| 020000037 |
Gateway Care & Rehabilitation Center |
020009260 |
B |
26-Apr-12 |
IRMQ11 |
3934 |
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 must ensure that each resident receives adequate supervision and assistive devices to prevent accidents.The facility violated the aforementioned regulation when it failed to supervise CNA 1 (certified nursing assistant) to ensure that she transferred Resident 1 with the appropriate lifting device and the assistance of another person. She used a standing lift (a lift used when a person can stand and pivot) instead of a Hoyer lift (a lift used when a person cannot bear weight), without the help of another staff member. The nursing assessments and Plan of Care specified that Resident 1 was nonambulatory, and needed two people to transfer her.The facility admitted Resident 1, an 84 year old female, on 1/30/08 with diagnoses that included dementia, and osteopenia (porous and fragile bones). She had a history of falls. The nursing staff developed a Fall Risk Care Plan, dated 2/8/11. The facility identified the following risk factors: limited mobility; poor safety awareness; confusion; poor balance; and unsteady gait. The goal for the problems was to ?Lower risk of injury potential?. The approaches/interventions for the Care Plan included, ?Transfer safely with assist of 2, via Hoyer lift?. The most recent comprehensive assessment, dated 5/4/11, showed that Resident 1 had memory problems, and moderately impaired decision making abilities. She was confused and had poor safety awareness, and impaired balance. She was totally dependent on facility staff for all activities of daily living. She required, ?Two plus persons physical assist?, for bed mobility, transfers, dressing, and toilet use. On 7/15/11, at 9 a.m., the Director of Nursing (DON) documented that, ?During transfer by CNA from bed using a lift, resident unable to stand?. The documentation showed that Resident 1 eased herself to the base of the lift with her legs fully flexed (bent). DON assessed Resident 1, and noted a reddened area on her upper arm, abrasions (scratches) on her abdomen and a small open area on her left leg. Resident 1 complained of pain in her left leg.At 11 a.m., DON noted that Resident 1 had swelling in both legs, near her knees, and was complaining of increased pain. DON gave Resident 1 Vicodin for pain. At 12:45 p.m., the facility sent Resident 1 to the emergency room to be evaluated.An X-ray report, dated 7/15/11, showed that Resident 1?s right femur (thigh bone) was fractured. The Radiologist also documented that her left tibia (shin bone) was, ?Probably? fractured.A Record of Counseling form, dated 7/15/11 reflected that, ?CNA 1 did not use the proper lift and did not have someone assist her with the resident. CNA 1 used a standing lift alone instead of a Hoyer lift. This resulted in the resident falling from the lift to the floor.?In an ?Unusual Incident Follow up?, dated 7/18/11, DON described Resident 1 as, ?Nonambulatory, dependent with ADL care except with eating?. DON documented that while CNA 1 was transferring Resident 1 from her bed to her wheelchair, using a transfer lift, Resident 1?s knees buckled. CNA 1 eased Resident 1 to the floor. In an interview with the DON and (SSD) Social Services Director, on 9/27/11 at 2:30 p.m., the DON stated, ?I don?t know what she was thinking, she (CNA 1) had looked after this resident a lot and always used the Hoyer lift prior to this incident?. In a phone interview with CNA 1 on 9/28/11, at 9:50 a.m., CNA 1 stated, ?I use the wrong lift. Standing lift was there. I usually use Hoyer lift. I used [a] belt and stand her-up, lady is very weak, bended knees. I hold her and eased her down, slow; called for help, put her on floor, blanket on her. I was [by] myself, work only me alone.? |
| 140000038 |
Greenridge Senior Care |
020011135 |
B |
25-Nov-14 |
35X411 |
6415 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the aforementioned regulation by failing to ensure that staff supervised Resident 1 while she was walking in the hallway, resulting in Resident 1 falling and sustaining a laceration on her forehead and fracturing her arm.Resident 1, who has poor short term memory, poor balance and was assessed to be a high risk for falls, was left alone in hallway on 7/19/14 while the CNA went to find a chair. Resident 1 attempted to follow the CNA and fell over a Hoyer lift (mechanical aide for transferring residents) sustaining a laceration and fracture of her arm. On 8/6/14, review of the medical record showed that Resident 1 was admitted to the facility on 4/13/11. Her diagnoses included dementia with behavior disturbance, chronic osteoarthritis (painful joints), syncope (a transient loss of consciousness due to inadequate blood flow to the brain) and collapse, and hypertension (high blood pressure). The facility did "Fall risk" assessments every three months that showed that she was at high risk for falls.Review of the complete resident assessment, dated 7/14/14, showed that Resident 1 had short and long term memory problems, was moderately impaired for decision making, required the extensive assistance of one staff for bed mobility, transfers, dressing, eating, toileting and bathing. She required moderate assistance of one staff for walking. Her ability to communicate was impaired with understanding others "sometimes" and "does not express her needs." Review of nurses notes, dated 7/19/14 at 2:15 p.m., showed, "Patient fell in hallway near bathrooms around 12:00 p.m. Patient walking in hallway and tripped on Hoyer lift that was in the hallway. Patient then fell and hit head. Neurological assessment done on patient. Patient had cut on left frontal lobe that was bleeding, measuring 6 x 1.55 x 0.5 cm(Centimeters). Second cut on left nostril, measuring 2 x 1.2 x 0.2 cm. Both were bleeding. 911 called and patient was kept on floor in lying position until ambulance arrived." Review of the hospital emergency department physician's history and physical, dated 7/19/14 at 4:44 p.m., showed, "82 year old female with chief complaint of head injury with laceration diagnosed as closed head injury, forehead laceration, and face laceration. Patient has history of dementia (baseline confused speech, transfers with assistance). TIA (transient ischemic attack which is a momentary lack of oxygen to the brain) with no residual who presents with head laceration. Witnessed mechanical fall. Fell forward and hit head and face into mechanical lift device. Patient answers 'yes' indiscriminately to all questions which is typical behavior for her. Exam: +6 cm (centimeter) gaping left forehead laceration with small area of bone exposed; no skull depression...+2.5 cm laceration directly below left nostril. No bone exposed. Do not leave unattended- Fall risk." Review of nurses notes, dated 7/19/14 at 11:06 p.m., revealed "Resident came back to facility...at 10 p.m. ...Noted left side forehead laceration 5.7. cm. with 11 sutures and upper lip 2.6 cm. with 6 sutures intact." Review of care plans showed, "Potential for trauma, falls," dated 7/24/14 due to history of a fall on 7/19/14, mental status and unsteady gait. Under the heading "Interventions" showed "Equipment should be placed out of hallway area when not in use. Transfer with assistance." During review of the Director of Nurses' (DON) investigative summaries, dated 7/30/14, showed, "Resident requires extensive to total assistance with activities of daily living due to impaired cognition and impaired mobility. When ambulating she can walk independently but is hand-held due to gait and balance...Resident 1 was left standing in the hall while her staff member went to look for a chair for her. The resident followed her and tripped on her shoe. When the staff turned to try and catch her from falling, the patient fell toward the mechanical lift (Hoyer) parked in the hallway. Patient's face hit leg of mechanical lift on which she sustained a laceration. Patient noted to have swollen left arm during morning care on 7/26/14. Patient exhibited facial grimacing and moaning on movement...On 7/27/14, nurse practitioner assessed patient and ordered x-ray to left arm. X-ray results received on 7/29/14 and it noted that patient has a fracture to left proximal (nearest to shoulder) humerus (upper arm bone). Results also showed degenerative changes and osteopenia (lack of hard bone formation). Physician was notified and ordered for acute hospital transfer.... Patient returned around 6:15 p.m. with splint to left arm..." During interview on 8/7/14 at 9:45 a.m., RN 1 (registered nurse) stated, "She ambulates independently but you have to take her hand and guide her." During observation of Resident 1 and interview with RN 1 on 8/7/14 at 10:15 a.m., two CNA's were assisting Resident 1 from bed to wheelchair. Resident 1 was dressed in street clothes and had a splint on her left arm. She smiled and responded to my questions with, "Right. Yes." RN 1 stated, "She requires more assistance since the fall. She wasn't using a wheelchair before the fall. Now she has a sling and pain." During phone interview on 8/20/14, the DON reviewed the medical record and stated, "There is no care plan in the record to prevent falls before she fell on 7/19/14." During phone interview on 8/20/14 at 2:55 p.m., CNA 1 stated, "I was walking with Resident 1 to the dining room and saw there were no chairs. I left her standing by the door and went around the corner to get a chair. Someone said she was following me. I turned around and saw her fall to the side- not towards me. I tried to catch her but she fell on top of the Hoyer lift which was left in the hallway. We store Hoyers in alcoves on each station but we leave them in the hall if we're going to use it soon." Therefore the facility failed to supervise Resident 1, who was ambulating in the hallway, resulting in Resident 1 falling and sustaining a laceration on her forehead and fracturing her arm. The above violation has a direct or immediate relationship to patient health, safety or security of residents |
| 140000038 |
Greenridge Senior Care |
020011346 |
B |
18-Mar-15 |
CF2C11 |
6242 |
483.12(b)(1)&(2) NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFER Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.483.12(b)(3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility violated the aforementioned regulations when it failed to provide a bed-hold notice, in writing, to the resident's responsible party when the resident transferred to the hospital, and then refused to readmit the Medi-Cal eligible resident at the end of hospitalization. During a phone interview on 1/9/15 at 1:55 p.m., the administrator (ADM) stated, "They did not pay for the bed-hold so the bed was not held. We have no long term beds." Review of the medical record on 1/12/15 showed Resident 1 was a ninety year old woman, admitted to the facility on 10/21/14. Her diagnoses included right leg cellulitis (inflammation of connective tissue), phlebitis (inflammation of a vein which causes pain and tenderness along the course of the vein), chronic kidney disease, protein malnutrition, anticoagulation monitoring, and atrial fibrillation (irregular and rapid contractions of the atria working independently of the ventricles). There was a physician's statement, dated 10/14/14, from the transferring hospital that Resident 1 had capacity to make healthcare decisions. Review of social services designee (SSD) notes, dated 1/12/15, showed, "Resident's daughter contacted SSD and wanted to see if there was a family care conference scheduled for today and SSD informed her, "No, because she has been transferred to the acute ..." A SSD note, dated 1/14/15 at 9:34 a.m., showed, "SSD and facility manager called the resident's daughter at 3:00 p.m., to ask if she wanted a bed-hold at the daily rate of $280.00 starting 1/13/15 for as long as the resident is in the acute. SSD informed her to call back within 24 hours of time the call was made to her on 1/13/15...SSD called the resident's daughter at 3:20 p.m., to confirm that family did not want a bed-hold since facility did not receive a call back within 24 hours." During interview on 1/12/15 at 8:40 a.m., the acting director of nurses (ADON) stated, "Resident 1 was sent out 911 to the emergency department at 4:30 a.m., on 1/12/15 due to