Friday then move to her new home. [Client A?s name] was handcuffed the police told her she was going to get some help, she screamed and cried. We told her to calm down, police stated that she was not being arrested but taken to the hospital. [Client A?s name] tried to hug me and tell me she was sorry. I told her now you?re hurting others and you cannot stay here anymore. I informed her due to her actions another consumer will be taken to urgent care for a follow up. She hit [Client C?s name] in the chest and head. Threw a plastic cup full of water at [Client B?s name]." During a telephone interview with the Direct Care Staff (DCS 1), on May 18, 2016 at 11:50 AM, she stated Client A threw a knife at her and slapped her on the face. DCS 1 stated Client A has never been on a one to one observation for protection of self and others. During a telephone interview with the Direct Care Professional (DCP) on May 18, 2016 at 1:40 PM she stated, Client A pushed her chair back and threw water at the DCP because she was not going to be discharged from the facility until the 25th of March and this made her upset because she wanted to leave beforehand. A review of Client B's clinical record, indicated Client B was admitted on December 30, 2008 with diagnoses of severe intellectual disability (an IQ {intelligent quotient} below 35 as well as learning and adaptive behavior problems), Downs Syndrome (causing intellectual impairment and physical including short stature abnormalities and broad facial profile), and anxiety (feeling of nervousness). During an interview with the DCP on May 18, 2016 at 1:40 PM, she stated Client B was sitting in the dining room and did not want to get up because he was drinking his cup of coffee. Client A threw a plastic cup and hit Client B on the side of his face. A review of Client C?s clinical record, indicated Client C was admitted on February 1, 1993 with diagnoses of profound intellectual disability (a subnormal ability to learn with impaired social adjustment and a substantially low IQ), spastic hemiplegia (a neuromuscular condition of spasticity that results in the muscles on one side of the body being in a constant state of contracture), and cerebral palsy (a condition marked by impaired muscle coordination typically caused by damage to the brain before or at birth). During an interview with the DCP on May 18, 2016 at 1:41 PM, she stated Client A punched Client C in the stomach. During a review of the written declaration statement of Client A, dated March 22, 2016 reflected, "I was mad when I want to move out, hit Client C two times back and head, but I hit myself." During a review of the written declaration statement of Client A, undated, indicated: "I want leave to new home. I don't want to stay in hospital, only two days or until Saturday morning." During a phone interview with the Direct Care Professional (DCP), on May 18, 2016 at 1:40 PM, she stated, Client A was upset because she wanted to be discharged prior to the date of March 25, 2016 to a new house. Client A was sitting at the table eating breakfast and all of a sudden she began to throw a full cup of water at her, and also threw a cup at and hit Client B on the side of the head. Client A punched Client C on the stomach. Client C was taken to urgent care. A review of the facility policy and procedure titled, "Consumer Rights", dated August 15, 2012, indicated: "To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect." A review of the facility policy and procedure titled, "Individual Conduct", undated, indicated: "Individuals with specific challenging behaviors have ISP's (Individual Service Plan) which contain plans for intervening and managing their behaviors. Individuals are to be encouraged to display appropriate and adaptive behaviors using positive reinforcement techniques." Because the facility did not have an effective plan in place to manage Client A?s behavior during episodes of aggression Client B and Client C were subjected to physical abuse from Client A. This violation had a substantial probability of death or serious physical harm to patients. |
| 250000596 |
FOXDALE HOUSE |
250009664 |
B |
12-Dec-12 |
Z9YG11 |
11620 |
Title 22: 76875(a) Health Support Services- Nursing ServicesIt was determined that nursing failed to provide adequate health care monitoring and services including appropriate and timely follow-up based on the client's need for individualized service. Nursing services were not provided to Patient A for changes in the patient's health status - urinary tract infection, constipation, bowel impaction and obstruction in accordance with the client's needs. The RN failed to recognize the signs and symptoms of fecal impaction. As a result the RN did not develop any care plan to treat or prevent further UTIs and fecal impactions. The RN did not instruct the facility staff what signs to monitor for and symptoms to report. The RN did not develop plan for monitoring, treatment and prevention, placing the patient at high risk for severe medical complication requiring hospitalizations that could have been prevented.The RN failed to develop a nursing care plan for constipation following Patient A's hospitalization on October 8, 2007, for constipation and to prevent fecal impaction. Nursing services were not provided to Patient A for changes in the patient's health status - constipation, bowel impaction and obstruction in accordance with the client's needs. As a result, Patient A was hospitalized a second time, on October 31, 2007, for bowel obstruction. On November 1, 2007, an unannounced visit was conducted to investigate a self- reported incident, in which Patient A was hospitalized due to a bowel obstruction on October 31, 2007.A record review for Patient A was conducted on November 5, 2007. The record indicated that Patient A was admitted to the facility on October 5, 1989, with diagnoses including spastic quadriplegia (loss of sensation and mobility in both the upper and lower body), and profound mental retardation. Review of Patient A's records revealed Patient A had a previous hospital admission on October 8, 2007 for constipation, and on October 5, 2007 for urinary tract infection. Hospital Discharge Instructions, dated October 5, 2007, indicated that Patient A had been diagnosed with a urinary tract infection and was prescribed antibiotics. Documentation in the Interdisciplinary Note (IDN) by the Relief Facility Manager (RFM), dated October 6, 2007, at 10 a.m., indicated, "(Patient A) did not feel good on Friday (October 5, 2007) while changing his diaper, staff noticed blood in his urine. Took him to the ER (Emergency Department). He appears to be feeling better after starting antibiotics for bladder infection. He refused breakfast."Further review of the record indicated that a care plan for the urinary tract infection was not developed. There was no documentation that fluids were being encouraged to flush the bacteria out of the bladder and to prevent further complications. There was no documentation that the patient's fluid intake and output was being monitored.In an interview with the Registered Nurse (RN), on July 15, 2008, at 2:30 p.m., the RN stated that going to the hospital for a urinary tract infection was a change in Patient A's condition, and that it should have been care planned with interventions for the staff to follow. "I missed it. There should have been a care plan for UTI." There was no documentation to indicate that the RN implemented measures for prevention of UTI. There was no documentation that the RN instructed staff on how to monitor for signs and symptoms of UTI/ dehydration and regarding measures to prevent further UTIs for Patient A.Documentation in the Interdisciplinary Note by the Facility Manager (FM), dated October 8, 2007, at 8:50 a.m., indicated that Patient A was not feeling well so he was taken to the ER where he was admitted for constipation. Documentation on October 9, 2007, indicated, "(Patient A was) still in the hospital." Documentation on October 9, 2007 at 8:50 p.m., indicated, "(Patient A) just came from the hospital at 6 p.m." Review of the Narrative Nurses' Notes revealed the following documentation by the RN: October 8, 2007, 8:00 a.m., "Checked this AM [abdomen] distended & firm. BM (Bowel Movement) felt in rectum, with small amount of bright red blood." Further documentation indicated the physician was notified and the client was taken to the emergency room for evaluation. Documentation at 6:00 p.m., indicated, "The client was admitted to the hospital for an impaction/constipation." October 9, 2007, at 1:30 p.m., indicated, "Seen at hospital this AM...per hospital staff enemas given with results times four...bowel x-ray negative for obstruction." Further review of the record revealed that a care plan had not been developed for constipation and for the prevention of fecal impaction (An immovable collection of compressed or hardened feces in the colon or rectum). An interview was conducted with the RN on November 5, 2007, at 2:30 p.m. The RN stated she did not develop a care plan for Patient A's constipation problem and hospitalization. The RN further stated that a plan of care for constipation should have been developed for Patient A after the first admission to the hospital, on October 8, 2007, which Patient A had been treated for impaction/constipation.A Special Incident Report, dated November 2, 2007, was completed for Patient A for an incident occurring on October 31, 2007. The report indicated, "(Patient A) didn't appear to feel well after eating breakfast on 10/31/07. He vomited and due to the fact he wasn't having regular bowel movements, staff transported him to the emergency department for evaluation...was diagnosed on [October 31, 2007] with a bowel obstruction..." Review of the Narrative Nurses' Notes revealed the following documentation by the RN: October 31, 2007, 9:00 a.m., "Notified of emesis, undigested food this AM. To be taken to ER for further evaluation...only small formed BM, poor appetite...abdomen slightly firm." November 1, 2007, 1:00 p.m., "Admitted...bowel impaction...N/G (nasogastric tube) in place for laxative...IV (intravenous) infusing...urine from foley...per hospital no reported BMs at this time..." November 6, 2007. 8:00 a.m., for hospital visit on November 5, 2007, "not cleared of BM for colonoscopy (procedure to visualize the colon through a flexible, lighted, tubular instrument)...to be discharged until abdomen clear". Hospital Discharge Summary indicated that Patient A was admitted to the hospital on October 31, 2007, with diagnosis of partial bowel obstruction, stool impaction, and dehydration (an abnormal loss of fluids). Further review of the IDNs for October, 2007, revealed the following documentation relating to bowel function: October 11, 2007, 8:10 p.m., "...had MOM (Milk of Magnesium) no BM in three days." October 12, 2007, 4:00 p.m. "Nurse came by at 4 p.m. [Client] given a Bisacodyl 10 mg suppository, he hadn't had a BM in 4 days only small." October 15, 2007, 10:00 a.m., "...he still haven't had a normal BM." October 19, 2007, 10:00 a.m., "Had 2 small BMs. Appears to be feeling OK. Did not eat breakfast." October 20, 2007, 6:00 p.m., "...ate [none] of his dinner, had a small BM..." October 22, 2007, 11:40 a.m., "...at 7:45 a.m. the nurse came in felt his stomach it appears hard he ate only 10% of his breakfast he refused to drink..." October 24, 2007, 9:30 a.m., "...had [one] small BM." October 24, 2007, 7:00 a.m., "...refused to eat his dinner he had a loose small BM..." October 25, 2007, 10:00 a.m., "...two BMs on the Noc shift...seems as though he doesn't have an appetite much." October 27, 2007, 8:25 a.m., "...had 2 [small] BM..." October 27, 2007, 6:30 p.m., "...had a form small BM..." October 28, 2007, 11/:00 a.m., "...according to NOC he had a small BM form he had [two] small loose BM in the afternoon..." October 28, 2007, 11:00 p.m., "...unfortunately did not eat his dinner..." October 29, 2007, 7:30 p.m., "...ate 0% of his dinner..." October 30, 2007, 9:30 a.m., "...had 1 small and 1 [medium] form BM." October 30, 2007, 7:00 p.m., "...did not eat any of had dinner..." October 31, 2007, 1:00 p.m., "...vomited this morning. RN was called FM instructed to take him to ER. October 31, 2007, 7:00 p.m., "...admitted into the hospital." November 7, 2007, 1:00 p.m., "...discharged..." A review of the Habilitation Flow sheet for the month of October 2007 indicated BMs of irregular form, consistency and frequency. There were no BMs recorded for October 5, 6, 7, 10, 11, 13, 14, 15, 17, and 21, 2007.Review of the medication Administration Records for October, 2007, revealed that Client 4 received Docusate Sodium 250 mg each morning at bedtime for constipation. Milk of Magnesia had been prescribed if no bowel movement in three days, maximum one time a day. Documentation indicated Milk of Magnesia had been administered on October 1, 7 and 11, 2007. Dulcolax 10 mg suppository had been prescribed if no bowel movement in four days. Documentation indicated Dulcolax had been administered on October 1, 12, 18 and 19, 2007. Bowel impaction is a type of constipation with severe pain and dangerous symptoms. If left untreated, even for a short period, bowel impaction may have severe ramifications. Fecal impaction is a potential complication of chronic constipation, which can be related to diet, fluid intake, medications, or decreased activity level. Prolonged fecal impaction can lead to an enlargement or obstruction of the colon, requiring emergency treatment. Signs and symptoms of fecal impaction are abdominal pain, back pain, high fever, vomiting blood, rectal bleeding, bloody stools, rigidity of the abdomen, inability to pass stool or gas, change of level of consciousness or alertness, change in bowel changes, difficulty urinating, abdominal swelling, distention, or bloating. Review of the Nursing Care Plan, dated June 13, 2007, revealed the problem: Maintain Health. There were no interventions relating to bowel and bladder function. The RN failed to develop a nursing care plan for constipation following patient A's hospitalization on October 8, 2007, and October 31, 2007. The RN failed to develop a nursing care plan for urinary tract infection following patient A's hospitalization on October 5, 2007. Nursing services were not provided to Patient A for changes in the patient's health status - urinary tract infection, constipation, bowel impaction and obstruction in accordance with the client's needs. The RN failed to recognize the signs and symptoms of fecal impaction. As a result the RN did not develop any care plan to treat or prevent further UTIs and fecal impactions. The RN did not instruct the facility staff what signs to monitor for and symptoms to report. The RN did not develop plan for monitoring, treatment and prevention, placing the patient at high risk for severe medical complication requiring hospitalizations that could have been prevented.It was determined that nursing failed to provide adequate health care monitoring and services including appropriate and timely follow-up based on the client's need for individualized service. The RN failed to develop a nursing care plan for constipation following Patient A's hospitalization on October 8, 2007, for constipation and to prevent fecal impaction. Nursing services were not provided to Patient A for changes in the patient's health status - constipation, bowel impaction and obstruction in accordance with the client's needs. As a result, Patient A was hospitalized a second time, on October 31, 2007, for bowel obstruction. The above violations, either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety, or security. |
| 920000004 |
Four Seasons Healthcare & Wellness Center, LP |
920009122 |
B |
16-Mar-12 |
05ET11 |
2022 |
California Health & Safety Code Section 1418.21 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (A) An area accessible and visible to members of the public. (B) An area used for employee breaks. (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.The facility failed to post the overall rating information (Five-Star Quality Rating) determined by the Centers for Medicare and Medicaid Services (CMS) in the required areas for review by the residents, staff, and the public. During the annual Recertification survey, on January 11, 2012, the Nursing Home Compare Five-Star Quality Rating System information was not posted in the areas accessible and visible to members of the public, employee break room, dining rooms, or activity room.On January 12, 2012, at 3 p.m., during an interview and observation of the facility?s consumer information board with the Director of Nursing (DON) and the Administrator, the Nursing Home Compare Five-Star Quality Rating System information was not posted in the areas as described above.On January 14, 2012, at 4:15 p.m., during an interview with the DON, she stated the Five-Star rating should have been posted, however, the facility had been renovating and the rating information had to be removed from the walls. She stated that the information should have been replaced in the designated areas as previously posted after renovation. Failure of the facility to post the overall rating information (Five-Star Quality Rating) determined by the Centers for Medicare and Medicaid Services (CMS) in the required areas for review had a direct relationship to the health, safety, and security of all residents. |
| 920000004 |
Four Seasons Healthcare & Wellness Center, LP |
920012714 |
B |
1-Nov-16 |
NDIN11 |
5775 |
CFR 483.12 (b) (3) Policy to Permit Readmission Beyond Bed-Hold A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. On 7/14/16, at 2:45 p.m. an unannounced visit was made to the facility to investigate a complaint regarding the facility not permitting Resident 1 to return to the facility after a short stay in a general acute care hospital (GACH). Based on interview and record review, the facility failed to follow a written policy under which residents whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, are readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the residents require the services provided by the facility, including: 1. Failure to allow Resident 1 to return to the facility after hospitalization. 2. Failure to offer Resident 1 the next available bed when on 3/9/16, the resident was ready for discharge from the GACH to Skilled Nursing Facility 1 (SNF 1) level of care, 23 days after the resident was transferred to the GACH. As a result, Resident 1 was unable to return to SNF 1, which he considered his home and expressed sadness, fear, and anxiety regarding moving to another SNF. A review of the clinical record indicated Resident 1 was initially admitted to the facility on 3/14/13, with diagnoses including Parkinson's disease (progressive degenerative neurological disease characterized by involuntary movements or tremors), hemiplegia (paralysis or the loss of the ability to move one side of the body), and difficulty walking, and muscle weakness. According to the quarterly Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/10/15, Resident 1 had no memory problems, was independent in cognitive skills for daily decision-making, required a walker and a wheelchair as mobility devices to get around, and was assessed as having no behavioral symptoms. A review of the Change of Condition (COC)/SBAR (Situation, Background, Assessment, Recommendation) Assessment form dated 2/15/16, timed at 1 p.m., indicated Resident 1 complained of generalized weakness with unrelieved pain to both lower extremities. The physician was informed and ordered to transfer Resident 1 to a GACH for evaluation and to hold the bed for seven days. A review of the GACH Social/Discharge Planning Assessment and the Interdisciplinary Notes regarding discharge planning indicated Resident 1consistently expressed his wish to return to SNF 1. On 3/9/16, when the GACH discharge planning staff contacted SNF 1, the response was SNF 1 was unable to accept the resident back. Since Resident 1 wanted to go back to SNF 1, the GACH discharge planning staff made several attempts to contact SNF 1 on 3/10/16 and 3/11/16 with no response to messages left. Resident 1 was offered to go to SNF 2. The discharge planning assessment indicated that on 3/11/16 the resident expressed sadness, fear, and anxiety regarding transferring to a new place. Resident 1 agreed and was transferred to SNF 2. On 6/29/16, at 2:30 p.m., during an interview, the administrator stated Resident 1 went out to the GACH, was given a tracheostomy (surgical opening through the neck into the trachea to allow direct access to the breathing tube) and the facility did not take residents with a tracheostomy. Further record review from the GACH disclosed no documentation Resident 1 had a tracheostomy. During an interview on 6/29/16, at 3:30 p.m., Social Services Director 1 (SSD 1) of SNF 2 stated Resident 1 still wanted to return back to his home (SNF 1) but SNF 1 indicated they would not readmit Resident 1 because the bed-hold was up. A review of the facility's policy and procedure titled, "Bed-Hold" revised1/1/2012, indicated in the event a resident was in the GACH for more than seven (7) days, met the standards for skilled nursing care, and was Medi-Cal eligible, the facility would readmit the resident to the first available bed in a semi-private room. The policy indicated if the bed-hold period expired and the resident did not elect to pay to keep the bed held, but wished to return to the facility, the facility would provide the resident with the first available bed covered by the resident's payer source. On 7/4/16, at 2:45 p.m., during an interview, Resident 1 stated he would like to go back to the facility, but they would not take him back. The resident stated SNF 1 was his home and he liked it there. The facility failed to follow a written policy under which residents whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, are readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the residents require the services provided by the facility, including: 1. Failure to allow Resident 1 to return to the facility after hospitalization. 2. Failure to offer Resident 1 the next available bed when on 3/9/16, the resident was ready for discharge from the GACH to Skilled Nursing Facility 1 (SNF 1) level of care, 23 days after the resident was transferred to the GACH. As a result, Resident 1 was unable to return to SNF 1, which he considered his home and expressed sadness, fear, and anxiety regarding moving to another SNF. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000015 |
FOUNTAIN VIEW SUBACUTE AND NURSING CENTER |
920012729 |
A |
1-Dec-16 |
9J6111 |
13944 |
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 (c) Treatment/Services to Prevent Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that? (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. On 6/27/16, at 1:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident related to Resident 1?s quality of care. Based on interview and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by failing to ensure residents who were admitted to the facility with no pressure sores (a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure), but were identified at risk for developing pressure sores, were provided with the necessary treatment and services for pressure sore prevention, and treatments to promote healing of pressure sores, including: 1. Failure to conduct an ongoing accurate assessment of the resident?s skin condition to promptly identify the development of a pressure sore to the right buttock and to the right posterior (back) leg prior to 5/6/16; and the development of an abscess (a localized collection of pus in the tissues of the body, accompanied by swelling and inflammation, frequently caused by bacteria) to the left buttock prior to 6/22/16. 2. Failure to develop a plan of care addressing Resident 1?s skin integrity problem to ensure any skin redness, swelling, or breakdown was promptly reported to the physician and treated accordingly to promote healing and prevent complications. 3. Failure to implement its policy on Skin Integrity Management to continually observe and monitor the residents for changes and implement revisions to the plan of care as needed; to identify resident?s skin integrity status and implement interventions; to perform skin inspection daily or weekly and document. The above failures resulted in the following: a. On 5/6/16 Resident 1 was transferred to a general acute care hospital (GACH) where he was found with an infected pressure sore Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle), after having no pressure sores at Stage I (intact skin, with non-blanchable redness of a localized area, usually over a boney prominence) on the right buttock with malodor (foul-smelling), severe sepsis (potentially life-threatening blood infection) secondary to the infected pressure sore. Resident 1 was also identified to have a superficial pressure sore (Stage II - a partial-thickness loss of skin involving epidermis and dermis, looks like a blister or abrasion) to the right posterior leg. These two pressure sores were not identified by the facility before transferring the resident to the GACH on 5/6/16. Resident 1 returned back to the facility on 5/18/16. b. On 6/22/16, Resident 1 was transferred again to the GACH, where he was found to have an abscess (a localized collection of pus in the tissues of the body, accompanied by swelling and inflammation, frequently caused by bacteria) to the left buttock which was not identified by the facility before transferring the resident to the GACH. Two days after admission to the GACH, Resident 1 expired. According to the Certificate of Death, Resident 1?s immediate cause of death was cardio-pulmonary arrest (heart attack). A review of the clinical record indicated Resident 1 was initially admitted to the facility on xxxxxxx with diagnoses including peripheral vascular disease (a blood circulation disorder that causes blood vessels to narrow or block), heart failure, chronic kidney disease, type 2 diabetes mellitus (high blood levels of sugar), and Alzheimer?s disease (progressive disease that destroys memory and other important mental functions). A Braden Scale ? For Predicting Pressure Sore Risk form dated 4/5/16 indicated Resident 1 scored 13, representing a moderate risk for developing pressure sores. A total score of 12 or less represents high risk. There was no documentation to explain why Resident 1 was at a moderate risk for developing pressure sores (ie, mobility, personal hygiene). According to the Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 4/8/16, Resident 1 was at risk for developing pressure sores and the resident did not have pressure sores at Stage I or higher. Further record review disclosed no documented plan of care addressing the resident?s risk to develop pressure sores. There were no interventions for the staff to implement in order to prevent pressure sore development and to identify early signs of new pressure sores A review of the Skin Assessment form dated 3/16/16, the Skin Integrity Report forms dated 4/8, 4/15, 4/22, and 4/29/16, and the Treatment Administration Record sheets from 4/1/16 through 5/5/16, indicated that there was no documentation Resident 1 had a pressure sore to the right buttock or to the right leg. These forms would indicate a monitoring of wounds or skin complications. According to a nursing note dated 5/6/16, Resident 1 had a low blood pressure 53/33 mmHg (millimeters of mercury - normal blood pressure 120/80 mmHg) and the heart rate was 91 beats per minute (normal range 60 - 80). The physician was notified and ordered to transfer Resident 1 to a GACH. The Nursing Home to Hospital Transfer form, dated 5/6/16, had no documentation to indicate Resident 1 had a skin problem upon transfer to the GACH. According to the GACH clinical record, Resident 1 was admitted on 5/6/16, with a Stage IV pressure sore to the right buttock and a pressure sore (superficial, Stage II) to the posterior (back) right leg. A consultation from the GACH dated 5/7/16 indicated that due to the infected right buttock pressure sore, Resident 1?s Stage IV pressure sore had malodor and severe sepsis secondary, or due to, to the pressure sore. The GACH consultation form indicated the second pressure sore on the right posterior leg was not infected. During a telephone interview, on 6/30/16, at 9:30 a.m., the GACH Surgeon 1 stated he debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) Resident 1's infected Stage IV pressure sore on 5/9/16 (two days after the resident was transferred to the GACH). According to the GACH clinical record review, Resident 1 returned to the facility on 5/18/16, with the Stage IV pressure sore on the right buttock and treatment orders. According to the facility?s clinical record, a care plan dated 5/20/16 indicated nutritional risk with a goal for the resident to have improved skin integrity for 90 days. The interventions included observing the skin condition with care daily and report abnormalities. Although Resident 1 had a Stage IV pressure sore, the Braden Scale dated 5/25/16 indicated a score of 15, representing mild risk for pressure sore. A review of the physician?s order, dated 6/22/16, indicated Resident 1 was transferred again to the GACH due to abnormal vital signs and altered mental status. The GACH History and Physical Examination dated 6/22/16 indicated Resident 1 was admitted to the GACH for altered level of consciousness and sepsis. According to the general surgery consultation note dated 6/23/16, Resident 1 had a left buttock abscess (a localized collection of pus in the tissues of the body, accompanied by swelling and inflammation, frequently caused by bacteria). Surgeon 1 documented he knew Resident 1 from the previous debridement surgery of the right buttock pressure sore performed on 5/9/16. Resident 1 expired at the GACH on 6/24/16. According to the Certificate of Death, Resident 1?s immediate cause of death was cardio-pulmonary arrest. Further review of Resident 1?s clinical record from the facility from 5/18/16 to 6/22/16 disclosed no documented evidence the nursing staff had identified the left buttock abscess. The facility treatment record from 5/18/16 to 6/22/16 had no treatment for a left buttock abscess or wound. The facility skin integrity reports dated 5/18/16 and 6/1/16, did not indicate the presence of a left buttock abscess or wound. A review of the Nursing Home to Hospital transfer form dated 6/22/16 indicated no documentation in the skin/wound section of a left buttock abscess. During a telephone interview on 6/30/16, at 9:30 a.m., Surgeon 1 stated Resident 1's left buttock abscess was new and it happened after the right buttock debridement. Surgeon 1 described the left buttock abscess as measuring four inches in diameter with reddish/brown, very foul smelling drainage, and stated, "The drainage smelled like a dead dog." On 6/30/16, at 1 p.m., during an interview, licensed vocational nurse 1 (LVN 1) stated she was the full time treatment nurse since the beginning of 5/2016 and she performed Resident 1's dressing change on the right buttock. When asked about Resident 1's left buttock wound she stated, "What about it, there was no treatment done to the left buttock." LVN 1 stated she did not see a left buttock abscess or wound and denied smelling a foul odor. A review of the facility's policy and procedure titled, "Skin Integrity Management," dated 7/7/01, indicated the staff would do the following: continually observe and monitor the residents for changes and implement revisions to the plan of care as needed. The purpose of the policy was to provide a safe and effective care to prevent the occurrence of pressure ulcers (sores), manage treatment, and promote healing of all wounds. The policy practice standards included for nursing staff to identify resident?s skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information; to perform skin inspection on admission/re-admission weekly and document; to perform wound observations and measurements and complete the Skin Integrity Report upon initial identification of altered skin integrity weekly and with anticipated decline of the wound; and to perform daily monitoring of wounds or dressings for presence of complications or declines and document. The policy further indicated that the facility would ?Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated.? The facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by failing to ensure residents admitted to the facility with no pressure sore and identified at risk for developing pressure sores, were provided with the necessary treatment and services for pressure sore prevention, and to promote healing of pressure sores, including: 1. Failure to conduct an ongoing accurate assessment of the resident?s skin condition to promptly identify the development of a pressure sore to the right buttock and to the right posterior leg prior to 5/6/16; and the development of an abscess (a localized collection of pus in the tissues of the body, accompanied by swelling and inflammation to the left buttock prior to 6/22/16. 2. Failure to develop a plan of care addressing Resident 1?s skin integrity problem to ensure any skin redness, swelling, or breakdown was promptly reported to the physician and treated accordingly to promote healing and prevent complications. 3. Failure to implement its policy on Skin Integrity Management to continually observe and monitor the residents for changes and implement revisions to the plan of care as needed; to identify resident?s skin integrity status and implement interventions; to perform skin inspection daily or weekly and document. The above failures resulted in the following: a. On 5/6/16 Resident 1 was transferred to a general acute care hospital (GACH) where he was found with an infected pressure sore Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle), after having no pressure sores at Stage I (intact skin, with non-blanchable redness of a localized area, usually over a boney prominence) on the right buttock with malodor (foul-smelling), severe sepsis (potentially life-threatening blood infection) secondary to the infected pressure sore. Resident 1 was also identified to have a superficial pressure sore (Stage II - a partial-thickness loss of skin involving epidermis and dermis, looks like a blister or abrasion) to the right posterior leg. These two pressure sores were not identified by the facility before transferring the resident to the GACH on 5/6/16. Resident 1 returned back to the facility on 5/18/16. b. On 6/22/16, Resident 1 was transferred again to the GACH, where he was found to have an abscess to the left buttock which was not identified by the facility before transferring the resident to the GACH. Two days after admission to the GACH, Resident 1 expired. According to the Certificate of Death, Resident 1?s immediate cause of death was cardio-pulmonary arrest. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result for Resident 1. |
| 920000004 |
Four Seasons Healthcare & Wellness Center, LP |
920012826 |
B |
21-Dec-16 |
38PH11 |
8201 |
F 223 483.13 (b) Free from Abuse/Involuntary Seclusion The resident has the right to be free from verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. F226 CFR 483.13 ( c) Abuse Policies and Procedures, Develop Implement The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On 12/21/15, at 8:45 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of resident abuse by a facility staff member. Based on observation, interview, and record review, the facility failed to ensure Resident 1 had the right to be free from verbal, mental, and physical abuse and failed to implement written policies and procedures that prohibit mistreatment and abuse, by: 1. Failure to ensure Resident 1 was not verbally, mentally, and physically abused by Certified Nursing Assistant 1 (CNA 1). 2. Failure to ensure CNA 1 was not assigned to care for Resident 1 as he requested. 3. Failure to investigate rough treatment from CNA 1 when Resident 1 reported it and requested not to assign CNA 1 to him. 4. Failure to implement the policy and procedure on Abuse Prevention by not having adequate staff to meet the residents? needs. As a result, CNA 1 told Resident 1 to, "Shut up," and squeezed the resident's neck for three seconds, causing Resident 1 to be afraid of CNA 1 and to cry when remembering the incident. A review of the clinical record indicated Resident 1 was admitted to the facility, on xxxxxxx, with diagnoses including muscle weakness, osteoarthritis (the cushion between joints breaks down leading to pain, stiffness and swelling), and abnormalities in gait and mobility. The History and Physical (H&P) examination signed by the physician on 8/31/15 indicated Resident 1 had the capacity to understand and make decisions. According to the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 9/10/15, the resident had clear speech, had the ability to be understood and understand others with clear comprehension. The resident was assessed as requiring extensive assistance with bed mobility, turning side to side while in bed, transferring from bed to chair, dressing and toilet use with one-person physical assistance. Resident 1 had movement limitation of the joints on the upper and lower extremities. According to a nursing entry on a Change of Condition (COC) Assessment form dated 12/15/15, timed at 6:15 p.m. Resident 1 reported to the DSD that on 12/13/15, at 8:30 a.m., Resident 1 requested for CNA 1 to put two pillows in one pillowcase and to put in on the resident's back but CNA 1 did not do it and to the resident to, "Shut up." When Resident 1 replied to CNA 1 with an expletive, CNA 1 tried to choke him. The plan of care documented in the same form, indicated as a problem/concern the resident?s false allegation. On 12/21/15, at 10:17 a.m., during an interview, Resident 1 stated that about three weeks prior, he (Resident 1) had informed a staff member (the assistant director of staff development - ADSD) that CNA 1 was rough when providing care and requested that CNA 1 not to be assigned to care for him. The ADSD told the resident 1 that CNA 1 would no longer be assigned to him. During the interview, Resident 1 broke down crying when recalling what had happened on 12/13/15 with CNA 1. Resident 1 stated on the morning of 12/13/15, CNA 1 was assigned to care for him and he told CNA 1 he wanted another CNA. CNA 1 told him there was no other CNA to care for him. While CNA 1 was to assist Resident 1 with transferring from the bed to the wheelchair, CNA 1 placed the pillows in a manner contrary to Resident 1?s wishes. When Resident 1 complained about the positioning of the pillows, CNA 1 told the resident four times to, "Shut up!" Then, CNA 1 held the resident down in bed and squeezed his neck for three seconds. Resident 1, while crying stated he thought CNA 1 was going to kill him and he was afraid of him. On 12/21/15, at 11:58 a.m., during an interview, the ADSD stated she was in charge of the CNAs assignment and about a month ago, Resident 1 informed her he did not want CNA 1 to care for him because CNA 1 did not take his time when giving care. The ADSD did not say Resident 1 reported CNA 1 being rough when providing care to him. The ADSD stated CNA 1 was no longer assigned to care for the resident and she was surprised on 12/13/15, CNA 1 was assigned to Resident 1. The ADSD indicated on 12/15/15, Resident 1 notified her CNA 1 tried to choke him. ADSD then notified the DSD. On 12/21/15, at 12:20 p.m., during a telephone interview, CNA 1 stated on the date of incident (12/13/15), he was assigned to Resident 1 even though, about two months ago, he was told by the ADSD the resident did not want him and he would no longer take care of Resident 1. CNA 1 stated the charge nurses were aware, but he was still assigned to Resident 1 on 12/13/15 because they were short of CNAs. CNA 1 denied mistreating the resident or trying to choke him. According to the employee record, CNA 1 was hired on 7/25/09 and rehired (new facility ownership) on 7/11/11. There was no documentation the employee had history of abuse or inappropriate care to the residents during employment. There was no documentation about Resident 1?s allegation of rough treatment. When Resident 1 requested to the ADSD not to assign to him CNA 1, the ADSD did not further investigate the reason for the resident?s request to promptly identify any mistreatment or misconduct made by CNA 1. A review of the facility's undated policy and procedure titled, "Abuse - Prevention Program," indicated the purpose of the policy was to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. Abuse is defined as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as, any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Prevention of abuse included maintaining adequate staffing on all shifts to ensure the needs of each resident were met. According to the facility's undated policy and procedure titled, "Abuse ? Reporting & Investigations, the purpose of the policy was to ensure all reports of resident abuse, mistreatment?. are promptly and thoroughly investigated. The procedure included that when the administrator or designee receives a report of an incident or suspected incident of resident abuse, mistreatment? the administrator or designee, will initiate an investigation immediately. The facility failed to ensure Resident 1 had the right to be free from verbal, mental, and physical abuse and failed to implement written policies and procedures that prohibit mistreatment and abuse, by: 1. Failure to ensure Resident 1 was not verbally, mentally, and physically abused by Certified Nursing Assistant 1 (CNA 1). 2. Failure to ensure CNA 1 was not assigned to care for Resident 1 as he requested. 3. Failure to investigate rough treatment from CNA 1 when Resident 1 reported it and requested not to assign CNA 1 to him. 4. Failure to implement the policy and procedure on Abuse Prevention by not having adequate staff to meet the residents? needs. As a result, CNA 1 told Resident 1 to, "Shut up," and squeezed the resident's neck for three seconds, causing Resident 1 to be afraid of CNA 1 and to cry when remembering the incident. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000004 |
Four Seasons Healthcare & Wellness Center, LP |
920013129 |
A |
24-Apr-17 |
NV0W11 |
20949 |
CFR 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?(2) and ?483.10?(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
CFR 483.24 Quality of Life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
CFR 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident?s choices.