restlessness, delirium and a fall from her wheelchair." During phone interview on 1/14/15, Resident 1's responsible party stated the SSD phoned her on 1/13/15 to give her notice that if she wanted the bed-hold, she would have to pay $280.00 per day. When she went to the facility to get Resident 1's dentures, she found that all of Resident 1's belongings had been gathered and put in garbage bags.During a phone interview on 1/20/15, Resident 1's responsible party stated, "The facility is refusing readmission because they say she does not need skilled care. She's still at the hospital. The (facility) owner told me their long term care patients are 'grandfathered in' and there's no space for her (Resident 1)." During phone interview on 1/20/15, the hospital case manager stated, "She needs skilled nursing care. She is still here in the hospital. [The facility] is refusing to take her back." During a phone interview on 1/20/15 at 9:50 a.m., the hospital social worker (SW) stated, "I am told that skilled nursing facilities have limited custodial beds. I have not been able to find placement for her." Review of the facility's census on 1/21/15 showed two empty female beds in semi-private rooms. This was confirmed by the business off manager (BOM) on 1/21/15 at 11:30 a.m. During phone interview on 1/26/15 at 9:15 a.m., physician 1 stated, "She has been confused and can't go home without twenty-four hour care. I recommended skilled nursing at another facility." Review of the facility's admission agreement, signed by Resident 1 on 10/22/15, showed, "If the resident is transferred to a general acute hospital, the facility shall notify the resident 'in writing' that the bed- hold of seven days may be exercised by the resident/ responsible party...In the event facility fails to follow this procedure, the facility shall offer the next available bed to the resident."A Transfer Discharge Hearing, conducted by the California Office of Administrative Appeals on 1/23/2015, ruled that the facility must readmit Resident 1. The facility was found to be in violation of Federal requirements for a written bed-hold notice at the time of transfer to the hospital and in violation of the requirement to readmit the resident.Therefore the facility failed to: 1. Provide a written bed-hold notice when Resident 1 was sent to an acute hospital. When Resident 1 fell and was sent to the hospital for evaluation, the facility staff phoned the responsible party, told her the daily room rate and stated that the bed would not be held if the amount was not received within twenty- four hours. Resident 1 was Medi-Cal eligible.2. Readmit the resident at the end of hospitalization to the first available bed. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 020000037 |
Gateway Care & Rehabilitation Center |
020012678 |
B |
26-Oct-16 |
PSN611 |
7268 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: The facility violated the aforementioned regulation by failing to ensure a safe environment when it failed to follow the manufacturer's instructions for use of the facility's wander management system (a system which tracks the person by use of a wrist or ankle band and alarms if the resident moves outside a defined area without being accompanied). This failure resulted in Resident 1 leaving the facility unsupervised, falling and sustaining an injury. The fall resulted in Resident 1 being sent to the emergency room and being treated for a possible closed head injury (trauma in which the brain is injured), laceration (deep cut in the skin) and hematoma (injury to a blood vessel causing blood to seep into surrounding tissues causing a blood filled bump). On 12/10/15, a review of the facility's report of the incident, untitled and dated 12/01/15, and signed by the facility's administrator, indicated Resident 1 was found outside the facility at approximately 9 p.m., on 11/30/15, being attended to by paramedics. Resident 1 was transported to the local hospital's emergency room. The report also indicated Resident 1 was wearing a wander guard (departure alert device) when she left the facility, unsupervised, on 11/30/15. Resident 1's wander guard was found to inconsistently alarm when checked by a technologist from the wander guard company, on 12/01/15, a day after the fall. According to the "Departure Alert System" policy, undated, the wander guard was wired to the doors in the lobby, back exit and side exit. The report also indicated that a staff member last saw Resident 1 in the facility at 8:45 p.m. Review of the paramedic's notes for Resident 1's incident, on 11/30/15, indicated the resident was found at 9:11 p.m., sitting on the curb beside a wheelchair, being attended to by the fire department's personnel. The notes indicated Resident 1 fell out of her wheelchair when she hit a hole. Resident 1 had a hematoma with a small laceration above her left eye. Review of the records from the emergency room, dated 11/30/15, showed Resident 1 was treated for a closed head injury a hematoma and a laceration to left forehead. The records also indicated that Resident 1 experienced throbbing pain on the left side of her forehead at a level 5 out of a possible 10 (pain assessment severity level with 1 being the least pain and 10 being the worst pain). Resident 1 was discharged from the emergency room to return to the facility on 12/1/15 at 12: 26 a.m. During a record review, on 12/10/15, of Resident 1's history and physical indicated she was first admitted on 3/18/14 and readmitted on 10/23/14 with diagnoses that included dementia (decline in mental ability) with delusional (cannot tell what is real from what is imagined) features. Review of the Minimum Data Set (MDS) (a standardized assessment tool which guides care) for Resident 1 indicated the resident had moderately impaired mental abilities. The MDS also indicated that Resident 1 was unable to walk but could propel herself in her wheelchair using her feet. Review of the care plan, dated 3/10/15, for Resident 1 indicated she was at risk for wandering and elopement (leaving the facility unsupervised). To reduce the risk of elopement, the care plan called for the use of a wander guard. The care plan also indicated the wander guard placement and functioning should be monitored and that Resident 1's whereabouts should be monitored at frequent intervals. Also Resident 1 should be redirected and distracted if needed to prevent her reaching exit doors. A Behavioral Medicine's progress note, dated 11/23/15, noted Resident 1's insight and judgement was rated poor. Review of the manufacture's information, for the wander guard system used at the facility, showed the system consisted of a transmitter that resembles a wristwatch that is worn by the resident on the wrist or ankle. The transmitter activates an alarm if the resident attempts to leave the facility through a monitored door. The manufacturer's user guide indicated that while in use transmitters must be tested weekly using the "transmitter tester" and the expiration date stamped on the transmitters must be checked weekly to verify it is not expired. The user guide also indicated the facility must keep records of the test and transmitter inspections. The undated facility's policy and procedure titled "Departure Alert System," indicated that a "departure alert device tester" (transmitter tester) was to be used to monitor the door and code alert system monthly by the Maintenance Manager. There were no instructions how to perform the tests, or the frequency for testing the transmitters worn by the residents, or how to document that the wander guards worked. During an interview on 12/10/15 at 1:50 p.m., the facility's Administrator (Adm) stated Resident 1 was wearing a wander guard transmitter at the time she left the facility, unsupervised, on 11/30/15. Resident 1 left the facility through the monitored front entrance door. The Adm stated the facility was not testing the transmitters used at the facility with a transmitter tester prior to Resident 1's elopement from the facility on 11/30/15. The Adm further stated the facility did not have a transmitter tester available in the facility until 12/8/15. The facility was not recording any checks of the wander guard transmitters used in the facility prior to Resident 1's elopement. During an interview on 12/10/15 at 2 p.m., the restorative nursing assistant 1 (RNA 1) confirmed that the facility was not checking the wander guard transmitters using a transmitter tester, prior to 12/8/15. RNA 1 also confirmed no staff member documented that weekly transmitter testing and expiration date checks were done. During an interview on 12/10/15 at 4:14 p.m., Registered Nurse 1 (RN 1) stated she was working at the facility at the time Resident 1 left the facility, unsupervised. RN 1 stated the door did not alarm when Resident 1 left the facility on 11/30/15. RN 1 confirmed the facility was unaware that Resident 1 left the facility until staff noticed an ambulance and fire engine outside the facility. During an observation and concurrent interview on 12/10/15 at 4 p.m., Resident 1 was seated in a wheelchair. A small wound was noted on her left eyebrow and old bruising (golden brown discoloration) was noted on the left side of her face. Resident 1 was alert and able to move about in her wheelchair. Resident 1 stated she recalled falling in a hole outside the facility. Resident 1 also stated she continued to have some pain on the left side of her face. Therefore the facility failed to ensure safe care and prevention of elopement when it failed to utilize the manufacturer's recommended device (transmitter tester) for testing the wander guard used by Resident 1. Therefore staff was unaware that Resident 1's wander guard was non-functioning. The violation had a direct relationship to the health, safety or security of Resident 1. |
| 020000125 |
Garfield Neurobehavioral Center |
020013399 |
B |
1-Aug-17 |
33DS11 |
3827 |
F223
483.12(a)(1) FREE FROM ABUSE/INVOLUNTARY SECLUSION
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;
The facility failed to follow the aforementioned regulation by failing to protect Resident 1 from sexual exploitation and abuse when housekeeper (HK) sexually assaulted Resident 1.
According to the undated medical record "Resident Information", Resident 1 was admitted on XXXXXXX2012 with diagnoses of, Dementia, Psychiatric Disorder (mental illness), and Post-Traumatic Stress. Review of the quarterly psychiatry report dated 3/20/17 indicated Resident 1 had a history of severe childhood abuse, sexual exploitation, and rape. The psychiatry report further indicated Resident 1's insight and judgement were poor and her memory was grossly impaired.
Review of the Minimal Data Set (MDS), (A set of screening, clinical assessment, and functional status tools, providing a comprehensive assessment for residents of long term care facilities), Cognitive Patterns section C, dated 5/25/17, indicated the brief interview of mental status (BIMS) reflected a score of 5 of 15 or severely impaired.
Review of Resident 1's care plan for, "At risk for altercations with others," initiated 12/19/14 and revised 6/23/16 indicated Resident 1 was at risk of being victimized by others given her history of abuse, mental illness, post-traumatic stress, and dementia. The care plan interventions indicated Resident 1 was to attend activities with increased supervision to decrease the risk of victimization.
Review of Resident 1 care plan for, "At risk for sexually inappropriate behavior," initiated 12/19/14 and revised 6/23/16 indicated a history of initiating sexual relationships due to poor judgment. The care plan interventions were to redirect resident when she was observed to be sexually provocative or inappropriate with peers; encourage Resident 1 to say "No!" when receiving unwanted attention from male peers.
In an interview with Certified Nursing Aide (CNA) on 6/13/17, at 12 p.m., CNA stated on 6/3/17 at about 1 p.m. she walked into the residents room and saw (HK) with his pants pulled down to his mid thighs and Resident 1 was on her knees facing HK. CNA stated she was shocked and said "what are you doing?", HK replied, "you didn't see anything" and quickly left the room. CNA stated she asked Resident 1 if she was having sex with HK, Resident 1 replied no she was "just sucking his d***".