CFR 483.25(d) Accidents and Bed Rails
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 1/10/17, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 was found in the bathroom unresponsive due to an apparent suicide, and pronounced expired by the paramedics.
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; failed to develop and implement a comprehensive person-centered care plan for Resident 1 that included a description of services to attain or maintain the resident?s highest practicable physical, mental, and psychosocial well-being; failed to ensure that its residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident?s choices; and failed to ensure that the resident environment remains as free of accident hazards as possible, and that each resident receives adequate supervision to prevent accidents and injuries, including but not limited to:
1. Failure to ensure Resident 1, who had a history of attempted suicide, was assessed and monitored for suicidal ideation.
2. Failure to provide supervision consistent with Resident 1's needs, goals, and plan of care.
3. Failure to obtain a psychiatric and psychological consultation, per Resident 1?s plan of care.
As a result, on 1/7/17, at 4:20 p.m. (three days after admission), Resident 1 was found in the bathroom slumped on the floor, with a shoelace tightly wrapped around his neck, cold to touch, and unresponsive, three days after the resident was discharged from the general acute care hospital (GACH) psychiatric unit. Resident 1's face was pale and his lower extremities were cyanotic (blue or purple in color). The registered nurse cut the shoelace with scissors, and the facility called 911. Shortly after arrival, the paramedics declared Resident 1 expired.
According to the general acute care hospital records (GACH) Emergency Department Summary Report, Resident 1 was taken to the emergency room, on 12/13/16, on a 5150 hold (involuntary 72 hour psychiatric hold on one suspected to have a mental disorder that makes them a danger to themselves, a danger to others, and/or gravely disabled). A review of the GACH History and Physical, dated 12/14/16, indicated Resident 1 was admitted to the geriatric/psychiatric ward for history of depression, danger to self for feeling depressed, and increasingly suicidal over the past several days. The GACH History and Physical indicated Resident 1 verbalized wanting to hang himself.
A review of the GACH's Involuntary Patient Advisement form, dated 12/15/16, indicated Resident 1 was placed on a 72 hour hold starting 12/13/16, due to the resident being increasingly depressed, suicidal over the past several months, and the resident reporting being "suicidal" every day.
A review of the GACH Consultation Report, dated 12/16/16, indicated Resident 1 received Zyprexa 5 milligrams (mg) at bedtime for psychosis, Ativan 1 mg every six hours as needed for anxiety, Wellbutrin SR (slow release) 150 mg every day for depression then increased to 200 mg on 12/20/16, Cymbalta 20 mg at bedtime for depression, Restoril 7.5 mg at bedtime as needed for insomnia (difficulty falling or staying asleep), and Trazadone 100 mg at bedtime for depression (six different medications).
A review of the GACH Nurses' Notes, dated 12/20/16, indicated Resident 1 was found in the bathroom, standing with a bed sheet around the resident's neck. The resident was alert and found to have redness around the neck area. A 1:1 (one to one) sitter was ordered for safety.
According to the GACH Progress Note, dated 12/21/16, Resident 1 was assessed with grave disability (the threat of harm to oneself may be through inability to care for oneself), due to depression. The progress note indicated the plan, per psychiatry, advised a continued 1:1 sitter and follow up with psychiatry for continued management, with recurrent attempts of suicide.
A review of the GACH Psychosocial Assessment, dated 12/21/16, indicated Resident 1 was depressed and tearful due to the second attempt of suicide on 12/20/16, and stated he was unable to stop impulses of feeling "useless." On 12/24/16, the Psychosocial Assessment indicated the resident was depressed with negative thoughts, not wanting to get psychologically better. A review of the Psychiatrist Progress Note, dated 12/29/16, indicated Resident 1 remained on 1:1 supervision.
A review of the GACH Psychiatrist's Progress Notes, dated 1/2/17, indicated Resident 1 was obsessing about attempting to harm himself while on the unit. A review of the resident's Assessment Plan, dated 1/2 and 1/3/17, indicated the resident had severe depression with suicidal ideation and intent, remained with a 1:1 sitter, and the plan was to continue 1:1 sitter and psychiatric management, per psychiatry.
A review of the GACH Psychiatrist's discharge order, dated 1/4/17, indicated Resident 1 was admitted to the acute hospital on 5150 hold for depression and was suicidal. The resident was to be followed-up with the facility internist and psychiatrist.
On 1/10/17, at 10:10 a.m., an interview was conducted with Admissions Coordinator/Marketing who stated, on 1/4/17, no time specified, the social worker from the GACH contacted him stating Resident 1 was ready to be discharged. The Admissions Coordinator stated he visited Resident 1 at the psychiatric ward of the GACH which was a "locked" unit. The Admissions Coordinator stated the goal for Resident 1 was to be transferred to the skilled nursing facility for physical therapy and rehabilitation.
According to the GACH Geriatric - Psychiatry Discharge Instructions, dated 1/4/17, at 2:30 p.m., the expected course of recovery was six months and to hold discharge, to follow up with psychiatric and medical doctors. Resident 1's present illness at the time was major depressive disorder, severe recurrent (depression, a mental disorder characterized by at least two weeks of low mood). The discharge instructions indicated Resident 1 was alert, oriented, and ambulatory, and the follow-up care indicated referrals for Medical Therapy with follow-up with internist, and Psychiatric Therapy with follow-up with a psychiatrist.
A review of the skilled nursing facility clinical record indicated Resident 1 was admitted, on XXXXXXXX17, with diagnoses which included acute renal failure (damage to the kidneys), recurrent major depressive disorder, psychosis (characterized by an impaired relationship with reality, a symptom of serious mental disorders) not due to substance or known physiological condition, and anxiety disorder. There were no diagnoses of history of suicide or suicidal ideation.
A review of the physician's orders, dated 1/4/17, indicated Resident 1 was to receive Zyprexa 5 milligrams (mg) at bedtime for psychosis manifested by recurrent outbursts of anger, Ativan 1 mg every six hours as needed for recurrent feelings of worrying regarding current medical condition, Wellbutrin SR (slow release) 200 mg every day for depression manifested by episodes of persistent weight loss and loss of appetite, Cymbalta 30 mg at bedtime (increased dosage) for depression manifested by episodes of persistent feelings of hopelessness and helplessness, Restoril 7.5 mg at bedtime as needed for insomnia (difficulty falling or staying asleep) manifested by episodes of inability to sleep, and Trazadone 100 mg at bedtime for depression manifested by episodes of persistent fatigue or loss of energy (a total of six different medications).
A review of Resident 1's care plan for behavioral and psychotropic medications (any medication capable of affecting the mind, emotions, and behavior), dated 1/4/17, indicated the nursing interventions were to determine triggers and de-escalation techniques, monitor for antecedal behaviors, minimize environmental stressors, utilize diversion distraction or redirection to limit reoccurrence, and social services to encourage expression of anger, frustration, and guilt. The care plan did not indicate the frequency to monitor the resident.
According Resident 1's Medication Administration Record, dated 1/4/17, at 11:20 p.m., Ativan 1 mg was administered to the resident for anxiety and a review of the resident's licensed nurse progress notes, dated 1/4/17, indicated no documented evidence the facility staff provided above interventions to relieve the resident's anxiety. During an interview, on 2/14/17, at 10 a.m., when asked if staff conducted the care plan interventions with Resident 1, the Director of Nursing (DON) stated the resident was fine.
A review of Resident 1's care plan for history of suicidal ideation, dated 1/5/17, indicated the goals included for the resident to discuss with staff and nurses, things that can trigger suicidal thoughts, and the resident would state he believed his life had value. The care plan interventions included being alert to the resident's behaviors especially decreased communication, conversation about death, to be alert for any manipulative attention seeking behavior, to assess or identify situations that may trigger suicidal thoughts, and clarifying things that were not under the residents control, such as other's actions, choices and health status.
A review of Resident 1's care plan for history of suicidal attempts, dated 1/5/17, indicated the goals included for the resident to have no recurring suicidal thoughts and express feelings and concerns to staff. The care plan interventions included orienting the resident to new environment, assessing for negative emotions, anger, anxiety and depression, redirecting behavior, and obtaining a psychiatric and psychology consultation.
A review of the licensed nurses progress notes dated 1/5/17, indicated Resident 1 was assessed by occupational therapy with a recommendation made for treatment. There was no documentation regarding Resident 1's psychosis, his behaviors (especially decreased communication or any conversations about death), orienting the resident to new environment, or assessing for negative emotions, anger, anxiety or depression, per the care plan.
According to the physician's order, dated 1/6/17, at noon (two days after Resident 1 was admitted to the skilled facility) Resident 1 was to receive a psychiatry consult and a psychology consult. A review of the clinical record indicated there was no documented evidence Resident 1 was seen by the psychiatrist or psychologist while in the skilled nursing facility from 1/4/17 - 1/7/17.
On 2/14/17, at 9:30 a.m., an interview was conducted with RN 1 who stated, on 1/6/17 around 9:30 a.m. through 10 a.m., RN 1 was going over medications with Resident 1. During this time, the resident asked to speak with the Psychiatrist and Nurse Practitioner (NP) regarding making adjustments to the medications. RN 1 called the Psychiatrist office and spoke with the NP. RN 1 informed the NP of the resident's requests, and the NP informed RN 1 she would come visit the resident on Monday, 1/9/17 (three days later).
A review of the Social Service Notes, dated 1/6/17 (no time documented), indicated Resident 1 was scheduled to see the psychologist on 1/10/17 (6 days after resident admitted to the facility). This indicated a psychiatric and psychology consult was not conducted, per the plan of care.
A review of the licensed nurse?s progress notes dated 1/6/17, indicated laboratory results were received and sent to the physician. There was no documentation regarding Resident 1's psychosis, being alert of the resident's behaviors especially decreased communication, or conversation about death, orienting the resident to new environment, assessing for negative emotions, anger, anxiety or depression, per the care plan.
According to the clinical record and licensed nurses progress notes, dated 1/7/17, there was no documentation that the social services department or a licensed nurse interviewed Resident 1 to determine if the resident had an immediate plan to injure himself, per facility policy. During an interview, on 2/14/17, at 10 a.m., when asked if staff implemented any of Resident 1's care plan interventions or followed facility policy regarding care, the DON stated the resident was fine.
A review of the Change of Condition Assessment Form, dated 1/7/17, at 4:20 p.m. (three days after admission) indicated Resident 1 was found in the bathroom unresponsive with a shoelace wrapped around the resident's neck. The charge nurse documentation on the change of condition form indicated, at 4:30 p.m., LVN 1 heard CNA 1 calling for help. LVN 1 came to Resident 1's room and found the resident slumped on the floor with the resident's back against the wall and a cord wrapped around the resident's neck. LVN 1 immediately called 911 and asked for assistance. LVN 1 found the resident unresponsive, cold to touch, pale face, lower extremities cyanotic (blue or purple in color), no pulse and not breathing. The change of condition form indicated RN 1 cut the shoelace from Resident 1's neck with scissors in an attempt to render CPR (cardiopulmonary resuscitation). The paramedics arrived at the facility, rendered CPR for two to three minutes with no success and declared Resident 1 expired.
During an interview, on 1/10/17, at 11 a.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 1 was alert, oriented, and was independent with walking in and out of the facility. CNA 2 stated she last saw the resident in bed at 2:45 p.m., on the day of the incident (1/7/17). CNA 2 stated the nursing staff never informed her Resident 1 had problems with suicide attempts or hurting himself, and had she known, she would have monitored the resident more often.
On 1/10/17, at 1 p.m., a telephone interview was conducted with CNA 1 who stated on the day of the incident (1/7/17), around 4:20 p.m., CNA 1 went to check on Resident 1's roommate. The roommate asked CNA 1 to check on Resident 1 in the restroom because the resident had been gone for a while. CNA 1 stated she opened the bathroom door in the room and found the resident sitting on the floor with a shoelace wrapped around the resident's neck. CNA 1 yelled out for help and LVN 1 ran in to the room.
During a telephone interview, on 1/10/17, at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on the day of the incident (1/7/17), CNA 1 yelled out for help. LVN 1 ran to Resident 1's room and found the resident slumped on the floor with a shoelace or cord tied to the resident's neck on one end and the other end was tied to the grab/towel bar. The resident was not responsive. LVN 1 stated she attempted to loosen the cord, but it was too tight. LVN 1 called 911 paramedics and asked for help. RN 1 cut the cord with scissors and attempted to render CPR.
On 1/12/17, at 11:20 a.m., an interview was conducted with Resident 1's roommate (Resident 2), who was alert and oriented. Resident 2 stated he was admitted to the facility on XXXXXXXX17 and Resident 1 confided in him stating he was "useless," had no "purpose in life," and "not wanting to live." Resident 2 stated he was unaware Resident 1 attempted suicide in the past and he would have asked the staff to monitor him more closely had he known the resident had a history of suicide attempts.
During an interview, on 2/14/17, at 10:10 a.m., the DON stated if Resident 1 showed signs or stated he was suicidal, then the facility would take actions to supervise and prevent the resident in attempting suicide, but since he seemingly did not show signs, they expected him to only receive physical therapy rehabilitation and go home. However, the DON also stated he was aware of Resident 1's psychological medical condition due to a previous denial of Resident 1's admission to the facility one day prior.
According to the facility's in service calendar, dated from August 2015 through December 2016, facility staff was not trained regarding how to handle residents with psychological disorders or handling residents with a history of multiple suicide attempts.
A review of Resident 1's Certificate of Death, dated 1/7/17 at 4:40 p.m., indicated the immediate cause of death was Asphyxia (a lack of oxygen or excess of carbon dioxide in the body that results in unconsciousness and often death and is usually caused by interruption of breathing or inadequate oxygen supply). The Certificate of Death indicated the underlying cause of death was by 'hanging'. The description of how injury occurred was by hanging self with a ligature (a thing used for tying or binding something tightly).
A review of the facility's policy and procedure titled, "Behavior - Threats to Harm Self," dated 1/1/12, indicated the facility was to respond appropriately to residents who were verbalizing suicidal thoughts and/or comments about self-harm. The procedures included social services department and/or licensed nurse would interview the resident to determine if the resident had an immediate plan to injure him/her self.
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; failed to develop and implement a comprehensive person-centered care plan for Resident 1 that included a description of services to attain or maintain the resident?s highest practicable physical, mental, and psychosocial well-being; failed to ensure that its residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident?s choices; and failed to ensure that the resident environment remains as free of accident hazards as possible, and that each resident receives adequate supervision to prevent accidents and injuries, including but not limited to:
1. Failure to ensure Resident 1, who had a history of attempted suicide, was assessed and monitored for suicidal ideation.
2. Failure to provide supervision consistent with Resident 1's needs, goals, and plan of care.
3. Failure to obtain a psychiatric and psychological consultation, per Resident 1?s plan of care.
As a result, on 1/7/17, at 4:20 p.m. (three days after admission), Resident 1 was found in the bathroom slumped on the floor, with a shoelace tightly wrapped around his neck, cold to touch, and unresponsive, three days after the resident was discharged from the general acute care hospital (GACH) psychiatric unit. Resident 1's face was pale and his lower extremities were cyanotic (blue or purple in color). The registered nurse cut the shoelace with scissors, and the facility called 911. Shortly after arrival, the paramedics declared Resident 1 expired.
The violation of these regulations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000037 |
Flower Villa, Inc. |
940012872 |
A |
7-Jan-17 |
JYRG11 |
13669 |
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. F323 - 42 CFR 483.25(h) (2). Accidents and Supervision. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision by failing to: 1. Provide frequent visual checks and monitoring to Resident 1 for seizure activity (a neurological condition where the brain electrical nerve activity is disturbed causing a person to have uncontrollable body movement and loss of consciousness, also known as convulsions) starting 10/26/16 when Resident 1's laboratory test results on 10/26/16 indicated that Resident 1's Dilantin (a medication used to treat seizures) level was low or sub-therapeutic (not producing a therapeutic effect) at 9.6 mcg/mL (normal range is 10.0 mcg/mL to 20.0 mcg/mL), in accordance with the fall and seizure precautions plans of care, placing Resident 1 at risk for seizures/fall. 2. Communicate to the licensed nurses Resident 1?s sub-therapeutic Dilantin blood level so that the licensed nurses could monitor the resident for a seizure episode and prevent a fall related to a seizure. 3. Conduct an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) care conference after a significant change in Resident 1's condition, wherein the resident had fallen secondary to a seizure, and develop a care plan addressing and managing the seizure and fall when the resident returned to the facility. Resident 1 sustained a six-centimeter (cm) forehead laceration from a fall on 11/9/16 at 4:50 a.m. due to a seizure (14 days after a low Dilantin level was identified on 10/26/16). Resident 1 was transferred and admitted to the general acute care hospital (GACH) from XXXXXXX to XXXXXXX, was given intravenous (IV, given directly into a vein) fluids, provided an anti-seizure medication and medication for nausea, given oxygen, and was diagnosed with a traumatic head injury and forehead injury after a fall related to a seizure. Upon return to the facility, Resident 1 had abnormally low lab level of Dilantin (medication to treat seizure), placing Resident 1 at risk to have another fall. A review of Resident 1's face sheet (admission record) indicated the resident was a 60-year-old female, who was admitted to the facility on XXXXXXX with diagnoses that included seizure disorder. The resident was hospitalized prior to the facility's admission, from XXXXXXX to XXXXXXX and was found to have Dilantin toxicity (a high level of Dilantin). A review of Resident 1's Minimum Data Set, (MDS, a comprehensive medical, mental, and psychosocial standardized assessment and care planning tool), dated 10/4/16, indicated that the resident had no hearing, speech, or vision problems, but had a moderate cognitive impairment (moderate amount of difficult remembering, focusing, and concentrating). The resident had no mood problems but required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with one staff for physical assist with transferring, walking, getting around the facility, toilet use, and personal hygiene. A review of Resident 1's admission physician's order, dated 10/4/16, indicated to administer to the resident Dilantin (generic name is phenytoin) in liquid form, 250 milligrams (mg) orally twice a day. According to Pfizer (2016) pharmaceutical company, the manufacturer of Dilantin (phenytoin), Dilantin is a prescription medicine used to treat seizures and prevent seizures?and careful monitoring of phenytoin serum levels should be carried out by your doctor to determine optimal dosage adjustments. Phenytoin doses are usually selected to attain therapeutic (blood) plasma total phenytoin concentrations of 10 to 20 micrograms per milliliters (mcg/mL), the normal range. Dilantin blood drug level results are used to individualize the Dilantin drug amount to be given in order to be within a safe level, or therapeutic range, to maintain the person's risk for seizing as low as possible. A review of Resident 1's fall risk assessment, dated 10/4/16, indicated that the resident was at high risk for falls. A review of Resident 1's fall care plan, initiated on 10/5/16, indicated that the staff will implement fall precautions and monitor for the side effects of the medication laboratory (lab) levels. A review of Resident 1's seizure precaution care plan, initiated on 10/10/16, indicated the resident was a high risk for injury due to seizure activity and use of the medication, Dilantin. The resident goals included not having a fall or injury in the next three months and the Dilantin level would be within normal limits from 10 mcg/mL to 20.0 mcg/ml. The interventions included but not limited to implementing the fall and seizure precautions, such as providing frequent visual checks and monitoring for the side effects of the medication lab levels. A review of Resident 1's physician's order, dated 10/25/16, indicated to draw serum (blood) Dilantin every month on the 4th Wednesday starting on 10/26/16. A review of Resident 1's laboratory results, dated 10/26/16, indicated the resident's Dilantin blood level was low or sub-therapeutic, at 9.6 mcg/mL, placing the resident at risk for seizures. The physician did not give new orders after being informed of the resident's low Dilantin blood level. Resident 1's clinical record did not have documented evidence the fall and seizure precautions care plans were revised to implement measures to prevent falls and injuries from a seizure activity due to a sub-therapeutic Dilantin blood level obtained on 10/26/16 (prior to the fall on 11/9/16). According to the article titled, "How to assess phenytoin (generic name for Dilantin) levels," published by Nursing 2005, page 19, Volume 35, Number 11, indicated, "The goal for any patient is to be free of seizures with minimal adverse reactions. Your patient can best achieve this goal by following an individualized plan of care that focuses on her needs." A review of Resident 1's nurse progress notes indicated that on 11/9/16 at 4:50 a.m., the resident was found in the hallway of the facility with a bleeding cut to the forehead (the resident had an unwitnessed fall). The resident was agitated, anxious, and unable to verbalize the account of what happened to her and how she got hurt. The resident was transferred to a GACH and was admitted. A review of Resident 1's GACH physician notes indicated the resident arrived at the emergency department (ED) on 11/9/16 and was found to have a six-centimeter (cm) forehead laceration (deep cut or tear of the skin) after a fall related to a seizure. Resident 1 required the ED physician to repair her forehead laceration and a hospital staff to insert an intravenous (IV, within a vein) catheter for fluids infusion, receive an anti-seizure medication and medication for nausea, receive oxygen, and to have a computerized axial tomography scan, (CAT scan, a type of x-ray imaging of that views the area in slices and is able to see inside the body's bone, organs, arteries, etc. and is used in diagnosing patients) of the head and spine. A review of the Resident 1?s GACH laboratory report, dated 11/13/16, indicated the resident?s Dilantin blood level was within normal range at 12.7 mcg/ml. Resident 1 was discharged from the GACH on XXXXXXX with a diagnosis of traumatic head injury and forehead laceration after a fall related to a seizure. A review of Resident 1's physician's orders indicated Resident 1 was readmitted to the facility on XXXXXXX from the hospital with a diagnosis of seizures with a recent fall. A review of Resident 1's clinical record indicated there was no documented evidence the facility conducted an IDT care conference upon the resident's return to the facility. Resident 1's care plans for high risk for fall (dated 10/5/16) and high risk for injury due to seizure activity (dated 10/10/16) were not reviewed and revised to reflect the Resident 1's change of condition (a fall due to a seizure sustaining head injury). A review of the facility's revised December 2009 policy on care plans indicated each resident care plan is designed to incorporate risk factors associated with identified problems and aid in preventing or reducing declines in the resident's functional status and/or functional levels. The policy indicated care plan revisions are to be made when there is significant change in the resident's condition, a desired outcome is not met, and the resident has been readmitted to the facility from the hospital. On XXXXXXX at 9:35 p.m., during an interview and review of Resident 1's clinical record with a licensed vocational nurse (LVN 1), LVN 1 stated there was no revision of care plan for seizure in Resident 1's clinical record. On 11/18/16 at 9:40 p.m., during an interview and review of Resident 1's clinical record with the director of nurses (DON), she stated there was no IDT care conference conducted to address Resident 1's change of condition and there was no fall risk assessment completed and revision of care plans for seizure or for fall after Resident 1's readmission to the facility after being recently admitted to the hospital for a fall related to a seizure. On 11/20/16 at 6:15 a.m., during an interview, a licensed vocational nurse (LVN 2) stated that she was not aware of Resident 1's sub-therapeutic Dilantin blood level that measured 9.6 mcg/mL on 10/26/16. On 11/20/16 at 3:10 p.m., during an interview, LVN 3 stated that she was not aware of Resident 1's sub-therapeutic Dilantin blood level that measured 9.6 mcg/mL on 10/26/16. On 11/20/16 at 9:35 p. m., during an interview, Resident 1 stated that she fell hard at the facility while having a seizure, which gave her a forehead wound and head pain. Resident 1 stated she had recently returned to the facility and had not had an interdisciplinary care plan meeting with the facility staff to discuss her new plan of care since her 11/9/16 fall related to seizure. During a concurrent observation, Resident 1 had a six-centimeter linear forehead laceration with a scab, which was covered with steri-strips (rectangle bandages used to join a wound for healing). The resident was observed with mild swelling to the area under her eyes. On 11/20/16 at 10:30 p.m., during an interview, the director of nursing (DON) stated she forgot to place a copy of the Resident 1's sub-therapeutic Dilantin blood level of 9.6 mcg/mL report, dated 10/26/16, to the resident?s clinical chart. The DON stated the resident's blood level report should have been in the clinical chart for the facility staff to see. The DON stated there was no immediate interdisciplinary care plan meetings, care plan revisions (for fall and seizure precautions as a result of the sub-therapeutic Dilantin blood level), and fall risk and/or re-assessments completed for Resident 1 after the facility received Resident 1's sub-therapeutic Dilantin blood level laboratory report on 10/26/16. A review of Resident 1's Dilantin blood level that was collected on 11/20/16 at 6:40 p.m., with a test result that was completed at 11:25 p.m. on the same day, indicated the resident?s Dilantin level was sub-therapeutic at 3.2 mcg/ml. A review of the facility's policy and procedure, revised on October 2010, and titled, "Lab and Diagnostic Test Results- Clinical Protocol," indicated the reason for monitoring a drug level is because it affects the urgency of acting upon the result. The policy indicated if the staff that first receive or review lab test results cannot follow the remainder of this procedure for reporting and documenting the results then, another nurse in the facility should. The facility failed to provide adequate supervision by failing to: 1. Provide frequent visual checks and monitoring to Resident 1 for seizure activity (a neurological condition where the brain electrical nerve activity is disturbed causing a person to have uncontrollable body movement and loss of consciousness, also known as convulsions) starting 10/26/16 when Resident 1's laboratory test results on 10/26/16 indicated that Resident 1's Dilantin (a medication used to treat seizures) level was low or sub-therapeutic (not producing a therapeutic effect) at 9.6 mcg/mL (normal range is 10.0 mcg/mL to 20.0 mcg/mL), in accordance with the fall and seizure precautions plans of care, placing Resident 1 at risk for seizures/fall. 2. Communicate to the licensed nurses Resident 1?s sub-therapeutic Dilantin blood level so that the licensed nurses could monitor the resident for a seizure episode and prevent a fall related to a seizure. 3. Conduct an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) care conference after a significant change in Resident 1's condition, wherein the resident had fallen secondary to a seizure, and develop a care plan addressing and managing the seizure and fall when the resident returned to the facility. 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. |
| 950000006 |
FIDELITY HEALTH CARE |
950009371 |
AA |
03-Jul-12 |
6M4I11 |
10233 |
F323 42 CFR ? 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This requirement was not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a safe resident environment, adequate supervision and assistive devices for Resident A, who had a history of elopement and had exhibited unsafe wandering. Although Resident A was wearing a ?WanderGuard?, bracelet, Resident A eloped from the facility unnoticed and was found dead on the freeway several hours later with his ?WanderGuard?, still in place on his wrist. Findings: On February 18, 2011, an unannounced visit was made to the facility to investigate an entity reported incident regarding a resident who wandered out of the facility on February 17, 2011, and was later found dead on a freeway. A review of a letter addressed to the Department submitted by the administrator indicated that a full internal investigation was in process. However the facility investigation report reviewed by the evaluator did not include a description or conclusion on how Resident A exited the building undetected by facility staff and/or the wander-guard system. Resident A was a 76-year old male who was admitted to the facility on February 12, 2011, with diagnoses that included rheumatoid arthritis, hypertension, anxiety, insomnia, and senile dementia. A wandering risk assessment dated February 12, 2011, which was conducted as a part of the facility?s admission protocol, indicated that Resident A was ambulatory and able to walk alone and was considered at risk for wandering. The Plan of care developed was for staff to conduct visual checks at least every two hours. The review of Resident A?s licensed nurses? notes indicated that on 2/13/11, the Resident was reported as being missing around 12 noon and was later returned to the facility by the police department around 10pm. The facility did not develop any monitoring checks prior to the first elopement on 2/13/11. A second wandering assessment was then done on 2/14/11, and the Resident was determined to be at risk for wandering. The plan of care developed to reduce the risk associated with wandering included:* To apply a ?WanderGuard? * Monitor every hour * Transfer to a room far away from a door.A review of the resident?s medical record revealed the resident was transferred from room 2 (located near the main entrance in the front of the building) to room 19 (located in the back of the facility) on 2/14/2011.A review of Resident A?s medical record dated February 17, 2011, revealed the following timed entries: 5:00 pm- Resident A was found sitting on his bed in his room waiting for his dinner tray. 5:15 pm- CNA reported that resident was nowhere to be seen. The licensed nurse looked for him around the facility. 5:17 pm- The licensed nurse asked four nursing aides to start looking for the resident within a five mile radius from the facility. 5:19 pm- The remaining nurse aide staffs were instructed to start searching for resident in every room and within facility vicinity including alleys and parking lots. 5:21 pm- An attempt was made to contact the Daughter of Resident A. There was no answer and therefore, a voice mail message was left stating to call the licensed nurse back. 8:15 pm- Police Officer arrived at the facility to provide a case number. 10:51 pm- Received phone call that Resident A was hit by a car on the freeway and died.? During an interview with Employee 1, a certified nurse assistant, on February 18, 2011, at 4:00 p.m., regarding the second episode of Resident A wandering out of the facility on February 17, 2011, he stated that on February 17, 2011, at 5:00 p.m., during dinner time, he saw that Resident A had his clothes on and was carrying a small suitcase. Employee 1, a certified nurse assistant, stated that he redirected Resident A and told him to go back to his room since it was time for dinner, and that he would bring Resident A?s dinner tray to him so he could eat his dinner.Employee 1, a certified nurse assistant, stated that when he saw that Resident A?s food tray was not on the cart, he went to the kitchen to get Resident A?s tray. Employee 1, a certified nurse assistant, stated that fifteen minutes later, he returned to Resident A?s room with his food tray and noticed that Resident A was missing from his room. During an interview with Employee 2, on February 18, 2011, he stated that Resident A had wandered out once before on February 13, 2011, but came back the same day. Employee 2, stated that Resident A was returned to the facility by the police department around 10 pm. A ?Wander-Guard? bracelet had been put on his wrist after that first episode.The evaluator conducted an inspection of the building on February 18, 2011, at 4:00 p.m., and observed five exit doors. Two of the doors had ?WanderGuard? alarms installed on them (the exit doors located at the main entrance and the kitchen) while the other three (the exit doors located between rooms 4 and 5, 30 and 31 and rehabilitation room and MDS office) did not have the ?WanderGuard? alarms but had a buzzer-like key lock alarm connected to the door. Two of the three doors mentioned above (the exit doors located between rooms 4 and 5 and 30 and 31) operated in such a way that, when the door is opened, a buzzer would initiate an auditory alarm. The only way to turn off the buzzer would be to insert a key in the key hole of the buzzer installed mechanism on the door to turn it off. A review of the facility?s wander guard log sheet on February 18, 2011, revealed that the ?WanderGuard? doors were tested every 7 days and on February 14, 2011, the log sheet indicated they were working. The exit door by the rehabilitation room and MDS office did not have any kind of an alarm or WanderGuard system. During a second interview with the Employee 2, on June 3, 2011, at 1:30 pm, he stated that at the time of the elopement of Resident A on February 17, 2011, there was no alarm system, ?WanderGuard? system or buzzer-like alarm system installed on the exit door located by the rehabilitation room and MDS office and that was the location from which the resident probably escaped. He also stated that there should have been an alarm system installed on that exit door. Employee 2, further stated during the interview that the system would be more completely secure if all five doors had ?WanderGuard? units installed. Employee 2 stated that he had tried without any success to get approval from the owner to buy ?Wander-Guard? sensor units for all of the remaining exit doors since his date of hire on August 5, 2010. Employee 2 also said that the resident?s WanderGuard bracelets are tested by the social service designee and a copy of the log sheets documenting the tests were given to him and that the ?WanderGuard System? was tested monthly.?During a review of the log sheets for the testing of the ?WanderGuards,? the facility was unable to provide any written documentation to indicate that the Wander-Guard bracelet assigned to Resident A had been tested before it was placed on him.A review of the manufacturer?s instructions indicate to test each signaling device before using and to thereafter, test the device daily and record the results in the resident?s record. Based on an interview with the Director of Nurses on March 8, 2012, at 2:00 p.m., she stated the ?WanderGuard? device applied to Resident A was a brand new device.A review of the facility?s policy titled ?WanderGuard? dated 2010 indicated that the social service staff will check the ?WanderGuard? every month and as needed for proper functioning and expiration date, and will replace the battery of the ?WanderGuard? as needed. The social service staff could not be interviewed because the staff no longer worked at the facility. Employee 1, a certified nurse assistant, stated in an interview on February 18, 2011, that he did not hear the sound of the alarm between the time he saw Resident A sitting on his bed and the time he returned to the room with his dinner tray. A review of the facility?s policy on wandering effective 2008, indicated to use alarm systems and door alarms, and ?WanderGuard? bands. It also indicated to use visual barriers such as stop signs, yellow ribbon curtain, and to cover door knobs.The DON stated during an interview on March 8, 2012, at 2:00 p.m., that there were two other residents who were wanderers at the time of the incident.A review of the photographs included in the traffic collision report dated April 7, 2011, that was obtained from the State highway patrol revealed that, Resident A was wearing a ?WanderGuard? bracelet on his right wrist at the time that he was hit by the motor vehicle. The location of the accident was on Interstate 605 Southbound, 975 feet south of lower Azusa road. This was approximately two miles from the facility. The time of the collision was February 17, 2011, at 6:20pm. This was one hour and five minutes after Resident A was determined to be missing from the facility.A review of the Coroner?s medical report dated February 18, 2011, indicated that the immediate cause of death of Resident A was Multiple Blunt Force Injuries, with the injuries occurring from an accident between an auto and a pedestrian.Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices, and to maintain a safe and secure environment for Resident A, who had a history of elopement and had exhibited unsafe wandering in violation of the regulation, including but not limited to:Not ensuring that the WanderGuard alarm system was fully installed on all five exit doors in the facility to ensure that Resident A, who had a wander guard bracelet in place, did not elope from the facility unnoticed.These violations presented a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Resident A. |