During an interview with the Medical Records Technician (MRT) on 6/13/17, at 12:30 p.m., the MRT stated she was assigned manager of the day 6/3/17. CNA came to MRT's office at about 1 p.m. to report the incident she just witnessed between Resident 1 and HK. The MRT stated when she found HK in the break room; the MRT requested his key and escorted him from the building. The MRT stated Resident 1 was then brought to MRT's office and when questioned about what had happened, Resident 1 said she "sucked HK's d***".
According to the facility's Policy and Procedure on Abuse reporting dated 9/20/98 and revised 4/10/13: "Purpose... Residents must not be subjected to abuse by anyone, including but not limited to facility staff...Definition 3) Sexual Abuse - sexual harassment, sexual coercion, and sexual assault are examples..."
Therefore the facility failed to protect Resident 1 from sexual exploitation and abuse when housekeeper (HK) sexually assaulted Resident 1. |
| 100000032 |
Golden Living Center - Chateau |
030009090 |
B |
08-Mar-12 |
TRMC11 |
4747 |
F-279 483.20 Develop Comprehensive Care Plans (d) A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care.F323 483.25 Free of Accident Hazards/Supervision/Devices (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made to the facility on 6/4/09 to investigate a facility self report #CA00180886. The Department determined the facility failed to: 1. Ensure Resident A's elopement detection system was functioning properly. 2. Develop a written plan of care based on assessed needs.These failures resulted in Resident A eloping from the facility and being found in the facility's parking lot twice on one day. Resident A's clinical record was reviewed on 6/4/09. Resident A was admitted to the facility on 06/30/2008. His admitting diagnoses included dementia and pre-senile organic psychotic conditions. Resident A's Quarterly MDS (Minimum Data Set-an assessment tool) documented Resident A as having short and long term memory problems, moderately impaired cognitive skills for daily decision making, sometimes able to make himself understood and sometimes able to understand others. The MDS also described Resident A as wandering and being resistive to care. Physician Orders for March 2009 contained an order, originally dated 8/1/08, for a (Brand Name) alert device to be applied at all times and staff to check for placement and functioning every shift due to risk for elopement. This alert system is designed to trigger an alarm if the resident crosses a defined exit or exit(s) in the building.Review of the facility's investigation report, dated 3/11/09, documented on 3/11/09 at around 11:00 a.m. Resident A was found in the facility's parking lot, in his wheelchair, with no apparent injury. According to the facility's investigation report Resident A stated that he wanted to go home. Under the section "Immediate Resident Protection Initiated" of the facility's investigation report documented "check wander guard for function." There was no documentation in the facility's investigation report or in Resident A's Nurses Notes regarding why Resident A was able to elope from the facility or if the wander guard was functioning properly. A facility investigation report, dated 3/11/09, documented on 3/11/09 at around 4:30 p.m. that Resident A was again found in the facility's parking lot with no apparent injury. Resident A stated he was looking for his car. Again there was no documentation in the facility's investigation report or in Resident A's Nurses Notes regarding why Resident A was able to elope from the facility or if the wander guard was functioning properly. Resident A's clinical record contained a care plan, dated 4/24/09, indicating he was at risk for elopement related to wandering and as having a history of trying to leave the facility. During an interview with Administrative Staff (AS) 1, on 6/4/09 at 9:30 a.m. , it was brought to her attention that Resident A's wander guard order was dated 8/1/08 and asked if there was previous care plan regarding Resident A being at risk for elopement. A care plan dated before 4/24/09 could not be located in Resident A's clinical record or overflow record overflow chart. AS 1 could not explain why there was not a care plan regarding Resident A's elopement potential.After the onsite investigation, a fax copy of a care plan for elopement risk was sent to the department with initiation date indicated as 03/11/09. However, there was no evidence that this plan of care was available to staff prior to the elopement on 03/11/09.During an interview with AS 1 on 6/4/09 at 9:30 a.m., she stated she didn't know if Resident A's wander guard was functioning correctly and further stated she was not employed at the facility during the time of the incident so was unable to answer any questions regarding the incident.The Medication Record had documentation that the system to prevent elopement was checked each shift prior to the elopement. However, Resident 2 did successfully elope undetected twice on 03/11/2009.The Department determined the facility failed to: 1. Ensure Resident A's elopement detection system was functioning properly to provide supervision to prevent elopement and a possible accident. 2. Develop a written plan of care based on assessed needs. This failure resulted in Resident A eloping from the facility and being found in the facility's parking lot twice on one day. This violation had a direct or immediate relationship to the health, safety or security of a long-term care facility patient or resident. |
| 100000092 |
Golden Living Center - Galt |
030009221 |
B |
12-Apr-12 |
99EV11 |
9718 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Patient Care Policies And Procedures - Title 22 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. An unannounced visit was made to the facility on 6/23/09 to investigate an Entity Reported Incident #CA00191342. The Department determined the facility failed to: 1) Ensure facility staff reported suspected abuse of Patient A within 24 hours as required by law. 2) Ensure facility policy related to abuse reporting was implemented. Patient A, an 86 year old female, was admitted to the facility on 11/25/08 with the following diagnoses: Alzheimer's disease, dementia, dysphagia and osteoarthritis.Patient A's Quarterly Minimum Data Set (MDS-an assessment tool), dated 4/24/09, indicated she had short and long term memory loss, moderately impaired cognitive skills for daily decision making, sometimes able to make herself understood and sometimes able to understand others. The MDS indicated Patient A had verbally abusive behavioral symptoms, had physically abusive behavioral symptoms and had socially inappropriate/disruptive behavioral symptoms. The MDS also indicated Patient A as needing extensive assistance with bed mobility, dressing, toilet use and personal hygiene and as needing limited assistance with transfer and locomotion off the unit. On 6/10/09 the Department received a "Report of Suspected Dependent Adult/Elder Abuse, dated 6/9/09, that indicated on 6/6/09 a Certified Nursing Assistant (CNA) reported that another CNA allegedly slapped Patient A while repositioning her.The facility's investigation report contained a written statement by CNA 2 dated 6/9/09. CNA 2 documented that on 6/4/09 she was asked by CNA 1 to team up and work their halls together. CNA 1 stated to her that it would make it easier. CNA 2 documented she was reluctant because in the past the charge nurse (CN) had voiced that she doesn't like two people in the same hall while the other hall is left without a CNA. CNA 2 documented she moved on to work her hall during their first round. During their second round CNA 1 asked her again to work together which at that time CNA 2 stated she agreed "to try it out." On 6/5/09 when CNA 1 mentioned working together again CNA 2 told her she would rather just do her hall. CNA 2 documented that just before they started their second round she asked CNA 1 to help her take care of Patient A due to "she is now a two sometimes three person assist." CNA 2 further documented that Patient A had been "fighting-hitting, biting, kicking, etc." CNA 2 documented she and CNA 1 walked in to Patient A's room and informed Patient A of what they were going to do and Patient A responded "uh-huh, uh-huh." CNA 2 documented that they proceeded to check to see if she needed to be changed at which time Patient A started to throw her hands up at us. CNA 2 documented she was on the right side of the bed while CNA 1 was on the left side. While Patient A was on her back CNA 2 tried to log roll her while I held Patient A's hands. At some point Patient A pulled one of her hands and ended up holding CNA 2's hand. In the meantime CNA 1 told her it was okay, Patient A was not wet, and they then left the room. CNA 2 documented she did "not hit or slap anyone and when you think about it even if I was the kind of person to do this, would I really do it front of a witness." CNA 2 further documented she was "shocked to hear that [CNA 1] had been spreading rumors" around that she hit a patient. CNA 2 further documented she could not "imagine why she would say such a terrible thing" about her. The facility's investigation report contained a written statement by Registered Nurse (RN) 1 dated 6/9/09. RN 1 documented that on Sunday night 6/7/09 CNA 1 informed her that while making rounds, with CNA 2, she witnessed CNA 2 push Patient A's arm away when the patient tried to hit CNA 2. RN 1 documented that she asked CNA 1 when the even occurred and she stated Friday 6/5/09. RN 1 documented she informed CNA 1 that she should have informed her nurse that night as she was not her CN that night. RN 1 also documented that CNA 1 needed to inform the Nursing Supervisor of the event as she was not a witness to the event and was being told about the alleged event two days later. RN 1 documented that was the last time they talked about the event until she informed by the DON. The facility's investigation report contained a summary statement by the Director of Nursing (DON), undated, indicating that on 6/9/09 at approximately 8:30 a.m. she received a telephone call from CNA 1 to inform her of a suspected abuse concern that occurred on Friday 6/5/09. CNA 1 reported she was working with CNA 2 when CNA 2 slapped the hand of Patient A while they were providing care. The DON documented that CNA 1 stated that she and CNA 2 were repositioning Patient A on the night shift, early in the morning around 5:30-6:00 a.m., when Patient A became uncomfortable with her leg while positioned on her side to allow for peri-care. CNA 1 stated Patient A put her hand down by her upper knee area and stated her leg hurt. CNA 1 alleged at that time that CNA 2 "slapped" Patient A's hand away from her leg so that care could be completed. The DON documented she asked CNA 1 if CNA 2 "actually slapped the resident (Patient A) or if [CNA 2] put her hand out to protect herself from being struck."The DON documented that Patient A has a "history of agitated behavior at times with cares and has struck out at the staff before" and that CNA 1 "agreed this could have been the case." The DON documented that the reaction by CNA 2 could have sounded like a slap as she put her hand out to protect herself and Patient A's hand did hit against CNA 2's hand. The DON also documented that CNA 1, who made the allegation of abuse, was asked but did not submit a written description of the alleged abuse. The DON further documented that she spoke with the nurses on the night of the alleged event and documented neither nurse was ever made aware of any problem with CNA 2. The DON also documented that she spoke with Patient A and asked her if anyone had ever harmed her verbally or physically in which Patient A responded," No, they are good to me here." The DON further documented that Patient A has been up and about in the facility per her baseline with no signs of distress. The DON documented the facility's conclusion of their investigation was that there was no indication CNA 2 intentionally slapped Patient A.Patient A was interviewed on 6/23/09 at 11:15 a.m. When asked how staff