| 950000006 |
FIDELITY HEALTH CARE |
950012064 |
AA |
24-May-16 |
E5GN11 |
14415 |
42 CFR ? 483.25(h) F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR ? 483.25 F309 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident A was a 67 year- old woman with a diagnosis of major depression and a history of several suicidal attempts. Resident A was found on the floor with her head hanging the side rail of her bed with a piece of cloth around her neck, unresponsive and not breathing, on XXXXXXX 2015 at 2:55 p.m. Resident A was pronounced dead on XXXXXXX 2015 at 3:10 p.m. Based on record review and interview, the facility failed to ensure Resident A?s environment was free of accident hazards, and failed to provide adequate supervision and assistance to Resident A to prevent suicide; and failed to provide Resident A with the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The failures include but are not limited to: 1. Failure to remove dangerous objects, such as a belt that could be used as a ligature, from the resident?s environment, in accordance with the facility?s policy and procedure for suicide threats. 2. Failure to provide constant and ample supervision to Resident A when in possession of dangerous objects, in accordance with the facility?s policy and procedure for suicide threats. On March 5, 2015, at 1:10 p.m., an investigation was initiated regarding Resident A, who strangled herself and expired at the facility. Record reviews with the Administrator indicated Resident A was originally admitted to the facility on XXXXXXX, having a history of two suicide attempts as follows: On XXXXXXX, Resident A was admitted to an acute hospital (Hospital 1) due to attempted suicide by ingesting toilet bowl cleaner and trying to cut her wrist. On March 24, 2010, while at Hospital 1, Resident A made another attempt to commit suicide by using an IV (intravenous-flexible plastic tubing) tubing to strangle herself. On XXXXXXX, Resident A was transferred from Hospital 1 to a psychiatric hospital (hospital specializing in the treatment of serious mental disorders), Hospital 2. The psychiatric report from Hospital 2, dated April 7, 2010, indicated Resident A needed continued psychiatric care. The discharge summary from Hospital 2, dated April 8, 2010, indicated Resident A had severe depression with suicide attempt. The report indicated Resident A stated she could not guarantee that she would not try to harm herself again. Resident A was admitted to the skilled nursing facility on XXXXXXX. On XXXXXXX, she was discharged to an acute hospital due to another suicide attempt. According to a "Discharge Summary" from that hospital, dated December 20, 2013, Resident A was transferred to another acute hospital, Hospital 3, due to a suicide attempt. On March 5, 2015, a review of the psychiatric evaluation conducted at Hospital 3, dated December 20, 2013, indicated Resident A tried to use clothes or a bed sheet to try and strangle herself in her bathroom at the skilled nursing facility, and there were strangle marks over the resident's neck. Resident A was brought to the emergency room, was placed on 72-hour hold for danger to self and was transferred to a psychiatric unit for acute psychiatric care and treatment. The psychiatric evaluation indicated Resident A heard voices telling her she has to kill herself, which was why she went to the bathroom and tried to strangle herself. The record reflected that Resident A felt depressed, hopeless, useless and with some bizarre delusions (false beliefs) that her family members, her son and daughter, were going to kill themselves. The evaluation further indicated there were also auditory hallucinations (perception of something not present, ?voices?) telling her to kill herself, or her family members were going to do so. The resident was placed on suicidal precautions and due to major depressive disorder with psychotic (diminished or distorted sense of reality) feature and suicidal attempt. Hospital 3 discharged Resident A back to the skilled nursing facility on XXXXXXX. The skilled nursing facility's admission face sheet indicated Resident A was readmitted to the facility from Hospital 3, on December 27, 2013, with diagnoses that included Parkinson's Disease (a central nervous system disorder that causes shaking, slowness of movement), dementia (decline in mental ability, severe enough to interfere with daily life), hypertension (elevated blood pressure), and major depression (a mental disorder of low mood that is accompanied by low self-esteem and a loss of interest in normal daily activities), and seizure disorder (body shakes uncontrollably). Resident A's physician's orders, on December 27, 2013, included Effexor XR 75 milligrams (mg) (a medication used to treat major depressive disorder, anxiety, and panic disorder) once a day by mouth, for depression manifested by verbalization, "I feel depressed"; Zyprexia 7.5 mg. for psychosis (severe mental disorder in which thoughts and emotions are impaired by a diminished or distorted sense of reality), manifested by auditory hallucinations (hearing voices saying someone will kill her son so she has to leave to save him); and Lorazepam 0.5 mg, by mouth, as needed every 6 hours, for anxiety manifested by agitation. On March 5, 2015, a review of the comprehensive care plan dated January 2, 2014, indicated the facility identified Resident A was at risk for further self-harm related to self-strangulation. The listed approaches included to monitor, document and report resident potential for suicide, monitor the resident's whereabouts, and monitor behavior manifestations daily. The plan also included to encourage religious functions. Another care plan dated April 28, 2014, indicated Resident A had depression manifested by the resident's verbalization of feeling depressed; and having auditory hallucinations, such as hearing voices saying her son will be killed and she has to leave to save him. The listed approaches included to monitor the resident's behaviors each shift and report any changes to the physician. The plan did not include specific measures of monitoring. The interventions failed to indicate environmental checks to remove objects the resident could use to harm or strangle herself again. An activity care plan, re-evaluated on June 2014, indicated Resident A attended group activities of choice, but preferred to stay in her room when not in the activity room. The interventions included to invite/encourage the resident to attend participate in group activity, be patient and give simple instructions, and call resident by her name. The plan failed to indicate precautions of not providing objects that may be used to harm herself. A nursing progress note, dated November 30, 2014, indicated Resident A left the facility undetected. When asked about what happened to her WanderGuard (departure alert signaling security device, worn as a bracelet), Resident A showed the staff the WanderGuard bracelet that was cut and hidden under her pillow. The staff also found scissors inside Resident A's sewing kit, which were removed from the sewing kit with the resident's permission. However, the care plans, including the activity plan, were not revised to ensure the resident was not provided anything that she could use to harm herself. The Minimum Data Set (a standardized assessment and care planning tool), dated January 12, 2015, indicated that Resident A spoke clearly, made herself understood, was able to understand others, needed supervision (cueing, oversight, encouragement) for activities of daily living. The current diagnosis indicated seizure disorder and depression. On March 5, 2015, a review of the social work progress notes, dated February 26, 2015, indicated Resident A had an increased behavior of auditory hallucinations such as hearing voices (someone is going to kill her son so she has to leave to save him). The social worker documented that the resident?s physician and her psychiatrist (a medical doctor who specializes in mental health) were made aware and her son was made aware of Resident A?s increased behavior and encouraged to visit the resident for emotional support and reassurance. The note indicated the psychiatrist would visit the resident during the first week in March. There was no evidence the Social Worker coordinated with the nursing staff to revise Resident A's plans of care for closer monitoring. There was no evidence the nursing staff monitored the resident's depression and potential for suicide, in accordance with the plan of care. The licensed nurses' weekly notes and the licensed progress notes, from January 14, 2014 to March 2, 2015, did not indicate licensed nurses assessed Resident A for suicidal ideation related to depression. A review of the psychiatric progress note dated March 2, 2015 indicated that Resident A was depressed, paranoid, but denied suicidal thoughts. This progress note also stated the resident said she just wanted to go to church to see if her son was safe or not. The nurses' progress notes indicated that, on March 4, 2015, at 12:30 p.m., when the CNA (Certified Nursing Assistant) was about to serve lunch, Resident A was not in the room. The staff searched all over and they found the resident at the Buddhist Temple about 50 yards away from the facility. On March 4, 2015, at 2:30 p.m., Licensed Vocational Nurse (LVN) 2 documented in the Nurses Progress notes that during visual rounds, Resident A was in bed, crying, and the resident refused to eat. There was no indication the staff identified the behavior exhibited as signs of depression. The staff did not conduct an environmental check or provide continuing supervision to ensure the resident was safe and not voicing suicidal thoughts. At 2:55 PM, LVN 2 indicated in the Nursing Progress, seeing Resident A on the floor with her head hanging against the side rail of her bed, with a piece of cloth around her neck. Nursing staff removed the piece of cloth and started CPR (cardio-pulmonary resuscitation) and called 911. On March 5, 2015, at 1:30 p.m., during an interview, LVN 2 narrated the following: On March 4, 2015, at 2:30 p.m., she checked Resident A, who was in her room located across the nursing station. She observed Resident A lying in bed, crying. The privacy curtain was not drawn. Resident A told LVN 2 that she was worried about her son. At 2:55 p.m., LVN 2 returned to Resident A's room, and observed the resident's privacy curtain was drawn. As LVN 2 entered the resident's room, Staff 2 saw the resident lying on the floor (next to her bed) with the resident's upper body leaning against the bed. LVN 2 opened the resident's privacy curtain and saw Resident A's face was blue and not breathing. LVN 2 immediately called Code Blue (a medical emergency code). In less than a minute, another nursing staff came into the room and tried to assist LVN 2 to place Resident A on her bed. Staff 2 explained that two staff were not able to move the resident because there was a cloth belt tied around Resident A's neck. LVN 2 released the belt, placed the resident on her bed and initiated CPR (Cardiopulmonary Resuscitation-An emergency procedure performed manually to restore spontaneous blood circulation and breathing in a person who is in cardiac distress.) Within a couple of minutes, paramedics arrived and took over the CPR, but they were not able to revive the resident. At 3:10 p.m., Resident A expired. During an interview with the Administrator on March 6, 2015, at 3 p.m., when asked about how staff monitored Resident A, the Administrator stated they were monitoring every hour. However, the DON (Director of Nurses) and Administrator were not able to show evidence this was done. When asked about how Resident A obtained the cloth belt that was tied around her neck, the Administrator stated the activity staff (not available for an interview) gave a sewing kit to Resident A as an individual activity. The resident sewed a cloth belt with buttons on it. On March 20, 2015, at 3:30 p.m., a review of the facility's suicide threats policy and procedure, dated August 2009, was conducted with the Administrator. According to the policy, the charge nurse is responsible for removing any dangerous objects from the resident's possession (i.e. glass objects, shoelaces, razors and/or blades, nail clippers or files, metal eating utensils, cords or belts, or excess linen). Residents under suicide precaution are allowed to use these articles only with constant and ample supervision. On September 2, 2015, at 3:10 p.m., a review of the medical examiner's autopsy report dated March 8, 2015, was conducted. According to the medical examiner, Resident A's cause of death was asphyxia (a condition caused by lack of oxygen to the body due to choking which can lead to coma or death) due to hanging. It indicated the resident's manner of death was suicide. The facility failed to ensure Resident A?s environment was free of accident hazards, and failed to provide adequate supervision and assistance to Resident A to prevent suicide; and failed to provide Resident A with the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The failures include but are not limited to: 1. Failure to remove dangerous objects, such as a belt that could be used as a ligature, from the resident?s environment, in accordance with the facility?s policy and procedure for suicide threats. 2. Failure to provide constant and ample supervision to Resident A when in possession of dangerous objects, in accordance with the facility?s policy and procedure for suicide threats. The above violations presented an imminent danger to the resident and was a direct proximate cause of Resident A?s death. |
| 950000006 |
FIDELITY HEALTH CARE |
950013274 |
B |
9-Jun-17 |
9LZI11 |
10017 |
F 157 483.10 (g)(14)
(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in ?483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in ?483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).
F 281 483.21 (b)(3)(i)
(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
F 314 483.25 (b)(1) (b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
On 4/4/2017, at 11:15 a.m., an unannounced visit was made to the facility to investigate a complaint regarding neglect in the care of Resident 2?s pressure ulcers.
Based on observation, interview and record review, the facility failed to:
1. Ensure Resident 2's right heel pressure ulcer did not redevelop.
2. Implement Resident 2's plan of care to float the resident's right heel with a pillow when in bed.
3. Ensure Resident 2's right heel was not directly in contact with the mattress or any pillows.
4. Inform Resident 2's physician that Resident 2's right heel pressure ulcer had redeveloped and did not provide any treatment to the right heel pressure ulcer for 5 days.
A review of Resident 2's Record of Admission indicated Resident 2 was admitted to the facility on XXXXXXX 2017. Resident 2's diagnoses included: pressure ulcer of the sacro-coccyx (lower end of the spine) region, muscle weakness, paraplegia (paralysis of the lower body), and unspecified cirrhosis of the liver (condition in which liver does not function properly due to long-term damage).
A review of Resident 2's Nursing Admission Assessment dated 1/11/2017 indicated Resident 2 had the following pressure ulcers (Pressure ulcer stages (National Pressure Ulcer Advisory Panel (NPUAP)) include: Stage I-presents as intact skin with non-blanchable redness (redness does not go away when pressure is relieved) of a localized area, usually over a bony prominence.) Stage II-characterized by partial-thickness loss of dermis presenting as a shallow open ulcer. Stage III-characterized by a full-thickness tissue loss. Fat under the skin may be visible but bone, tendon, or muscle is not exposed. Stage IV-presents with full-thickness tissue loss with exposed bone, tendon, or muscle exposed.)
1. Right heel- Stage III pressure ulcer on the right heel
2. Sacro-coccyx- Stage IV pressure ulcer
3. Left mid buttock- Stage IV
4. Left lower buttock- Stage III
5. Left medial thigh- Stage III
A review of Resident 2's Braden Scale- for Predicting Pressure Sore Risk dated 1/11/2017 indicated Resident 2's score was 14 indicating a moderate risk for developing a pressure ulcer.
A review of Resident 2's MDS dated 1/20/2017 indicated Resident 2 had five unhealed pressure ulcers and was totally dependent on staff for bed mobility, transfer, toilet use, and personal hygiene.
A review of Resident 2's Alteration in skin integrity/ Potential for development of pressure ulcers care plan dated 1/11/2017 included the following interventions:
1. Daily body checks for redness, open areas, etc.
2. Turn and reposition resident every 2 hours, or more for dependent residents.
3. Use pillows for support (e.g. back, between knees, and to other bony prominence).
4. Provide support surface for heels. Elevate heels off bed surface.
5. Notify MD promptly for any skin breakdown.
A review Resident 2's Nurses Progress Notes indicated Resident 2's:
1. Right heel pressure ulcer healed on 1/20/17.
2. Left lower buttock pressure ulcer healed on 1/27/17.
A review of Resident 2's wound care specialist notes dated 2/24/17 indicated Resident 2's:
1. Sacral coccyx pressure ulcer had healed.
2. Treatments to Resident 2's left buttock and left medial thigh pressure ulcers continued.
On 4/4/17, at 12:10 p.m., an observation and concurrent interview with Resident 2 was done. Resident 2 was observed in lying in a flat position with legs curled up in bed. Both heels were observed resting directly on the mattress. Resident 2 stated he had problems extending his legs to make them straight. Resident 2 stated he had a sore on his left hip, could not get up by himself, and had limited mobility in bed.
On 4/4/17 at 12:30 p.m., 12:50 p.m., 1:45 p.m., 2:45 p.m., and on 4/6/17 at 2:30 p.m., 3:40 p.m., 4:15 p.m. and 4:30 p.m., Resident's 2 was observed still lying in the same position on his back with his legs curled up in bed and with his heels resting on the mattress.
On 4/6/17, at 11:50 a.m., an interview was conducted with Certified Nurse Assistant (CNA 1). CNA 1 stated the facility staff turned residents who are bedridden every 2 hours. CNA 1 also stated she reports any unusual skin observation to the treatment nurse (TN), Charge Nurse (CN) and to the DON.
On 4/6/17, at 2:30 p.m. a treatment observation of Resident 2's wound care was conducted with the TN. The TN proceeded with the treatments to Resident 2's medial thigh and left buttocks pressure ulcers. Resident 2's right heel was exposed and was observed with a purplish maroon color and the skin at the ball of the heel had partially peeled off. At the end of the treatment, TN did not assess Residents 2's other parts of the body.
On 4/6/17, at 3:15 p.m. an interview was conducted with the TN. The TN stated she did not observe any discoloration on Residents 2's right heel and she would re-assess Resident 2.
On 4/6/17, at 3:40 p.m., an observation and concurrent interview was conducted with the DON at Resident 2's bedside. The DON confirmed Resident 2's heels were resting directly on the mattress. The DON stated Resident 2's right heel had discoloration and an open skin area The DON also stated Resident 2 was contracted (chronic loss of joint movement) on both lower extremities and both heels had to be offloaded (kept off the mattress, no pressure to the heels). The DON asked Resident 2 if there was pain on his right heel and Resident 2 responded "it is tender to the touch."
On 4/6/17, at 4:00 p.m., an interview was conducted with CNA 2. CNA 2 stated the facility used a turning clock to remind staff to reposition the residents every 2 hours. CNA 2 also stated that residents who had pressure ulcers to their heels, the heels need to be elevated off the mattress.
On 4/11/17 a review of Resident 2's clinical record indicated that there was no documentation of the following:
1. Resident 2's right heel pressure ulcer had been assessed,
2. Resident 2's physician had been notified of the new right heel pressure ulcer.
3. Resident 2's right heel pressure ulcer received any treatments.
On 4/11/17, at 1:15 p.m., an interview was conducted with the DON. The DON stated she had discussed with the TN Resident 2's right heel condition on 4/6/17. The DON stated and confirmed TN did not assess Resident 2's right heel condition, inform Resident 2's physician, and had not done any treatments to Resident 2's right heel.
A review of the facility policy titled Guidelines for Assessing Potential for Pressure Sores dated 8/2005, indicated:
1. The nurse documents on the comprehensive nursing assessment and nurse's notes all skin problems identified.
2. All pressure points are checked for redness; Turning and repositioning are noted in the daily nurse assistant notes in the residents' charts.
3. When pressure ulcers developed the charge nurse immediately contacts the physician for an order.
Therefore the facility failed to:
1. Ensure Resident 2's right heel pressure ulcer did not redevelop.
2. Implement Resident 2's plan of care to float the resident's right heel with a pillow when in bed.
3. Ensure Resident 2's right heel was not directly in contact with the mattress or any pillows.
4. Inform Resident 2's physician that Resident 2's right heel pressure ulcer had redeveloped and did not provide any treatment to the right heel pressure ulcer for 5 days.
These violations jointly, separately, or in any combination had a direct or immediate relationship to the resident?s health, safety, or security. |
| 630014467 |
Family Circle CLHF, Inc. |
980012854 |
A |
4-Jan-17 |
SCV511 |
21154 |
T22 DIV5 CH3 ART3-72311(a)(2) Nursing Service ? Administration of Medication (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. T22 DIV5 CH3 ART3-72311(a)(3)(B) Nursing Service-General (a) Nursing service shall include, but no 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 October 7, 2016, at 2 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s quality of care and neglect. Based on record review and interview, the facility failed to administer treatment as prescribed by the physician and failed to notify the attending physician promptly of any sudden and marked adverse change in signs and symptoms exhibited by Patient 1, including: 1. Failure to notify the physician when Patient 1 had moderate to large amount of thick, green and/or brown secretions from his tracheostomy tube (a tube inserted into the windpipe to open the restricted airway and enable breathing) on September 28, 29, 30, October 1, 2, and 3, 2016 (total of six days), with episodes of labored breathing and shortness of breath while resting on September 29, 2016 and October 2, 2016. 2. Failure to notify the physician when Patient 1 had several episodes of heart rate above 100 beats per minute, ranging from 154 to 176 beats per minute, on September 29, 30, October 2, and 3, 2016 (total of four days). 3. Failure to notify the physician when Patient 1?s had rust colored urine draining from the urinary catheter (flexible tube passed through the urethra and into the bladder to drain urine) and had hematuria (blood in the urine) on September 29, 30, and October 3, 2016 (total of three days). 4. Failure to administer treatment ordered by the attending physician (Physician 1), by not checking the trach cuff (a balloon outside the tracheostomy tube. When the balloon is inflated, blocks any air from flowing around the tube and assures that the patient is well oxygenated) pressure every shift and as needed, by not checking the trach cuff post manipulation, and by not inflating the cuff to maintain seal pressure. As a result, on October 4, 2016, at 6:40 a.m., Patient 1 coughed and vomited brown liquid with strong fecal odor. At 8:45 a.m., the patient was transferred via paramedics to General Acute Care Hospital 2 (GACH 2) where he was diagnosed with septic shock (bacteria in the bloodstream that can cause multi organ failure and death) with septicemia (blood poisoning) secondary to aspiration pneumonia (inflammation of the lungs which occurs when food, saliva, liquid, or vomit is breathed into the lungs) with the trach cuff deflated, multi-organ dysfunction, tachycardia (resting heart rate over 100 beats per minute), small bowel obstruction (the small intestine is partially blocked and prevents foods, liquids and gas from moving through the intestines), urinary tract infection (UTI - infections in any part of the urinary tract - kidneys, ureters, bladder and urethra), acute on chronic respiratory and renal failure. Patient 1 was also found to have 500 milliliters (ml) of feculent (fecal) material suctioned from the patient's tracheal tube. Additionally, a computerized tomography (CT scan - combines a series of x-ray images taken from different angles) of the abdomen and pelvis (hip) showed the patient's urinary catheter with the balloon inflated was in the urethra (not in the bladder) and the catheter tip was also in the urethra (instead of within the bladder) with associated marked distention of the bladder. Patient 1 was admitted to Intensive Care Unit (ICU) for further treatment on the same day of arrival to GACH 2. A review of the admission record indicated Patient 1 was admitted to the facility on September 20, 2016 with diagnoses including chronic respiratory failure (limited air movement through the body, less oxygen gets in and less carbon dioxide gets out), unspecified hypoxia (low blood oxygen levels) and hypercapnia (excessive carbon dioxide in the bloodstream), stomach cancer, chronic kidney disease, and ventilator dependent (mechanical breathing support because of inability to breathe effectively). A review of the Nursing Admission and Assessment sheet dated September 20, 2016, timed at 10:30 p.m. indicated Patient 1 was initially admitted to the facility from another Congregate Living Health Facility (CLHF) with a tracheostomy connected to a ventilator and a jejunostomy tube feeding (J-tube - a soft, plastic tube surgically placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medicine). Patient 1 was alert, oriented, able to make decisions, and required total care. On September 22, 2016 at 12:30 a.m., the Resident Transfer Record indicated Patient 1 was transferred to GACH 1 due to the J-tube becoming detached. Patient 1 returned on XXXXXXX at 3 p.m., but was sent back to GACH 1 due to elevated temperature and increased heart rate. The Nursing Note indicated on the same day (September 27, 2016) at 8:30 p.m., Patient 1 was readmitted back to the facility. The Nursing Admission and Assessment dated September 27, 2016, timed at 8:30 p.m., indicated Patient 1 was readmitted alert, oriented, able to make needs known, with a tracheostomy connected to the ventilator, had thin and thick white secretions, with a J-tube feeding and an indwelling urinary catheter draining clear yellow urine. Patient 1?s temperature was 97.8 Fahrenheit, pulse was 89 per minute, blood pressure was 140/70, and respiration was 24 per minute. The physician?s orders on readmission indicated to continue previous orders (from the initial admission on XXXXXXX, which included suctioning tracheal secretions every one to two hours and as needed) and to administer the antibiotic Levaquin through the J-tube daily for seven days due to pneumonia. The Physician?s Orders for the month of October 2016 included: provide tracheostomy care; suction tracheal secretions every one to two hours and as needed; check trach cuff pressure every shift and as needed; check trach cuff pressure post manipulation; and inflate the cuff to maintain seal pressure. There were no physician's orders regarding the use and care of indwelling urinary catheter. According to the Nursing Flow Sheet dated September 28, 2016, timed at 10 a.m. Patient 1 was suctioned moderate amount of thick, green/brownish secretion from his tracheostomy tube. Patient 1 had two episodes of bowel movements during the 7 a.m. to 7 p.m. shift and the urine was clear and yellow in color. A Nursing Note dated September 29, 2016, timed at 7 a.m., indicated Registered Nurse 1 (RN 1) notified the attending physician regarding Patient 1?s watery stools with a distinct odor. The physician ordered the antibiotic Flagyl 500 milligrams (mg) every six hours for seven days for prophylactic treatment of the infection with Clostridium Difficile (bacteria that causes inflammation of the colon and diarrhea). The documentation did not indicate RN 1 notified the physician of the thick, green/brownish respiratory secretions suctioned. A Nursing Flow Sheet dated September 29, 2016, timed at 8 a.m., indicated Patient 1?s temperature was 97.4 Fahrenheit (F- normal range between 97-99), the heart rate was 154 beats per minute (normal range between 60-100), the respiration rate was 20 breaths per minute (normal range between 12-20) and the blood pressure was 136/95 mmHg (normal range below 120/90). Patient 1 had large amount of thick, green secretions from his tracheostomy tube. There was no documented evidence the licensed nurses notified the physician of the thick, green secretion from his tracheostomy tube and his increased heart rate. The Nursing Flow Sheet for 7 p.m. to 7 a.m. shift of September 29 to September 30, 2016, indicated Patient 1?s temperature was 96.4 F, the pulse rate was 154 beats per minute, the respiratory rate was 18 breaths per minute and blood pressure was 136/95 mmHg. The patient had labored breathing, shortness of breath while resting, and rhonchi (coarse rattling respiratory sounds caused by secretions in the airways) on both lungs. At 1:45 a.m., the patient had thick, green, brown secretions that were leaking out of the tracheostomy tube. Patient 1 had rust colored urine with hematuria (blood in urine) draining from the urinary catheter. There was no documentation the physician was notified of the change in the color of secretions, the increased heart rate, the rust colored urine and the hematuria. The Nursing Flow Sheet for 7 p.m. to 7 a.m. shift of September 30, 2016, indicated that at 11 p.m., Patient 1 had moderate amount of thick, green and brown secretions upon suctioning the tracheostomy tube. At 12 a.m., the patient?s heart rate was 154 per minute and a breathing treatment was held. At 1:45 a.m., Patient 1 coughed up large amount of thick, green and brown secretions into the respiratory tubing circuit. There was no documentation the physician was notified of Patient 1?s changes in respiratory and urinary conditions, the increased heart rate, and the need to hold a respiratory treatment. The Nursing Flow Sheet for 7 p.m. to 7 a.m. shift of October 1 to October 2, 2016, indicated Patient 1 had diminished lung sounds (by listening to the lungs through the use of a stethoscope), had productive cough with large amount of thick yellow and green secretions from the tracheostomy tube. There was no documentation the trach cuff pressure was checked to inflate the cuff as needed and to maintain seal pressure. There was no documentation regarding the patient?s urine condition (amount and color) and no evidence the physician was notified of Patient 1?s changes in respiratory and urinary condition. The Nursing Flow Sheet for October 2, 2016, timed at 7 a.m. indicated Patient 1?s tracheostomy tube had moderate amount of thick, green secretions upon suctioning and rhonchi sounds. The status of the urine was not documented. There was no documented evidence the physician was notified of Patient 1?s changes in respiratory and urinary condition. The Nursing Flow Sheet for 7 p.m. to 7 a.m. shift of October 2 to October 3, 2016, indicated Patient 1 had labored breathing, productive cough (with mucus), shortness of breath while resting, and had rhonchi sounds on both lungs. At 8:15 p.m., Patient 1?s heart rate was 164 beats per minute and decreased to 99 beats per minute. There was no documentation the trach cuff pressure was checked to inflate the cuff as needed and to maintain seal pressure. There was no description of the condition of the urine. There was no documented evidence the physician was notified of Patient 1?s changes in respiratory and urinary condition. The Nursing Flow Sheet dated October 3, 2016, for the 7 a.m. to 7 p.m. shift, indicated the patient was suctioned obtaining moderate amount of thick, brownish secretions from the tracheostomy tube. There was no documentation the trach cuff pressure was checked to inflate the cuff as needed and to maintain seal pressure. Nurse Practitioner 1 examined the patient at 8 a.m., and did not give any new orders. Physician 1 examined the patient at 10 a.m., and did not give new orders. There was no documentation the licensed nurses reported to Physician 1 or to Nurse Practitioner 1 the patient?s respiratory and urinary condition and the increased heart rate ranging from 154 to 176 per minute. A review of the Subacute Progress Note dated October 3, 2016, completed by Nurse Practitioner 1, indicated Patient 1 denied shortness of breath and had moderate amount of yellow secretions. The assessment and plan included to continue trach care, pulmonary toilet, and aspiration precautions. A review of Patient 1?s Physician?s Progress Notes dated October 3, 2016, timed at 6 p.m., completed by Physician 1 indicated no respiratory findings such as coughing or expectoration (secretions from the lung), the patient had no chest congestion or dyspnea (difficult or labored breathing,); there were no gastric findings such as nausea, vomiting, diarrhea, blood in stool, or abdominal distention; there were no urinary findings such hematuria; and Patient 1?s lungs sound were clear with no rhonchi. The Nursing Flow Sheet for 7 p.m. to 7 a.m. shift of October 3 to October 4, 2016, documented by Licensed Vocational Nurse 1 (LVN 1) , indicated at 1 a.m. Patient 1?s blood pressure was 150/68 mmHg and the heart rate was 176 beats per minutes which went down to 154 beats per minute in 10 minutes. Patient 1 was hyperventilating (excessive quick breathing), pulling and bending ventilator circuits to make the alarm sound and seek attention. At 3 a.m., Patient 1 was still hyperventilating and was medicated with Lorazepam (anti-anxiety medication) but it was not effective. At 5 a.m., the patient was suctioned sticky brown secretions from the tracheostomy tube. There was no documentation LVN 1 checked the trach cuff pressure to ensure seal pressure and there was no physician notification. LVN 1 documented Patient 1 used a urinal, when the patient had a urinary catheter and there was no documentation it was removed. At 6:40 a.m., LVN 1 documented Patient 1 was coughing and brown liquid was running down his face and in the ventilator tubing. The patient was suctioned and continued to cough up thin brown liquid with a very foul odor. At 6:50 a.m., a bed bath was given to the patient and the ventilator circuits were changed. The Nursing Flow Sheet dated October 4, 2016, timed at 7 a.m., indicated the patient was suctioned with dark brown secretions; the respiration was labored, and had severe chest congestion. Physician 1 was notified and ordered to transfer the patient via paramedics to GACH 2. A review of Patient 1?s clinical record (Patient Care Timeline) from GACH 2 indicated on October 4, 2016, Patient 1 arrived to the emergency room at 8:41 a.m. with tachypnea (abnormal rapid breathing) and thick green sputum. Patient 1?s vital signs were pulse of 99 beats per minute, blood pressure of 87/55 mmHg, respirations were 17 breaths per minute and temperature was 97.8 degrees F. A review of Physician?s Progress Note from GACH 2 dated October 4, 2016, indicated Patient 1 was brought in by paramedics. Patient 1 arrived in the emergency room with his tracheostomy cuff reported as deflated and had 500 ml of feculent material suctioned from the tracheostomy tube. The physician?s diagnoses included septic shock with acute multi-organ dysfunction and septicemia secondary to aspiration pneumonia, acute on chromic hypoxemic respiratory failure, tachycardia, distal small bowel obstruction, UTI, and acute on chronic renal failure. A CT scan of the abdomen and pelvis showed the patient's urinary catheter with the balloon inflated and the catheter tip in the urethra and not within the bladder with associated marked distention of the bladder. The urinary catheter was replaced in the emergency room. Patient 1 was admitted to ICU on the same day of arrival to GACH 2 and remained hospitalized until XXXXXXX. On October 25, 2016 at 10 a.m. during an interview, LVN 1 stated he suctioned thick, greenish, brown secretions at one time but could not remember if he reported to the physician. When asked about the documentation about Patient 1 using a urinal, he stated he did not