treated her she stated, "Fine." When Patient A was asked if a staff member had ever hit/hurt her she stated, "No, I have three sons." Review of the facility's policy "Resident Rights," dated July 2006, "All allegations will be reported immediately to the administrator or his/her designated representatives." Review of the facility's Abuse policy, dated January 2007, indicated the definition of "Physical abuse includes hitting, slapping, pinching and kicking..." The Abuse policy also indicated "A. All health practitioners and all employees in a long-term healthcare facility are mandated reporters....B. Any mandated reporter who, in his/her professional capacity, or within the scope of his/her employment, has observed or has knowledge of an incident that reasonable appears to be physical abuse...C. Mandated reporters are required to report incidents of known or suspected abuse in two ways: By telephone immediately, or as soon as practically possible to the local ombudsman or the local law enforcement agency and by written report, Department of Social Services from (SKC Form 341), "reports of suspected dependent adult/elder abuse" sent within to (2) working days. D. Any associate who suspects an alleged violation shall immediately notify the E.D (Executive Director), or his/her designee."The facility failed to ensure staff reported suspected abuse of Patient A within 24 hours as required by law. The policy also indicted "Where the circumstances of the alleged violation warrants, the DNS or his/her designee shall initiate a physical and mental assessment of the resident (patient) and document the findings." The policy further indicated "The DNS, or his/her designee, shall notify the resident's (patient's) representative regarding the alleged violation and assessment findings...This contact shall be documented." Review of Patient A's clinical record revealed no documentation that Patient A's representative was notified of the alleged/suspected abuse and there was also no documentation that a physical assessment was completed and documented per the facility's policy.During an interview with the DON, on 6/23/09 at 11:35 a.m., she confirmed CNA 1 did not report the alleged/suspected abuse until 6/9/09, more than 24 hours later. The DON also confirmed Patient A's family/responsible party was not notified of the alleged/suspected abuse and that there was no documentation that Patient A was assessed for any injuries per the facility's policy.The Department determined the facility failed to: 1) Ensure facility staff reported suspected abuse of Patient A within 24 hours as required by law. 2) Ensure facility policy related to abuse reporting was implemented. Failure to comply with the requirements of this section of the Health and Safety Code shall be a Class B Citation. |
| 100000092 |
Golden Living Center - Galt |
030009507 |
B |
20-Sep-12 |
MSPR11 |
9203 |
F157 Notification of changes (injury/decline/room, Etc.) 483.10 (b)(11) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in Section 483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in Section 483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. F327 Sufficient Fluid to Maintain Hydration 483.25 (j) The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.Unannounced visits were made to the facility on 5/6/10 and 5/10/10 to investigate complaint #CA00226218. The Department determined the facility failed to: 1) Provide Resident A with the necessary fluids for hydration.2) Notify Resident A's physician timely regarding the resident's insufficient intake of fluids. These failures resulted in Resident A being admitted to the hospital where he received required treatment for dehydration. Resident A, a 96 year old male, was admitted to the facility on 2/12/09 with the following diagnoses: lung cancer, laryngeal cancer, chronic airway obstruction, malaise and fatigue, renal insufficiency and history of urinary tract infection (UTI). Resident A's Annual Minimum Data Set (MDS - an assessment tool), dated 2/19/10, indicated he had short term memory loss, independent cognitive skills for daily decision making, no difficulty with hearing, able to make himself understood and able to understand others. The MDS indicated Resident A had socially inappropriate/disruptive behavioral symptoms and self-resists care (resisted taking medications/injections, Activities of Daily Living (ADL) assistance, or eating). The MDS also indicated Resident A needed extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene and as needing limited assistance with walking in room and corridor, locomotion off the unit and eating.On 2/26/09 the physician signed an untitled form that Resident A's care was "supportive [maintain current level of function]." Resident A's "Therapy/Intervention" included hospitalization, intravenous fluids and antibiotics but no CPR (cardiopulmonary resuscitation). Resident A's "Nutritional Screening & Assessment" form, dated 2/5/10, indicated Resident A was to receive an estimated 1320 cc per day (30cc = 1 fluid ounce). Facility staff documented on the form, "Resident I & O (Intake and Output) Log" the amount of fluids (cubic centimeters - cc) consumed by Resident A each shift (7-3, 3-11, 11-7). The 24 hour totals for the 19 opportunities from 4/1/10 - 4/19/10 indicated the following recorded amounts of fluid consumed per day:4/1/10 - 1130 cc 4/2/10 - 480 cc 4/3/10 - 480 cc 4/4/10 - 450 cc 4/5/10 - 1020 cc 4/6/10 - 915 cc 4/7/10 - 720 cc 4/8/10 - 840 cc 4/9/10 - 500 cc 4/10/10 - 780 cc 4/11/10 - 870 cc 4/12/10 - 805 cc 4/13/10 - 400 cc 4/14/10 - 540 cc 4/15/10 - 450 cc 4/16/10 - 710 cc 4/17/10 - 270 cc 4/18/10 - 330 cc 4/19/10 - 240 cc The above data reflected that for 19 of 19 (100%) of the recorded opportunities Resident A consumed less than the calculated 24 hours intake goal of 1320 cc from 4/1/10-4/19/10, per Registered Dietician (RD) documented assessed needs. Resident A's "Nurse's Progress Notes" (Nurse's Weekly Notes), from 3/20/10 to 4/18/10, indicated "Hydration Status" was "encouraged." Review of Resident A's care plan, "Potential for Weight Loss," dated 2/13/09, indicated under the section "Interventions" "Monitor for S/S [signs & symptoms] of dehydration." During an interview with the Director of Nurses (DON), on 5/10/10 at 10:05 a.m., she confirmed Resident A was consuming less than the calculated 24 hours intake goal of 1320 cc from 4/1/10-4/19/10. She also confirmed there was no documentation the Licensed Nurse (LN) assessed Resident A's I & O and confirmed there was no documentation Resident A's physician was aware of the amount of fluids the resident was consuming.In a Nurse's Progress Note, dated 4/19/10 at 3:25 p.m., the LN documented that Resident A refused his morning medications, that fluids were being encouraged and that Resident A had taken a couple of bites of his meal. The LN further documented that a fax was sent to the physician regarding Resident A's poor appetite, poor fluid intake and the refusal to take his medications four times this month. Review of the fax sent to the physician on 4/19/10 indicated Resident A was having a poor appetite for the past week with a meal intake of 25%, sometimes only takes a couple of bites of food or sometimes refuses to eat. The fax also documented that Resident A had "poor intake of fluids also with average of 60ml to 240 ml per shift with encouragement." Resident A was described as having hematuria upon urination and described as appearing to be "very thin and dehydrated." In a Nurse's Progress Note, dated 4/19/10 at 7:22 p.m., the LN documented that Resident A was encouraged to eat and drink but was refusing. Documentation indicated a telephone call was placed to the physician regarding "dehydration concerns." An order was received and implemented for an IV, as well as lab tests to be drawn. A Nurse's Progress Note, dated 4/20/10 at 3:56 a.m., indicated Resident A's vital signs were the following: blood pressure - 80/58, temperature - 98.8, pulse - 82 and respirations - 22. The progress note indicated that Resident A was being monitored for refusing to eat, drink or take his medications. Resident A was described as having hematuria (blood in urine). A urine sample was collected by the LN and was described as "red in color." Documentation indicated Resident A's physician was notified regarding the Resident change of condition and an order was received to transfer Resident A to the ER for an evaluation. Review of Resident A's clinical record revealed he had lab tests on 2/2/10 while at the facility. His BUN (Blood Urea Nitrogen - a kidney function test with a reference value 8-23 mg/dl) was 27, Creatinine (reference value 0.7-1.3 mg/dl) was 1.2, and Sodium (reference level 136-145 mEq/L) was 140. Resident A's White Blood Count (WBC) (reference value 4.4-11.0) on 2/2/10 was 5.1. Review of Resident A's General Acute Care Hospital (GACH) records revealed a Admission History & Physical (H & P),dated 4/20/10, that indicated Resident A was admitted to the hospital in August of last year (2009) and was found to have a bladder mass. At the time, Resident A was too frail to undergo any procedures and was given antibiotic treatment and the hematuria resolved. According to the H & P "the Patient apparently again developed hematuria in the skilled nursing home. The Patient also had been not taking any medications...While in the emergency room the Patient was found to have elevated white blood cell count of 713,000. The patient's BUN 120, Creatinine 2.56, which had been significantly increased from the previous baseline."The H & P indicated under the section Physical Examination (in part) that Resident A had "poor oral hygiene" and diagnoses included sepsis, urinary tract infection, dehydration, and bladder mass. The H & P also indicated (in part) that "the Patient came in with sepsis most likely source is due to urinary tract infection...We are going to hydrate the Patient and also start the Patient on antibiotic treatments...We are also going to aggressively hydrate the Patient since the patient's BUN and creatinine have been significantly elevated compared with the last admission...The Patient also has a history of lung cancer, laryngeal cancer and most likely also has bladder cancer. His prognosis is extremely poor." Resident A was admitted to the hospital on 4/20/10, improved with treatment, and was discharged from the GACH on 5/2/10. The Department determined the facility failed to: 1) Provide Resident A with the necessary fluids for hydration.2) Notify Resident A's physician timely regarding the resident's insufficient intake of fluids. These failures resulted in Resident A being admitted to the hospital where he was treated for dehydration. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001823 |
Golden Living Center - Portside |
030009836 |
B |
25-Apr-13 |
664S11 |
5018 |
F-323 Free Of Accident Hazards/supervision/devices 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An entity reported incident was received by the Department on 2/26/10 regarding Resident A, who had eloped from the facility that morning at approximately 5:50 a.m. The report indicated Resident A was found "roughly" 1.8 miles away. An unannounced visit was made to the facility on 6/8/10 to investigate complaint #CA00219754. The Department determined facility staff failed to provide adequate supervision and interventions to prevent one confused resident from eloping from the facility, undetected by the facility staff, which resulted in the patient being found 1.8 miles away from the facility. Resident A was admitted to the facility on 12/8/09 with a diagnosis of organic brain syndrome and schizophrenic disorder of the paranoid type. Review of a Minimum Data Set (MDS), an assessment tool, indicated Resident A had problems with short and long term memory and was moderately impaired in decision making ability. The MDS further indicated she wandered. A departure alert system (DAS) bracelet was placed on Resident A's wrist upon admission and a physician's order dated 12/8/09 instructed that the device be checked for placement every shift and for function daily.Review of a Plan of Care initiated at admission revealed Resident A was "At risk for elopement related to: history of elopement. Resident left board and care and was wandering in the neighborhood per RP [Responsible Party]." An intervention on the care plan, dated 12/8/09, indicated a [DAS bracelet] was in place and the placement and function of the device were to be checked daily. No other interventions regarding the [DAS] were entered into Resident A's plan of care prior to the elopement event of 2/26/10. A Nurses Note dated 2/26/10 at 8:12 a.m. indicated that at 5:45 a.m., CNA 1 reported to the nurse on duty that Resident A was not on the unit. CNA 1 reported Resident A had last been seen at 5:30 a.m. The resident was located in the community at approximately 7 a.m. by a facility staff member.A document entitled "Precaution Observation Sheet-Visual Observation Q [every] 15 minutes" dated 2/26/10 was reviewed. In the space marked 5:00 a.m. the comment "changing clothes" appears. In the spaces marked 5:15 a.m., 5:30 a.m., 5:45 a.m., 6:00 a.m., 6:15 a.m., and 6:30 a.m. the comment "up in room" was entered. In the space marked 6:45 a.m. the comment "missing" is entered.In an interview with the Alzheimer's Unit Director on 6/8/10 at 1:35 p.m., she stated, "Resident A sometimes voiced that she wanted to go home, but had never tried to leave the facility to my knowledge." She also stated Resident A had never taken off her DAS bracelet before 2/26/10, as far as she knew. In a telephone interview with CNA 1 on 6/9/10 at 9:35 a.m., he stated Resident A took her DAS bracelet off frequently. Regarding the elopement of 2/26/10, he stated he saw Resident A at approximately 4:45 a.m. when he accompanied the roommate to the toilet. He stated he did his usual rounds and returned to Resident A's room at about 5:45 a.m., and discovered she was not in the room. He stated he saw Resident A's DAS bracelet on the desk in the room.In a telephone interview with RN 1 on 6/10/10 at 10:35 a.m., he stated he discovered Resident A could take her DAS bracelet off about a month before the elopement event. He further stated he would have expected to see something about Resident A being able to remove the bracelet in the Plan of Care. The facility's Elopement Policy, dated 3/07, was reviewed. It documented in pertinent parts: "Care plan should address the resident's potential to wander or exit facility and the measures taken to prevent wandering/elopement" and "All residents at risk of elopement are assessed quarterly and as needed . . ."The facility's Care Plan policy, dated 5/01, was reviewed. It documented in pertinent parts: "The interdisciplinary care plan is reviewed, revised and updated quarterly and more frequently if warranted by a change in resident's condition." Staff knowledge of Resident A's ability to remove the DAS bracelet was not addressed by the Care Plan to prevent the elopement of 2/26/10. In addition, the Alzheimer's Unit Director was not informed of Resident A's increased potential for elopement due to the ability to remove the safety device at will. Resident A was checked every 15 minutes per documentation, but it is unclear if this actually occurred on the morning of 2/26/10 because the documentation does not reflect the caregiver's verbal account of the events of that morning.Therefore, the Department determined the facility failed to provide adequate supervision to prevent accidents. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000073 |
Golden Living Center - Hy-Pana |
030009986 |
B |
03-Jul-13 |
R65811 |
9724 |
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. 72313 (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. An unannounced visit was made on 6/23/2010 to initiate the investigation of complaint#CA00233171. As a result of the investigation the Department determined that the facility failed to: 1. Ensure Patient A was protected from a significant medication error by giving Patient A the wrong medication. 2. Follow the physician's order to hold all sedative medications. The combined effect of these errors resulted in increased sedation and confusion that necessitated administration of medication to counteract the sedative effect. Patient A experienced a dangerous elevation in blood pressure after the administration of this medication and required an unplanned transfer to the acute care hospital for evaluation and treatment. Review of Patient A's clinical record was conducted on 6/23/2010. Patient A was an 81 year old admitted on 12/18/2008, with diagnosis of hypertensive heart disease with heart failure and dementia with behavioral disturbances. Resident A's Admission Minimum Data Set (MDS, a standardized assessment tool), dated 11/28/2009 documented Resident A as having short-term memory loss, difficulty in new situations with daily decision making skills, clear speech, able to make herself understood and able to understand others. Patient A needed no assistance with walking, limited assistance with dressing, and extensive assistance with personal hygiene and toileting. Patient A was documented as not being in pain while on her current pain medicine regimen. Patient A's medication regimen included:Norco (acetaminophen-Hydrocodone, a narcotic pain medication), 325-10 milligrams tablet, was given by mouth, every four hours, around the clock. Remeron (Mirtazapine) 15 milligram tablet was given daily at bedtime for depression. Ambien (Zolpidem Tartrate) 5 milligrams tablet was given at bedtime every day for insomnia. Cardiac medications included: Imdur (Isosorbide Mononitrate), 30 milligrams, one daily was given for hypertensive heart disease with heart failure and Metoprolol Tartrate, 25 milligrams, 1 tablet every eight hours was given for congestive heart failure. Patient A's clinical record progress note dated 6/20/2010 at 13:25 (1:25 pm), documented RN 1 gave the wrong medication to Patient A. RN 1 was standing by the medication cart preparing medication for Patient B when she noticed Patient A was rolling by the cart in her wheel chair to go to lunch. RN 1 asked Patient A if she wanted her afternoon medication and "she stated that she did. I prepared her medication, set the cup [medication cup] down on the medication cart, turned to get her a glass of juice, [turned back] and picked up the wrong cup and gave it to her at 13:25.(1:25 pm)." The cup given to Patient A contained the afternoon medication for Patient B. The medication given in error to Patient A was Avinza (Morphine Sulfate Beads) a 90 milligram capsule Extended Release. It is intended to have effect for 24 hours. The following information (in part) was taken from: "Drugs.Com, Official FDA drug information." "Avinza is Morphine, a pure opioid (pain medication)...In addition to analgesia, the widely diverse effects of morphine include drowsiness, changes in mood, respiratory depression, decreased gastrointestinal motility, nausea, vomiting, and alterations of the endocrine and autonomic nervous system."Review of the Progress Notes dated 6/21/2010 at 14:29 (2:29 pm) documented the following: "Verbally responsive, brief periods...morning medications given...Afternoon medications held due to some sedation." * The physician was not notified that the noon medications were held due to sedation noted by the nurse.On 6/22/2010, the physician telephone order stated, "Hold all sedative medications until sedative effects of Morphine wear off. No Ambien, No Norco for 3 days..." The order was not timed. A progress note dated 6/22/2010 at 15:59 (3:59 pm) documented, "At 1330 (1:30 pm) called MD to get additional orders; IV (intravenous) orders of [Dextrose in 5 1/2 normal saline at 75 milliliters per hour for three days] and medication orders endorsed all to next shift." Review of the MARs (Medication Administration Record) sheets for June 2010 revealed Patient A was taking Norco (Acetaminophen-Hydrocodone 325-10 milligrams, by mouth, every four hours, around the clock for her pain. She continued to get the Norco after getting the 90 milligrams of Morphine Sulfate extended release was given in error. Patient A received eleven doses of the Norco during the period of 6/20/2010 at 16:00 (4 pm) through 6/23/2010 at 4 am. Ambien was also given for sleep on 6/20/2010 and 6/21/2010The order to hold all sedative medications was written on 6/22/2010. Four doses of Norco 325-10 milligrams were given by the night shift nurse, LVN 2, after the order was written. During an interview with LVN 2 on 2/27/2012 at 6:30 am, she stated, "That is my initials on the medication sheet. We routinely give Norco 325-10 mg every four hours around the clock. I gave the medication at 0000 [midnight] and at 4 am on 6/22/2010 and on 6/23/2010. I don't know how I missed the order to hold the Norco. I should have notified the Doctor. I should not have given the medication." During an interview on 6/23/2010 at 12:15 pm with the Acting DON (Director of Nursing), she was asked, "Based on what you have seen in the MARS, what do you think should have been done?" She stated, "I probably should have had an order to hold the sedative medications on Sunday [6/20/2010]...We should have questioned it and got a hold order from the physician." Review of a Progress Note dated 6/22/2010 at 15:59 (3:59 pm) revealed the following, "Resident continues on charting for medication error. Resident is alert and confused. This A.M. checked on resident, resident sleeping in bed...Offered resident breakfast, resident refused. Came in to medicate resident at 0830, unable to arouse resident for medications. Continue to monitor resident until 11:00 when called MD [Medical Doctor] as resident still had not gotten up. MD ordered one dose of Narcan given at 11:25. Monitored resident VS (vital signs) prior to administration of Narcan..." Narcan is a drug with a specific use to reverse known or suspected opiod induced effects such as decreased responsiveness, drop in blood pressure or respiratory depression. Side effects may include nausea, vomiting, sweating, increased heart rate, increased blood pressure and seizures.The 6/22/2010 at 22:36 (10:36 pm) Progress Note documentation noted "Resident is alert to verbal stimuli. Continues to have slow speech and complains of being tired. IV assist place peripheral IV in right arm...started on Dextrose 5 1/2 Normal Saline at 75 ml. (milliliters) per hour. The 6/23/2010 at 6:49 am Progress Note from the night shift contained the following documentation, "VS - Temperature 99.5, Pulse 66, Respirations 18, and Blood Pressure of 147/63." Two doses of Norco 325-10 were given to Patient A during the night shift, at 0000 (midnight) and 4 am, even after the 6/22/2010 physician order to hold all sedative medications. The 6/23/2010 at 17:39 (5:39 pm) Progress Note from the day shift contained the following documentation, "VS [vital signs] Temperature 99.5, Pulse 66, Respirations 18, and Blood Pressure of 182/71. Resident is alert with periods on confusion. Upon arrival was given report that resident was still feeling effects of medication error given on Saturday. With grogginess and sedation still prevalent. Checked Resident. Easy to arouse when spoken to. Held all A.M. medications at 0900 due to sedation of resident unable to arouse easily and high risk for aspiration...MD ordered a second dose of Narcan to be given and to call him back after administration. At 1430 (2:30 pm) shift change, orders reviewed. Narcan given at 1520 (3:20 pm), first set of vitals at 1530 (3:30 pm) indicate BP is increasing due to dose given. Resident awake and alert but extremely confused. At 1545 (3:45 pm) BP was 201/109...call was placed to MD. MD requested to wait 30 more minutes and see what happens. MD called resident's son to inform of current situation. At 1612 (4:12 pm) called MD with last set of vitals and MD ordered resident to ER (Emergency Room)... Transported at 1700 (5:00 pm) to the [Hospital Name]..."Patient A was admitted to the hospital for evaluation and was returned to the facility on 06/24/2010. The Department determined the facility failed to: 1. Ensure Patient A was protected from a significant medication error when she was given the wrong medication. Ninety milligrams of Avinza (Morphine Sulfate Beads, extended release for 24 hours), meant for another patient, was administered to her in error. 2. Follow the physician's order written on 6/22/2010 at 11 am to "hold all sedative medications...No Norco for 3 days" after Patient A had received a strong, long acting narcotic analgesic in error. The combined effect of these errors resulted in increased sedation and confusion that necessitated administration of medication to counteract the sedative effect. Patient A experienced a dangerous elevation in blood pressure after the administration of this medication which required an unplanned transfer to the acute care hospital for evaluation and treatment. These violations had a direct or immediate relationship to health, safety, or security, of long-term care facility patients. |