remember if Patient 1 had a urinary catheter. During an interview with the Assistant Administrator (LVN 2) on October 25, 2016 at 11 a.m., she stated the nursing staff should have notified the physician right away regarding Patient 1's rust colored urine and the presence of hematuria. On December 7, 2016, at 10:30 a.m., during a telephone interview, Nurse Practitioner 1 stated when he visited Patient 1 on October 3, 2016 the nurses did not inform him Patient 1 had thick, greenish/brown secretions or rust colored urine for the past few days. Nurse Practitioner 1 also stated what he documented in his progress note was his observation of Patient 1. On December 7, 2016 at 11 a.m., during a telephone interview, Physician 1 stated he was notified regarding Patient 1?s thick green and brown secretions and rust colored urine which he considered normal secretions and the patient had no fever. He also stated on October 4, 2016 (when the patient vomited fecal contents), Patient 1 vomited food coming from his stomach. Physician 1 added Patient 1 had chronic renal disease so his urine becomes concentrated, and it is normal for the patient to have rust colored urine. On December 20 and 21, 2016, at 3:45 p.m. and 9:50 a.m., respectively, during a telephone interview, LVN 2 and the Chief Executive Officer (CEO) stated that Patient 1 had physician?s orders for the month of October 2016 that included to check trach cuff pressure every shift and as needed; check trach cuff pressure post manipulation; and inflate the cuff to maintain seal pressure. The CEO stated the licensed nurses were supposed to document in the nursing flow sheets that the patient?s trach cuff was checked to inflate the cuff as needed and to maintain seal pressure as ordered by the physician. According to the facility's policy and procedure titled, "Change in a Patient's Condition or Status," (undated) the nurse supervisor/charge nurse would notify the patient's attending physician when there has been a significant or unexpected change in the patient's physical/emotional/mental condition, which could result in a safety issued or threat. According to the facility?s policy and procedure dated January 1, 2016, titled, ?Patient Care-Care Plan Development,? the physician would be notified promptly of any sudden or marked adverse changes in the patient?s condition. The facility failed to administer treatment as prescribed by the physician and failed to notify the attending physician promptly of any sudden and marked adverse change in signs and symptoms exhibited by Patient 1, including: 1. Failure to notify the physician when Patient 1 had moderate to large amount of thick, green and/or brown secretions from his tracheostomy tube (a tube inserted into the windpipe to open the restricted airway and enable breathing) on September 28, 29, 30, October 1, 2, and 3, 2016 (total of six days), with episodes of labored breathing and shortness of breath while resting on September 29, 2016 and October 2, 2016. 2. Failure to notify the physician when Patient 1 had several episodes of heart rate above 100 beats per minute, ranging from 154 to 176 beats per minute, on September 29, 30, October 2, and 3, 2016 (total of four days). 3. Failure to notify the physician when Patient 1?s had rust colored urine draining from the urinary catheter (flexible tube passed through the urethra and into the bladder to drain urine) and had hematuria (blood in the urine) on September 29, 30, and October 3, 2016 (total of three days). 4. Failure to administer treatments ordered by the attending physician (Physician 1), by not checking the trach cuff (a balloon outside the tracheostomy tube. When the balloon is inflated, blocks any air from flowing around the tube and assures that the patient is well oxygenated) pressure every shift and as needed, by not checking the trach cuff post manipulation, and by not inflating the cuff to maintain seal pressure. As a result, on October 4, 2016, at 6:40 a.m., Patient 1 coughed and vomited brown liquid with strong fecal odor. At 8:45 a.m., the patient was transferred via paramedics to General Acute Care Hospital 2 (GACH 2) where he was diagnosed with septic shock (bacteria in the bloodstream that can cause multi organ failure and death) with septicemia (blood poisoning) secondary to aspiration pneumonia (inflammation of the lungs which occurs when food, saliva, liquid, or vomit is breathed into the lungs), small bowel obstruction (the small intestine is partially blocked and prevents foods, liquids and gas from moving through the intestines), and urinary tract infection (UTI - infections in any part of the urinary tract - kidneys, ureters, bladder and urethra). Patient 1 was also found to have 500 milliliters (ml) of feculent (fecal) material suctioned from the patient's tracheal tube. Additionally, a computerized tomography (CT scan - combines a series of x-ray images taken from different angles) of the abdomen and pelvis (hip) showed the patient's urinary catheter with the balloon inflated was in the urethra (not in the bladder) and the catheter tip was also in the urethra (instead of within the bladder) with associated marked distention of the bladder. Patient 1 was admitted to ICU for further treatment on the same day of arrival to GACH 2. The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1. |
| 060000033 |
FLAGSHIP HEALTHCARE CENTER |
060013519 |
A |
27-Sep-17 |
2QLG11 |
9928 |
F483.25(d)(1)(2) Free From Accident Hazards/Supervision:
(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 provide the necessary care and services to ensure adequate supervision was in place to prevent a fall, which resulted in injuries for Resident 2.
Resident 2 fell to the floor while Certified Nurse Assistant (CNA) 8 was providing incontinence care, sustaining a skin tear to the upper lip, right frontal scalp hematoma (abnormal collection of blood outside of a blood vessel), and fracture of the left distal femoral shaft (thigh bone above the knee joint).
Findings:
According to the Journal of the American Geriatrics Society (June 2005), an air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress. Precautions may include following manufacturer equipment alerts and increasing supervision.
Medical record review for Resident 2 was initiated on 8/11/17. Resident 2 was admitted to the facility on 10/22/14, with diagnoses including paraplegia and contractures.
Review of the History and Physical Note dated 9/28/16, showed Resident 2 did not have the capacity to understand and make decisions.
Review of the Fall Risk Assessment dated 7/31/17, showed Resident 2 was assessed to be at high risk for falls.
Review of Resident 2's plan of care showed a care plan problem with the initiation date of 9/28/15, to address the risk for falls. A revision to the interventions dated 5/1/17, showed two persons' assistance with transfers, bed mobility, and all activities of daily living (ADL) care, including incontinence care.
Review of Resident 2's Minimum Data Set (a standardized assessment tool) dated 7/31/17, showed the resident had severe cognitive impairment and required total assistance of one to two persons for bed mobility, dressing, toilet use, and personal hygiene.
Review of the Order Recap Report for August 2017 showed a physician's order dated 8/4/17, for a LAL mattress (low air loss mattress = air-filled mattress) for pressure ulcer prevention.
Review of the Service Document from the mattress company showed the LAL mattress was ordered and delivered for Resident 2 on 8/4/17.
According to the LAL mattress manufacturer's specifications regarding safety information on resident migration, specialty bed products are designed to reduce/redistribute pressure and the shearing/friction forces on the resident's skin. The risk of inadvertent bed exit may be increased due to the nature of these products.
Review of the plan of care did not show a care plan problem was developed or revised to address the safety precautions for the use of the LAL mattress.
Review of the Incident/Accident Report prepared by RN (Registered Nurse) 1 dated 8/5/17 at 2338 hours, showed CNA 8 was providing incontinence care to Resident 2 who was turned towards her right side. Resident 2 moved her arms, rolled off the mattress, and fell to the floor. Resident 2 sustained a skin tear on her upper lip and was later found to have a bruise on the right side of her face. The form stated the incident was also witnessed by RN 1.
Review of the SBAR Communication Form and Progress Note dated 8/5/17, showed RN 1 notified Resident 2's physician at 2140 hours regarding Resident 2's fall. For the entry for functional status changes (compared to baseline), N/A was checked off. The other areas not checked off included falls and description of symptoms or signs. In the area for assessment by an RN, RN 1 documented the right face and upper lip small skin tears were noted. No other assessments were found.
Review of the Skin - Head to Toe Skin Checks dated 8/5/17, showed Resident 2 was noted with bruises to the top of the scalp and the back of the head; and skin tears to the upper lip and face. There were no measurements included in the assessment.
Review of the Progress Notes showed the following:
- An entry dated 8/6/17 at 0457 hours, by RN 1 showed, "on assessment bruise on forehead & back of the head noted, ice pack with lateral position applied. continue monitoring."
- An entry dated 8/6/17 at 0558 hours, by LVN (Licensed Vocational Nurse) 7 showed a slight bump to the right side of Resident 2's head with purple discoloration was noted. New orders were obtained from the physician for a skull x-ray;
- An entry dated 8/6/17 at 1615 hours, by RN 3 showed Resident 2 was noted to be moaning and grimacing during incontinence care. CNA 7 noticed Resident 2's left leg was flaccid, which was not normal for Resident 2. The x-rays were ordered and the result showed a fracture of the left distal femur. Resident 2 was transferred to the acute care hospital for further evaluation.
Review of the ED record from the acute care hospital showed an x-ray of the left femur was done on 8/6/17. The result showed the following conclusions: comminuted (a break of the bone into more than two fragments), impacted (broken ends of the bone were jammed together), and displaced (the bone ends were displaced from their original position) fracture of the left distal femoral shaft (thigh bone above the knee joint).
Review of the ED record showed a CT scan (computerized tomography = a series of x-ray images taken from different angles using computer processing to create cross-sectional images)
of the brain was done on 8/6/17. The conclusion included right frontal scalp hematoma.
Review of the ED history and physical examination dated 8/6/17, showed a clinical impression of a left distal femur fracture and head contusion (an accumulation of blood under the skin, usually from a blow to the head) likely secondary to fall.
Review of the ADL flowsheets from 7/1 to 8/11/17, showed inconsistencies in the number of staff required to provide care for bed mobility, toileting, personal hygiene, dressing, and transfers.
On 8/11/17 at 0916 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 2 had required two persons' assistance for all ADL care before the fall.
On 8/11/17 at 1020 hours, an interview was conducted with LVN 3. LVN 3 stated before the fall, Resident 2 required total assistance of two persons for her ADL care since she was contracted to the both upper and lower extremities.
On 8/11/17 at 1030 hours, an interview was conducted with LVN 1. LVN 1 stated she had been the unit manager on the unit where Resident 2 resided. LVN 1 stated prior to the fall, Resident 2 had required two persons' assistance with care.
On 8/11/17 at 1339 hours, an interview was conducted with Resident 2's RP. Resident 2's RP stated he came to visit Resident 2 every day during lunch and dinner time. Resident 2's RP stated he observed when the staff provided incontinence care, occasionally, two staff members would provide care, at times there would only be one staff person, depending on who the staff were.
On 8/11/17 at 1516 hours, an interview was conducted with RN 1. RN 1 stated he witnessed Resident 2's fall on 8/5/17, at approximately 2130 hours. RN 1 also stated he saw Resident 2 roll over from the bed, hitting her left knee on the floor first, then her head hit the feeding pump pole standing next to her bed. RN 2 stated he assessed Resident 2 right away, however, did not try to assess range of motion of bilateral upper and lower extremities due to Resident 2 was contracted.
On 8/11/17 at 1534 hours and 8/15/17 at 1606 hours, an interview was conducted with CNA 8. CNA 8 stated he worked the shift from 1500 to 2300 hours and was assigned to Resident 2. CNA 8 stated Resident 2 had always required one person's assistance with ADL care, including incontinence care. CNA 8 stated the only thing different that day was Resident 2's mattress was changed to a LAL from a regular mattress. CNA 8 stated before he provided incontinence care, he raised the bed up to his waist level (measured three and a half feet high) to protect himself from injury. CNA 8 turned Resident 2 to her right side, placed his left hand on Resident 2's left buttock, and wiped the buttocks with his right hand. CNA 2 stated Resident 2 made a sudden jerk, slid off the bed, and fell to the floor. CNA 8 stated he did not receive any in-service regarding the use of the LAL mattress. CNA 8 also stated he thought Resident 2 was not a fall risk because she had not had any prior falls.
On 8/15/17 at 1642 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she received the order for the LAL mattress on 8/4/17. When asked if the care plan was updated when Resident 2's mattress was changed to a LAL, LVN 1 stated no. LVN 1 also stated there were no new interventions implemented for the risk for falls in reference to the use of the LAL mattress. When asked if she received an in-service regarding the use of LAL mattress, LVN 1 stated no. LVN 1 also acknowledged Resident 2 required two persons' assistance and the care plan was revised on 5/1/17; however, she failed to update the ADL care plan.
On 8/17/17 at 1326 hours, a telephone interview and concurrent medical record review was conducted with RN 2. RN 2 verified the inconsistencies in the number of staff support required to provide care for Resident 2 from 7/1/17 to 8/11/17. Resident 2 had required one and two persons' assistance with bed mobility, toileting, personal hygiene, dressing, and transfers.
The above violation 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 physician harm would result. |
| 970000015 |
FOUNTAIN VIEW SUBACUTE AND NURSING CENTER |
920013525 |
B |
29-Sep-17 |
R2UT11 |
10061 |
483.15(c)(1)(i)(ii) F 201
(c) Transfer and discharge
(1) Facility requirements
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident?s welfare and the resident?s needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident?s health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
On 6/13/17, an unannounced visit was made to the facility to investigate a complaint regarding admission, transfer and discharge rights.
Based on interview and record review, the facility failed to ensure must permit each resident to remain in the facility, and not transfer or discharge a resident when the discharge was not necessary, including:
1. Failure to ensure the facility?s policy on Discharge and Transfer by not having a discharge of Resident 1?s focused on discharge goals and effective transition to post discharge care.
2. Failure to ensure Resident 1 was not discharged to a homeless shelter where her care needs could not be met.
As a result, on 6/9/17, on the same day of discharge, Resident 1 fell in the bathroom of the shelter and was admitted to a General Acute Care Hospital (GACH) where the resident was treated for low back pain in the emergency room (ER) and subsequent transfer to another Skilled Nursing Facility (SNF).
A review of the Admission Record indicated Resident 1 was admitted to the facility, on 4/30/15, with diagnoses including difficulty walking, muscle wasting, and atrophy (complete muscle wasting away), stress fracture right ankle, overactive bladder, major depression (mental disorder), and fracture of the femur (thigh bone). The clinical record indicated Resident 1 was at risk for falls relating to impaired mobility, and sustained a fall outside the facility on 5/28/16, resulting in an acute right ankle fracture.
A review of the Minimum Data Set (MDS - a care planning and assessment tool), dated 3/12/17, indicated Resident 1 was alert and oriented, and required extensive assistance one person assist with dressing, toilet use, and bathing. The resident was assessed with impairment on both upper and lower extremities, and using a walker or a wheelchair to ambulate. The MDS indicated Resident 1 was incontinent with bowel and bladder (the inability to control bowel movements and urinating), and was on a pain management regimen. A review of the History and Physical, dated 5/22/17, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's care plan, initiated on 6/1/17, for potential of discharge indicated the goal was to provide a safe and effective discharge. The care plan interventions indicated to discuss with the resident potential barriers to discharge transition planning, evaluating discharge planning needs taking into consideration care plans, goals, cognitive skills, functional mobility, and need for assistive devices. Additional care plan interventions included making referrals to community-based agencies, providers, and communicating the resident's needs and barriers of care.
According to the Certified Nursing Assistant Activity of Daily Living (ADLs) form, dated 6/1/17 through 6/8/17, Resident 1 required extensive assistance with one person assist for bed mobility, extensive assistance with one to two persons assist for transfers, extensive assistance with one person assist for toilet use during the day and evening. The resident was totally dependent with one person assist at night.
A review of the final Licensed Nurses Progress Notes, dated 6/8/17, at 5 p.m., indicated no documentation the attending physician ordered to discharge Resident 1. There was no documentation of the reason of discharge, no documentation of Resident 1's condition at the time of discharge, or an assessment of the resident's pain prior to discharge. According to Resident 1's final Licensed Nurses Progress Notes, the section for disposition of belongings and resident?s medication were left blank without a licensed nurses' signature.
According to the Post Discharge Plan of Care, undated, Resident 1's appointments and discharge services were not provided and remained blank. Follow up appointments, transportation, medical equipment, and community resources were indicated as, "Not Applicable," or the section remained blank, unsigned, and undated.