| 030001831 |
Gramercy Court |
030009993 |
B |
08-Jul-13 |
72UG11 |
5082 |
Health & Safety Code - 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse of suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. This citation was written as the result of an unannounced visit to the facility on 3/26/13 to investigate a facility reported incident #CA00347773 pertaining to a staff to patient abuse reported to the Department on 3/19/13. The Department determined the facility failed to notify the Department within 24 hours of an allegation of neglect when Patient A's call light was not answered for 2 hours which resulted in Patient A not being repositioned for a total of six hours. This caused Patient A to experience pain and discomfort. Patient A was readmitted to the facility on 1/25/13 with diagnoses including history of a stroke, generalized weakness and contractures of the lower extremities (permanent contractions of a muscle due to spasms or permanent loss of function). Patient A's Significant Change in Status MDS (Minimum Data Set-an assessment tool) dated 3/14/13 indicated she had no memory problems and that she needed extensive assistance with bed mobility and repositioning. In an interview with the Administrator (AD 1) on 3/26/13 at 2:30 p.m. he stated he had done the 3/5/13 abuse investigation concerning Patient A and Certified Nursing Assistant 1 (CNA 1). AD 1 stated Patient A had approached him on 3/5/13 and had told him how she had put her call light on at 2 a.m. on 3/5/13 and that by 4:15 a.m., none of the facility staff had answered her light. By then she felt she needed to yell out into the hall to get the staff's attention. AD 1 stated CNA 1 should have answered Patient A's call light right away and from the investigation and CNA 1's past work performance, CNA 1 was terminated for neglecting to promptly answer Patient A's call light and reposition her.Review of a letter to CNA 1, dated 3/8/13, an investigation of suspected abuse and neglect on 3/5/13, had been done concerning her and Patient A. The letter indicated Patient A had turned on her call light to be repositioned at 2 a.m. and that no one answered her light until the patient started yelling out, at 4:15 a.m. The letter also indicated that when CNA 1 came into Patient A's room at 4:15 a.m., she did not seem to care about turning Patient A. The letter indicated "Upon conclusion of the investigation: you [CNA 1] neglected to provide care basic turning and repositioning (facility policy every 2 hours) for a resident under your direct care...[the facility] has decided to terminate your services as a Certified Nursing Assistant due to the fact that this [sic] your second incident of suspected neglect of care for a resident [patient] under your care." In an interview with Patient A on 3/26/13 at 3 p.m., she stated she was unable to reposition herself because of contractures and her generalized weakness. She stated that she remembered being turned on her side around 10 p.m. on 3/4/13. She then put her call light on at 2 a.m. to be turned again because she was uncomfortable and in pain. Patient A then stated no one answered her light and she had to yell out into the hall at approximately 4 a.m. to get the staff's attention. It was at this time CNA 1 came into her room and attempted to reposition her. (This represented a time frame of 6 hours Patient A was lying on the same side and at least 2 hours were she experienced pain from not being repositioned). Patient A stated she became upset with CNA 1 at this time because CNA 1 had grabbed at her leg in such a way that it caused her to experience more pain and discomfort.Review of the facility's policy titled, "Resident (Patient's) Rights: To Be Free from Abuse", dated 1/15/13, under Reporting: "All employee [sic] are mandated reporter [sic] and are required by law to report incidents of observing, obtaining knowledge of, or suspecting physical abuse that does not involve 'serious bodily injury' to all of the listed below within 24 hours: Department of Public Health: A written report to the local district office of Licensing and Certification..." In an interview with AD 1 on 3/26/13 at 3:30 p.m., he stated the incident happened on 3/5/13 and did not get reported to the Department until 3/19/13. He stated, "I was late informing the Department about the abuse allegation."Therefore, the Department determined the facility failed to: Notify the Department within 24 hours of an allegation of neglect when Patient A's call light had not been answered for 2 hours, resulting in Patient A not being repositioned for a total of six hours. This caused Patient A to experience pain and discomfort.These violations had a direct or immediate relationship to the health, safety, or security of the long-term care facility patients or residents. |
| 030000063 |
Gold Country Health Center |
030010251 |
B |
14-Nov-13 |
7KR311 |
4416 |
F323 Free Of Accident Hazards/supervision/devices - 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This citation was written as a result of an unannounced visit on 12/27/11 to investigate an entity reported incident number CA00283800. The Department determined the facility failed to ensure Resident 1's bed alarm was in place and working properly to alert staff when she got out of bed without assistance.This failure resulted in a fall on 9/16/11 in which Resident 1 sustained a fracture of her right lower leg.Resident 1 was a 97 year old admitted to the facility on 11/23/09. She had diagnoses including dementia and osteoporosis (brittle bones). A quarterly Minimum Data Set (an assessment tool), dated 8/3/11, indicated Resident 1 had moderately impaired cognitive skills and was unsteady when standing and walking. Resident 1 was observed on 12/18/11 at 10:50 a.m. She was in bed awake with her bed in the low position. During a concurrent interview Resident 1 was pleasant and spoke with some confusion. Resident 1 was not able to recall her fall on 9/16/11. A Falls Care Plan, dated 11/23/09, indicated Resident 1's fall risk was "related to gait/balance and mental status, as evidenced by unsteady gait." The Plan included under Approach, "Alarm in bed." Resident 1 had a physician's order, dated 12/21/09, for "Bed alarm (ON in bed)." A bed alarm was to be attached to the bed and clipped to the resident so an audible alarm sounded to alert staff when the resident started to get out of bed without assistance. This was an intervention to prevent falls. A Fall Occurrence Review document, dated 9/19/11, described Resident 1's fall on 9/16/11 at 3 a.m. "[Certified nurse assistant (CNA)] saw resident walking by pushing her [wheelchair] toward her [bedroom] door. She went to help her and [Resident 1] started to sit down by holding her arm out behind her." Under Probable Cause, the document indicated, "Confused didn't know what she was doing or going (sic). Removed her clip alarm." A Nurses Notes, dated 9/16/11 at 3 a.m., indicated Resident 1 "[complained of] [right] lower leg pain. She stated she had told [physician] about her sore leg in the past. She is able to move her leg. [Right] lower leg elevated [and] it seems to give her relief." A Nurses Note, dated 9/16/11 at 10 a.m., indicated Resident 1 "[complained of] pain [right] lower extremity. Leg swollen...[physician] notified." The physician ordered an x-ray of her leg. A Nurses Note, dated 9/16/11 at 1 p.m., indicated Resident 1's "[right] leg now noted to be shorter than [left] leg." The physician was again contacted and gave orders to transfer Resident 1 to the emergency room.A Nurses Notes, dated 9/16/11 at 1:30 p.m., indicated Resident 1 was transferred to the emergency room for evaluation of her right leg. An X-ray report, dated 9/16/11, indicated Resident 1 had a "fracture of the distal (lower) third of the right tibial shaft (bone)." A Nurses Notes, dated 9/16/11 at 5:30 p.m., indicated Resident 1 returned from the emergency room with a "cast to [right] leg." An interview was conducted with CNA 1 on 12/28/11 at 9:25 a.m. She stated, "Bed alarms are checked weekly to ensure they are working." CNA 1 did not have a record of the alarm status for Resident 1's alarm. She stated, "I am aware her alarm may not have been working when she fell" on 9/16/11.An interview was conducted with CNA 2 on 12/30/11 at 10:50 a.m. She stated she was walking down the hall and observed Resident 1's fall from several rooms away. CNA 2 stated, "She lost her balance...the bed alarm was not going off (sounding)." Review of the facility policy titled "Low Beds, Floor Pads, Bolsters and Safety Devices, dated 1/31/11, included, "It is the policy of this facility to use the least restrictive methods to prevent falls whenever possible. This included the use of...bed/chair alarms...and other devices to reduce the risks of serious injuries to our residents." The Department determined the facility failed to ensure Resident 1's bed alarm was in place and working properly to alert staff when she got out of bed without assistance.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001831 |
Gramercy Court |
030010254 |
B |
19-Nov-13 |
WJIB11 |
12997 |
72311 - Nursing Service -- General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. 72311 - Nursing Service -- General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (C) An unusual occurrence involving a patient, as defined in Section 72541. 72313 - Nursing Service - Administration Of Medication (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 72523 - Patient Care Policies And Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Unannounced visits were made to the facility on 2/6/12, 2/7/12 and 2/14/12 to investigate complaint # CA00297802. The Department determined the facility failed to: 1. Ensure Patient A's tab alarm (an alarm that sounds when a patient rises from bed or wheelchair to alert staff) was implemented. 2. Ensure the attending physician was notified when Patient A refused to take her medications. 3. Ensure Patient A's care plans included care to be given. 4. Ensure the facility's policies and procedures were implemented to ensure patient related goals and facility objectives were achieved.These failures resulted in Patient A sustaining a small subdural hematoma [bleeding into the skull cavity] and minimally displaced nasal bone fracture, as well as, lacerations [cuts] to the left facial area. Patient A's clinical record was reviewed and indicated Patient A was originally admitted to the facility on 9/5/07 with diagnoses including dementia, history of falls, cerebral vascular accident (CVA-stroke), urinary incontinence and history of urinary tract infection (UTI).Patient A's Quarterly Minimum Data Set (MDS - a standardized assessment tool), dated 12/29/11, indicated Patient A had short and long term memory problems, impairment in decision making skills, disorganized thinking, and problems communicating. The MDS indicated Patient A needed extensive assistance with bed mobility and dressing, and limited assistance with transfers and eating. The MDS indicated Patient A was dependent on staff for toilet use and personal hygiene.Patient A's Physician Order Report for 1/1/12-1/13/12 contained a nursing order, dated 2/2/11, for "Pad and tab alarm while in bed and in wheelchair." The following care plans were found in Patient A's clinical record: Patient [patient] at risk for falling, dated 5/20/11; Potential for injury related to hx [history] of fall, dated 2/22/11; At risk for increasing confusion..., dated 1/23/11; and Increased confusion related to possible urinary tract infection, dated 1/15/12. None of these care plans addressed the implementation of the physician's order for pad and tab alarms for Patient A while in bed or in a wheelchair.Patient A's clinical record contained a Patient Progress Note, dated 1/15/12 at 7:10 p.m., Licensed Vocational Nurse (LVN) 2 documented Patient A's UA [urinary analysis] results were received. Patient A's attending physician was contacted and an order was obtained for Patient A to receive an antibiotic for a UTI (Urinary Tract Infection). Patient A's Patient Progress Notes were reviewed and indicated Patient A refused to take her medications on the following dates in January 2012: 1/7, 1/14, 1/15, 1/17, 1/18, 1/19, 1/20 and 1/21. Review of Patient A's clinical record revealed no documented evidence that Patient A's physician was notified that Patient A was refusing to take her medications. During an interview with the Director of Nursing (DON), on 2/7/12 at 10:25 a.m., she confirmed she was unable to find any documented evidence that Patient A's physician was notified that Patient A was refusing to take her medications.Review of a Patient Progress Note, dated 1/21/12, at 7:37 p.m., (edited at 10:58 p.m.), LVN 1 documented that Patient A fell in the day room at around 10 p.m. LVN 1 documented that Patient A was observed to have no injuries and there was no complaint of pain. There was no documented evidence that Patient A had a tab alarm on or that the tab alarm was sounding when she fell.A Patient Progress Note, dated 1/21/12 at 9 p.m., (recorded as a late entry on 1/23/12 at 4:05 p.m.) which referred to Patient A's 1/21/12 10 p.m. fall. The progress note indicated Registered Nurse (RN) 1 was called to assess Patient A after Patient A had an un-witnessed fall in the day room. RN 1 documented Patient A was found on the floor and was assessed for injuries. A red area on Patient A's right shoulder was observed but no complaint of pain from Patient A.Review of a form titled "Falls-Fall Risk," dated 1/21/12 at 11 p.m., LVN 2 documented that Patient A "has refused all/most medication last 5 days." In a Patient Progress Note, dated 1/21/12 at 11:30 p.m. LVN 2 documented she heard a loud crashing sound from the day room. She observed Patient A on the floor (2nd fall that night) with her left side facing the ground. LVN 2 documented she notified the RN supervisor and called 911. LVN 2 documented Patient A's physician was called and the on-call physician gave an order to send Patient A to a hospital emergency room (ER) for an evaluation. There was no documented evidence that Patient A had a tab alarm on or that the tab alarm was sounding when she fell.LVN 2 was interviewed via telephone on 2/7/12 at 3:05 p.m. She was unable to recall if Patient A's tab alarm was sounding at the time of Patient A's fall on 1/21/12 at 11:30 p.m. She stated "probably." In a Patient Progress Note, dated 1/21/12 at 11:30 p.m. RN 2 documented she was called to come over and look at Patient A. RN 2 documented she saw Patient A lying on the floor in the day room. She described Patient A's cut on her left upper eyelid and wrote it measured approximately 2 centimeters (cm) by 5 cm. The cut on Patient A's left lower eyelid measured 2 cm by 4 cm. RN 2 documented Patient A was alert with confusion and the pupils of her eyes were normal sized (3 millimeters-ml) and they reacted appropriately to light.In a Patient Progress Note, dated 1/21/12 at 11:56 p.m., LVN 3 documented that at the beginning of her shift she heard a loud crashing noise in the day room. LVN 3 documented "all staff member on the floor" ran to the day room and found Patient A lying on the floor. LVN 3 documented that patient A had a UTI and "was not taking her medication refusing often and was more confused than before." There was no documented evidence that Patient A had a tab alarm on or that the tab alarm was sounding when she fell.In a form titled "Safety Events," dated 1/22/12 at 12:24 a.m., LVN 3 documented "Yes-w/c (wheelchair)" under the question "Were restraints/adaptive equipment in use at time of the fall?" There was no documented evidence that Patient A had a tab alarm on or that the tab alarm was sounding when she fell.The facility's investigation report contained a written statement by Certified Nursing Assistant (CNA) 1, dated 1/26/12. CNA 1 documented her and another CNA tried to get Patient A to bed but she refused so they took her back to the day room. CNA 1 documented that after taking Patient A to the day room she went and provided care to her other patients. CNA 1 wrote that around 8:45 p.m. she went to try and put Patient A back to bed but Patient A refused to go to bed. Patient A asked her to take her back to the day room so CNA 1 did so. CNA 1 documented she was doing her "last round" when she heard her Charge Nurse (CN) running towards the day room. CNA 1 documented she saw Patient A "was on the floor around 9:45 p.m." CNA 1 documented that at around 10:10 p.m. she tried to take Patient A back to her room but she refused to go to bed and be changed so CNA 1 brought her back to the day room.During a telephone interview with CNA 1, on 2/14/12 at 2:58 p.m., she confirmed what she wrote in her statement on 1/26/12 regarding having tried several times to get Patient A to go to bed. CNA 1 stated at the time of Patient A's first fall she was in the hallway when she saw the nurse running to the day room and that she followed her into the day room. CNA 1 described Patient A as "confused." She stated Patient A was supposed to have a tab alarm while in bed but no tab alarm while up in her wheelchair. CNA 1 stated there was no tab alarm sounding when Patient A fell.The facility's investigation report contained a written statement by LVN 1, dated 1/23/12. LVN 1 documented that around 9:40 p.m. she was at her medication cart when she "heard a loud crashing noise from the day room." LVN 1 documented she ran into the day room and found Patient A on the floor laying on her right side. LVN 1 documented the RN supervisor finished her assessment and Patient A was assisted back into her wheelchair. LVN 1 documented that later that evening she "heard a loud crashing noise again from the day room." LVN 1 documented when the RN supervisor arrived to assess Patient A she left to prepare the transfer packet and transfer form (for Patient A to go to the hospital ER).LVN 1 was interviewed on 2/7/12 at 11:20 a.m. She confirmed what she wrote in her 1/23/12 statement regarding Patient A's first fall. LVN 1 stated she didn't know if Patient A was to have a tab alarm because she was not assigned to Patient A. LVN 1 confirmed she didn't hear a tab alarm going off when Patient A fell the first time. LVN 1 stated she was counting narcotics when she heard a loud bang the second time Patient A fell. Again she confirmed she did not hear a tab alarm sounding.The facility's investigation, dated 1/23/12, was reviewed. The DON documented that Patient A "was not considered to be a high risk faller and all interventions we could do were in place." Patient A's clinical record was reviewed and revealed no documented evidence of a Fall Risk Assessment after one dated 7/12/11 (6 months prior to Patient A's falls). Review of a form titled "Falls-Fall Risk-Posey," dated 7/12/11, revealed under the section "Evaluation-Calculate points and record total. Score of 10 or higher represents a high risk for falls." The LVN documented Patient A's score was "17," indicating Patient A was at high risk for falls.According to the facility's policy, "Fall Prevention Program Facility Checklist," undated, "A Fall Risk Assessment is completed at admission, quarterly and at change of condition." Review of Patient A's clinical record revealed no documented evidence that a Fall Risk Assessment was completed quarterly and after her first fall on 1/21/12. According to the facility's policy "Protocol for Falls and Fall Documentation," undated, after a patient falls the nurse was to "Document under 'event' section of electronic medical record what you found and what you observed. Do not speculate and say someone fell just because they were found on the floor. Facts only using your observations and assessments." Review of Patient A's electronic medical record revealed no documented evidence regarding Patient A's first fall on 1/21/12 under the section "event." During an interview with the DON, on 2/7/12 at 10:25 a.m., it was brought to her attention that Patient A's last fall risk assessment, completed on 7/12/11, indicated her score was "17." The DON confirmed that "17" indicated that Patient A would be considered at high risk for falls. The DON further stated that Patient A had not had a fall in quite some time. The DON also confirmed she was unable to locate any documented evidence that a Fall Risk Assessment was completed quarterly and after Patient A's first or second fall on 1/21/12. The DON confirmed she was unable to find any documented evidence under the section "event" in Patient A's electronic medical record regarding Patient A's first fall on 1/21/12. The DON further confirmed there was no documented evidence that Patient A had a tab alarm on or that the tab alarm was sounding when she fell both times.The Department determined the facility failed to: 1. Ensure Patient A's tab alarm was implemented. 2. Ensure the attending physician was notified when Patient A refused to take her medications. 3. Ensure Patient A's care plans included care to be given, specifically the application of the tab and/or pad alarm. 4. Ensure the facility's policy and procedure for fall risk assessment was implemented. These failures resulted in Patient A sustaining a small subdural hematoma and minimally displaced nasal bone fracture, as well as, lacerations to the left facial area. These violations had a direct or immediate relationship to the health, safety or security of a long-term care facility patient or Patient. |
| 030001831 |
Gramercy Court |
030012541 |
B |
29-Aug-16 |
5KDG11 |
2430 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of entity reported incident #CA00492618. Unannounced visits were made to the facility on 06/21/2016, 08/09/2016 and 08/16/2016 to investigate a facility reported incident received on 06/21/2016 at 11:04 a.m. regarding an incident of alleged resident to resident abuse on 06/19/2016. The Department determined the facility failed to: Report to the Department an allegation of abuse of Resident 1 immediately, or within 24 hours. Resident 1 was admitted to the facility in March 2013. Diagnoses included dementia without behavioral disturbance and muscle weakness. An interview was conducted with Resident 1 on 06/21/2016 at 3:30 p.m. Resident 1 stated a light skinned man forced her to perform oral sex on him. Resident 1 stated she told her son about the abuse. A Nurse's Note, dated 06/19/2016 at 6:48 p.m., indicated on 06/19/2016 at 5:25 p.m. Resident 1's son reported Resident 1 alleged she had been sexually assaulted. An interview was conducted with the Director of Nurses (DON) on 08/16/2016 at 3:05 p.m. She stated their Social Services Designee takes care of investigating and reporting abuse. An interview was conducted with the Social Services Designee (SSD) on 08/16/2016 at 3:35 p.m. She stated she initiated the investigation of Resident 1's allegation of abuse on 06/20/2016, but reported the abuse allegation to the Department on 06/21/2016. The facility policy titled "Resident Abuse Prevention & Mandated Reporting Policy & Procedures," dated 08/15/2013, under the section titled "All Staff are Mandated Reporters," and the subsection titled "Reporting Procedures," directed, "All employees are mandated reporters and are required by law to report any incidents of alleged, suspected and/or actual resident abuse within 24-hours to the Department of Public Health and the Local Ombudsman Office by fax..." The Department determined the facility failed to: Report to the Department an allegation of abuse of Resident 1 immediately, or within 24 hours. Failure to comply with the requirements of Health & Safety Code Section 1418.91 shall be a class "B" violation. |