A review of Resident 1's Medication List for Discharged Patients, dated 6/8/17, indicated the resident was discharged with Trazadone 25 mg, 10 1/2 tablets (antidepressant but ordered for insomnia). Trazadone side effects include drowsiness, increased sedation, fatigue, and ataxia (lack of muscle control).
A review of the GACH emergency room (ER) record indicated Resident 1 was admitted, on 6/9/17, for increased low back pain after the resident fell in the bathroom at a shelter. Resident 1 was treated for pain in the ER and placed in observation unit pending social worker?s evaluation for skilled nursing facility placement.
On 6/13/17, at 9:05 a.m., during an interview, the Administrator who stated the Nurse Consultant denied Resident 1's return to the facility because the resident no longer needed skilled nursing services. The Administrator stated he contacted Uber, scheduled a pick up time, and paid for the ride to transport the resident to the shelter.
On 6/13/17, at 11:05 a.m., an interview was conducted with the Director of Nursing (DON) and the Director of Staff Development (DSD). The DON and the DSD stated and confirmed no documented evidence of nursing notes reflecting the discharge for Resident 1. The DON stated it was the responsibility of the Registered Nurse to coordinate and ensure safe discharge and transfer plan in place for the resident. The DON also stated there was no documented evidence of the Interdisciplinary Team (IDT) notes addressing Resident 1's plan for discharge.
During an interview, on 6/13/17, at 12:49 p.m., an interview was conducted with the Registered Nurse 1 (RN 1) unit manager who stated licensed vocational nurses (LVNs) were supposed to complete discharge documents and summary prior to being discharged. RN 1 stated this was not in accordance with facility policy.
A review of the facility policy and procedure titled, "Discharge and Transfer," dated 11/28/16, indicated the Registered Nurse was ultimately responsible to ensure there was a safe and coordinated discharge and transfer plan in place for the resident. All residents would receive a Notice of Transfer of Discharge and/or Discharge Transition plan whenever discharge occurs to meet resident's needs, and facilitate a safe transition to another setting; the Interdisciplinary Care Team (IDT) would provide sufficient preparation prior to discharge; and a copy of the Discharge Transition Plan would be placed in the resident's medical record.
On 7/7/17, at 1:34 p.m., an interview was conducted with Social Worker / Case Manager 1 at the shelter, who stated Resident 1 arrived with no equipment to ambulate and could barely walk. The resident fell overnight at the shelter and cried because she was in a lot of pain. Case Manager 1 stated the shelter was not equipped to handle this type of resident, was not an appropriate placement, and she contacted the Administrator at the skilled nursing facility who refused to take Resident 1 back. Case Manager 1 stated the shelter called 911 to transfer Resident 1 to the Emergency Room because the resident required help the shelter could not provide.
A review of the facility's Discharge Planning Process Roles and Responsibilities, dated 3/2017, indicated Post Discharge (within 72 hours of Discharge) Social Services or designee contacts patient or family to ensure successful transition to discharge setting and satisfaction with services.
A review of the facility's Policies and Procedures titled Discharge Planning Process, dated 2/13/17, indicated the facility must develop and implement an effective discharge planning process that focused on the resident's discharge goals, effectively transition them to the post discharge care, and reduce factors leading to preventable re-admissions. The policy indicated to implement a weekly review by the Interdisciplinary Utilization Management, and discharge planning meeting for evaluation of potential discharge. Social Services staff initiates the Discharge Transition Plan, communicates the discharge dates and prepares the patient and family for transition. The policy indicated the IDT would use discharge planning process to document that the resident had been asked about his/her interest in receiving community based services. Documentation would include nurse progress notes indicating Discharge Transition Plan and reviews.
The facility failed to ensure must permit each resident to remain in the facility, and not transfer or discharge a resident when the discharge was not necessary, including:
1. Failure to ensure the facility?s policy on Discharge and Transfer by not having a discharge of Resident 1?s focused on discharge goals and effective transition to post discharge care.
2. Failure to ensure Resident 1 was not discharged to a homeless shelter where her care needs could not be met.
As a result, on 6/9/17, on the same day of discharge, Resident 1 fell in the bathroom of the shelter and was admitted to a General Acute Care Hospital (GACH) where the resident was treated for low back pain in the emergency room (ER) and subsequent transfer to another Skilled Nursing Facility (SNF).
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 950000006 |
FIDELITY HEALTH CARE |
950013645 |
B |
22-Nov-17 |
J7UT11 |
5057 |
F225
483.12(a)
The facility must
(3) Not employ or otherwise engage individuals who
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
On 10/12/17 at 8:52 a.m., an unannounced visit was made to the facility to investigate a staff to resident allegation of verbal abuse by a facility staff (CNA 2) towards Resident 14.
The facility failed to ensure that an allegation of abuse was reported to the State Survey Agency immediately or not later than 24 hours in accordance with the State law and the facility's policy and procedures for the incident between CNA 2 and Resident 14.
This deficient practice resulted in placing Resident 14's safety at risk by not reporting the alleged case of resident abuse in a timely manner.
A review of Resident 14's Admission Record indicated the resident was admitted to the facility on 5/10/12 and readmitted 1/17/15, with diagnoses that included legally blind and End Stage Renal Disease (ESRD/when the kidneys are no longer able to remove the excess waste and water from the body).
The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/22/17, indicated Resident 14 scored 15 on the brief interview for mental status (BIMS, a score of 15 means no cognitive impairment) and required limited assistance in activities of daily living.
A review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated 8/28/17, indicated on 8/26/17, around 10:00 a.m., Resident 14 alleged that CNA 2 yelled at her the morning of 8/26/17. The form further indicated the type of abuse reported was verbal.
During an interview on 10/14/17, at 10:21 a.m., the Director of Nursing (DON) stated the incident was reported to her because CNA 2 used a loud voice in Resident 14's room because he felt Resident 14 was not happy with him. The DON further stated she reported the incident to the Ombudsman only because, based on the diagram for reporting SOC 341, it indicated to report only to the Ombudsman.
A review of the undated facility's policy and procedure titled "Policy and Procedure on The Prevention of Resident abuse," indicated facility shall ensure reporting of all alleged and/or substantiated violations to the state agency.
The state law indicates, 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.
A review of the facility's undated policy and procedure titled "Policy and Procedure on The Prevention of Resident abuse," indicated facility shall ensure reporting of all alleged and/or substantiated violations to the state agency.
The facility staff failed to report the incident of a verbal abuse for Resident 14 and CNA 2 to the department within 24 hours, placing the resident's safety at risk.
This violation had a direct relationship to the health, safety and security of the residents. |
| 950000006 |
FIDELITY HEALTH CARE |
950013644 |
B |
22-Nov-17 |
J7UT11 |
5890 |
F223
483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
483.12(a) The facility must
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
On 10/12/17 at 8:52 a.m., an unannounced visit was made to the facility to investigate a staff to resident allegation of verbal abuse by a facility staff (CNA 2) towards Resident 14.
The facility failed to prevent verbal abuse by failing to:
1. Investigate Resident 14's alleged verbal abuse by CNA 2 which occurred on 8/1/17.
2. Take necessary steps to prevent recurrence of the alleged verbal abuse on 8/26/17.
This deficient practice resulted in a Staff to Resident incident of verbal abuse on 8/26/17.
Resident 14 notified the facility, on 8/1/17, that CNA 2 had used foul language (bad words) when providing care to her which made her feel threatened and requested Certified Nursing Assistant (CNA 2) not to be assigned to her care and not to come in Resident 14's room.
The facility staff (CNA 2) continued to come in Resident 14's room taking care of Resident 14's roommates.
On 8/26/17, CNA 2 was slamming doors in Resident 14's room which resulted in an altercation between Resident 14 and CNA 2. The altercation was overheard by LVN 2.
A review of Resident 14's Admission Record indicated the resident was admitted to the facility on 5/10/12 and readmitted 1/17/15, with diagnoses that included legally blind and End Stage Renal Disease (ESRD/when the kidneys are no longer able to remove the excess waste and water from the body).
The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/22/17, indicated Resident 14 scored 15 on the brief interview for mental status (BIMS, a score of 15 means no cognitive impairment) and required limited assistance in activities of daily living.
A review of the Interdisciplinary Progress Notes, dated 8/26/17 at 10:48 p.m., indicated Resident 14 requested not to assign CNA 2 to care for her. The note further indicated Resident 14 had an altercation with CNA 2 in the morning of 8/26/17, and Resident 14 felt threatened for her safety and security. The Ombudsman was contacted and a voice message was left.
A review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated 8/28/17, indicated on 8/26/17, around 10:00 a.m., Resident 14 alleged that CNA 2 yelled at her the morning of 8/26/17. The form further indicated the type of abuse reported was verbal.
During an interview on 10/14/17, at 10:21 a.m., the Director of Nursing (DON) stated the incident was reported to her because CNA 2 used a loud voice in Resident 14's room, and CNA 2 felt Resident 14 was not happy with him.
During an interview with the Licensed Vocational Nurse (LVN 2), on 10/14/17 at 10:35 a.m., when asked about the incident on 8/26/17, LVN 2 stated he heard a loud noise and Resident 14 yelling. LVN 2 further stated he went to Resident 14's room to see why the resident was yelling. LVN 2 stated Resident 14 was upset and told LVN 2, CNA 2 was slamming doors and scared her. Resident 14 asked CNA 2 to stop and that was when CNA 2 yelled back at Resident 14. LVN 2 stated he separated CNA 2 from Resident 14 because it was a form of verbal abuse.
During an interview with Resident 14, on 10/14/17, at 1:00 p.m., when asked about the incident she stated she had told the facility's staff she did not want CNA 2 as her CNA early in the month of August (8/1/17). Resident 14 stated she reported to the Director of Staff Development (DSD), CNA 2 would enter her room and would address her using foul language such as "Mrs. ... how the F*** are you today?? And she didn't have to deal with that type of treatment. Resident 14 further stated CNA 2 was a "young at risk kid" and didn't have to deal with his behavior and felt threatened due to her blindness and uncertainty of not knowing what to expect from a person with that behavior. When asked if she was okay with the CNA coming into her room to care for the other two residents (RSR 19 and 21) in her room, Resident 14 responded "I preferred him (CNA 2) not to come in," she further stated she was told the "facility was short of staff."
During an interview with the Director of Staff Development (DSD), on 10/14/17 at 1:32 p.m., she stated Resident 14 reported to her on 8/1/17 that she did not want CNA 2 assigned to her. The DSD further stated Resident 14 reported CNA 2 spoke foul language and referred CNA 2 as "El Cholo" (a term used to refer to a teenage boy who is a member of a street gang). When asked if CNA 2 was still assigned to Resident 14's room after the report she stated "Yes".
There was no evidence the facility staff investigated Resident 14's allegation of verbal abuse after it was reported on 8/1/17.
A review of the assignment sheet from 8/1/17 to 8/25/17 indicated CNA 2 continued to come in Resident 14's room to care for the roommates (RSR 19 and 21) on 8/7/17 and 8/25/17.
A review of the undated facility's policy and procedure titled "Policy and Procedure on The Prevention of Resident abuse," indicated the facility shall institute procedures of identifying events that constitute abuse and shall make reasonable efforts to protect residents from harm during the investigation process.
The facility staff failed to prevent verbal abuse for Resident 14 by failing to investigate Resident 14's alleged verbal abuse by CNA 2 on 8/1/17 and as a result, an alleged verbal abuse occurred on 8/26/17.
This violation had a direct relationship to the health, safety and security of residents. |
| 250001210 |
FLEMING-HEIMARK HOUSE |
250013670 |
B |
21-Dec-17 |
ZDK911 |
6017 |
?B? citation
W 368 483.460 (k) (1) All drugs are administered in compliance with physician?s orders.
Client A had Depakote (anti-seizure medication) administered by the facility at twice the dosage ordered by the physician for 21 days. This resulted in Client A?s hospitalization due to Depakote toxicity and increased the potential for the client?s death.
On August 19, 2015, at 1:15 p.m., an unannounced visit was made to the facility to investigate a self-reported incident that, ?Client A was admitted to the hospital after test results showed his Depakote level was high.?
On August 19, 2015, Client A?s health record was reviewed. Client A, a 53 year old male, was admitted to the facility on July 14, 2014, with diagnoses which included mild intellectual disability and seizure disorder. On August 18, 2016, a review of the Physical Therapy Assessment dated July 4, 2015, indicated Client A walked for all his mobility needs, and was independent with transfers.
On August 19, 2015, at 1:20 p.m., a telephone interview was conducted with the facility Registered Nurse (RN), who stated the physician?s order was for Depakote 750 milligrams (MG) PO (by mouth) BID (twice daily). At the beginning of new cycle medication (refills), the pharmacy staff delivered Depakote 3 tablets 500 mg each tab which was packed in daily doses in a bubble pack and erroneously labeled with the medication amount as 750 mg. The RN stated, ?The drug label was wrong.?
On August 19, 2015, at 2:30 p.m., the House Manager (HM) was interviewed and stated the pharmacy delivered all cycle medications at least three days before the 15th of each month. The medication certified staff signed and received the medication in a brown paper bag, locked the medications in the medication room, and notified the RN, who would check the medications before the 15th of each month.
During a follow up visit made to the facility on August 2015, at 10:55 a.m., an interview was conducted with the RN. The RN stated the physicians order for Client A was Depakote 750 mg PO twice daily. She stated Depakote usually came packaged with three tablets of 250 mg each to total 750 mg in a bubble pack for each dose to be administered twice daily. On July 8, 2015, the pharmacy sent three tablets of 500 mg each to total 1,500 mg per dosage in the bubble pack. The bubble pack was mislabeled and indicated the dosage was 750 mg. As a result, Client A received Depakote 3,000 mg daily instead of the physician ordered 1,500 mg daily for three weeks.
The RN also stated when the facility staff received the clients? new/refill medications, she was notified to check the medications. The RN stacked all medications together for each client, and went through THERAP (computerized documentation) medication sheet, compared the sheets to the bubble pack, and wrote the administration time on the sheets for the medications.
On August 19, 2015, Client A?s health record was reviewed. The physician?s order, dated August 2015, included an original order, ?Depakote (Enteric Coated) 750 mg PO BID (seizures).? A review of the Medication Record with the HM indicated Client A received Depakote EC 750mg PO BID, but the client actually received 1,500 mg PO BID, from July 15 through August 4, 2015, for 21 days.
According to Drugs.com, Depakote is a medication used to treat various types of seizure disorders. While using Depakote frequent blood tests may be needed. The recommended range for Depakote is 50-100 ug/ml (milligrams per milliliter) for seizure disorders and 85-125 ug/ml for acute mania. Depakote side effects include problems with balance or walking and muscle weakness.
The RN THERAP notes dated August 4, 2015, at 4:54 p.m., indicated, ?TC (telephone call) to Dr (physician name) re: client?s shuffling gait, weakness, leaning on someone to walk?he tries to lift his feet when walking if you ask him to but it is brief then he returns to the shuffle?DR (physician name) wants him sent to ER for an evaluation?Client says his feet and legs are sore?.
The RN THERAP notes dated August 5, 2015, at 3:14 p.m., indicated, ?Saw (Client A) in hospital and spoke with the discharge planner?his VPA (Valproic acid, generic name for Depakote) level when he came in was in the 170?s??
On July 7, 2016, at 4 p.m., the hospital records for Client A were reviewed. The form, ?Therapeutic Drug Monitoring,? dated August 4, 2015, indicated Client A?s Depakote level was 171 (therapeutic range 50-100). The hospital discharge summary indicated Client A was admitted on August 4, 2015, and was discharged on August 7, 2015, with a diagnosis of, ?weakness/lethargy secondary to Depakote toxicity.?
On August 20, 2015, a review of the facility?s document, titled, ?Shipping Manifest Pharmaceuticals,? dated July 8, 2015, indicated the facility received Depakote EC 500 mg tab (3 tabs in bubble pack) for Client A to equal 180 tabs for the cycle medication beginning on July 15 through August 14, 2015.
On August 19, 2015, a review of the facility?s policy and procedure, titled, ?DRUG ORDER PROCEDURE,? indicated, ??4. Refills?7. Checking drugs in: A. Only a licensed nurse or med (medication) certified staff is to receive the drugs from the pharmacy. B. When the drugs are received, the delivery must be checked against the order sheet to be sure all drugs are received. Check the following items: 1) Label is correct with proper name, drug, dosage, instructions for administration, physician?s name, and amount in the container.?
The facility nurse failed to check the medications. As a result of this failure, Client A?s was administered double the physician ordered medications and the client became toxic from those medications for 21 days, which resulted in Client A?s hospitalization and an increased potential for death.
The above violation had a direct impact or immediate relationship to the health, safety or security of Client A. |