| 030001823 |
Golden Living Center - Portside |
030012577 |
B |
20-Sep-16 |
TG5V11 |
4040 |
Health and Safety Code, 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of an investigation of facility reported incident #CA00493992. An unannounced visit was made to the facility on 08/01/16 at 11 a.m. The Department determined the facility failed to: Report to the Department an allegation of resident to resident abuse involving Resident A and Resident B within 24 hours of the incident. Resident A was an 80 year old with diagnoses including dementia with behavioral disturbances. Resident B was a 78 year old with diagnoses including dementia with behavioral disturbances. A Progress Note dated, 7/25/16 at 2:17 p.m., indicated Resident A and Resident B were sitting side by side talking to each other. Suddenly Resident A raised her voice and started "yelling, screaming, kicking, and hitting" Resident B. Resident A was also trying to take Resident B's purse. The Note indicated Resident A was very difficult to redirect. It took two staff to redirect her. A Progress Note, dated 7/25/16 at 2:35 p.m., indicated Resident B was hit and kicked by Resident A. The Note indicated neither Resident A nor Resident B sustained injury. An interview was conducted with the Director of Nursing (DON) on 8/1/16 at 12:45 p.m. While reviewing the incident between Resident A and Resident B, the DON was asked if this incident of resident to resident abuse had been reported to the Department. The DON stated she had been told by Administration the incident did not require reporting to the Department. An interview was conducted with the "acting" Facility Administrator (FA) on 8/1/16 at 1 p.m. The FA was asked if the incident of resident to resident abuse between Residents A and B was reported to the Department. The FA stated the incident was not reported because both of the residents had dementia. The FA stated according to the Corporate Executive Director (ED), the incident only required reporting to the Ombudsman, not to the Department. The FA referenced a Mandated Reporter algorithm produced by the California (CA) Long-Term Care Ombudsman. The FA was asked if she was aware the direction of the CA Long-Term Care Ombudsman does not meet State abuse reporting requirements. The FA stated she was acting on direction of the Corporate ED. The facility's policy titled Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property CA Version #2 (undated) included, in part, the following: "Policy: The ED shall report all "alleged" or "suspected" abuse resulting in serious bodily injury of a resident to local law enforcement by telephone immediately and no later than two hours, and to the [Department] of Health Services. If the suspected abuse does not result in a serious bodily injury, a written report must be submitted within two hours to the local law enforcement agency, and the ombudsman (CA H&S Code 1418.91a)." The California Health and Safety Code 1418.91(a) was the referenced law for the above directions. "Reporting: Any employee who suspects an alleged violation shall immediately notify the ED/[Director of Rehabilitation (DOR)]. The ED/DOR shall notify the appropriate state agency, in accordance with state law ... The ED/DOR of the center shall report all alleged or suspected violations to the operational director and to the Department of Health Services ... The results of all investigations must be reported to the appropriate state agency, as required by state law, within 5 working days of the alleged violation." The Department determined the facility failed to: Report to the Department an allegation of resident to resident abuse involving Resident A and Resident B within 24 hours of the incident. |
| 100001511 |
Gapasin Manor ICF DDN #3 |
030013050 |
B |
16-Mar-17 |
2BZV11 |
3094 |
California Health and Safety Code, Section 1418.91
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The following citation is written as a result of complaint #CA00515581. An unannounced visit was made to the facility on 12/23/16 to investigate an allegation of potential sexual abuse.
The Department determined the facility failed to implement State law related to alleged and suspected patient abuse reporting.
An entity reported incident (ERI), received on 12/23/16, disclosed a partially witnessed client to client interaction where Client 1 was found lying clothed on top of Client 2, who was also clothed.
An interview was conducted with Direct Care Staff (DCS) 1 on 12/23/16 at 2:10 p.m. DCS 1 stated Client 1 came home from the Day Treatment Program (an outside service that provides skills acquisition training/teaching) on 12/20/16 at 1:05 p.m. DCS 1 provided incontinent care to Client 1 and twice during the incontinent care Client 1 touched DCS 1's breast and stomach. DCS 1 redirected Client 1 and told him, "That's not acceptable" behavior. DCS 1 stated Client 1 came out to the living room with his peers for a while and then went back to his room. Later, when DCS 1 went to check on Client 1, he was not in his room. DCS 1 looked throughout the facility and found Client 1 lying clothed on top of Client 2, who was also clothed. DCS 1 stated she called for help from another DCS member. When DCS 1 called out Client 1's name, he removed himself from lying on Client 2 and stood behind his wheelchair.
An observation of Client 2 was conducted on 12/23/16 at approximately 3:45 p.m. Client 2 was unable to vocalize or call for assistance.
A concurrent observation and interview was conducted with Client 1 on 12/23/16 at 4:15 p.m. Client 1 had full use of his upper and lower extremities and used a wheelchair for mobility. Client 1 stated, "I don't know why I did it. I am sorry..."
A facility document titled ADMINISTRATIVE POLICIES AND PROCEDURES, dated February 2007, read in pertinent part, "...PROCEDURE...3. in every case of suspected or alleged abuse, neglect, exploitation...the Administrator is responsible for notifying the necessary agencies: a. Department of Health Services...REPORTING:...DHS (Department of Health Services) Licensing and Certification must be notified by phone or via fax machine within 24 hours..."
A Fax report of the incident was received by the Department on 12/22/16, two days after the incident occurred.
An interview was conducted with the Licensee on 12/23/16 at approximately 3:00 p.m. The Licensee stated she did not have a reason for reporting late.
Therefore, the Department determined the facility failed to implement State law related to alleged and suspected patient abuse reporting.
Failure to comply with the requirements of Health & Safety Code Section 1418.91 shall be a Class B Citation. |
| 100000073 |
Golden Living Center - Hy-Pana |
030013126 |
B |
14-Apr-17 |
CWS811 |
5922 |
F225 483.12 Investigate/Report Allegations/Individuals
(a) The facility must-
(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.
The following citation was written as a result of an unannounced visit to the facility on 2/28/17 for the Annual Re-Certification Survey.
As a result of the survey, the Department determined the facility failed to follow their abuse policy to thoroughly investigate and report an allegation of abuse.
Resident 4 was admitted to the facility over 2 years ago with multiple diagnoses including depressive disorder, chronic pain, and most recently a right upper arm fracture. The most recent Minimum Data Set (MDS, an assessment tool), dated 12/8/16 indicated Resident 4 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS), indicating she had no memory impairment. The MDS indicated Resident 4 required extensive assistance of at least two staff to help with dressing.
Resident 4's clinical record contained a physician progress note, dated 12/28/16 which indicated, in part, "Complaints of difficulty [with] nurse... [due to] rough encounter getting dressed this AM."
There was no documented evidence in Resident 4's clinical record indicating the allegation was investigated and/or reported to the authorities as required by law.
During an observation and interview with Resident 4 on 3/2/17 at 2:17 p.m., she was observed in her room sitting up in her wheelchair wearing a sling to her right arm. Resident 4 said she had gone to consult with a doctor on 12/28/16 due to her broken right shoulder following a fall. When Resident 4 was asked about the documented allegation on the progress note, she stated a Certified Nursing Assistant 5 (CNA 5) had treated her inappropriately with verbal words, "Called me a Bitch...scares me in a way...her way or no way." Resident 4 was unable to recall the exact date the incident occurred, but stated it happened last December. Resident 4 stated no one at the facility had spoken to her regarding the allegation documented in the physician progress note dated 12/28/16.
During a concurrent physician progress note review and interview with Licensed Nurse 6 (LN 6) on 3/2/17 at 2:22 p.m., she indicated she had received the progress note, dated 12/28/16, after Resident 4 returned to the facility from the physician consultation. LN 6 stated she had spoken to Resident 4 and CNA 5 regarding the allegation. LN 6 validated there was no documented evidence she had spoken to Resident 4 or CNA 5 regarding the allegation.
The facility's undated abuse policy titled, "Reporting and Investigation of Alleged Violations of Federal and State Laws involving Mistreatment... Abuse...," directed the facility's Executive Director (ED), "...shall ensure an investigation of each alleged violation in accordance with the company's investigation guidelines and protocols. The ED...and /or Mandated reporter shall report the known or suspected instance of abuse by telephone immediately or as soon as practically possible, send a written report within twenty-four (24) hours, to the local ombudsman or the local law enforcement agency (Welfare and Institutions Code, Division 9. Part 3, Chapter 11, Article 3 mandatory and ...reports of abuse Section 15630)...If the suspected perpetrator is an employee, the ED...shall place the employee on immediate investigatory suspension while completing the investigation...All health practitioners and all employees in a long-term healthcare center/location are mandated reporters...ensure an appropriate investigation...determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident...Documentation in the medical record shall be made where necessary for continuity of care for the resident."
A physician progress note, dated 12/28/16, was reviewed during a concurrent follow up interview with the ED on 3/2/17 at 2:27 p.m., the ED stated she was not aware of the documented allegation. The ED indicated the nurse who was assigned to Resident 4 on 12/28/16 should have reported the allegations to her, as she was the abuse coordinator to facilitate investigation and reporting.
Therefore, the facility failed to investigate and report an allegation of abuse for 1 of 21 sampled residents (Resident 4) when there was no documented evidence the alleged incident had been investigated and reported to the authorities as required by law.
This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility residents. |
| 040000033 |
GOLDEN LIVING CENTER - FOWLER |
040009782 |
B |
13-Mar-13 |
57FZ11 |
6441 |
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility failed to provide a safe, functional and sanitary environment for residents, staff and public when there was a sewage backflow, foul odor, and a plumbing leak due to a broken plumbing pipe. The bathroom toilet between Rooms 2 and 3 was not available for one month due to the sewage leakage.On 2/15/13 California Department of Public Health was in receipt of a complaint #CA00343660 that alleged the following: Resident 1's restroom commode and sink had been out of order for over a month with a sign placed over the toilet. The Complainant stated the odor was really bad. The facility provided an invoice dated 1/21/13 from a plumbing company. There was a "smell in Rm 3, toilet keeps backing up...Video inspect line found bad pipe approx. 9' from closet flange, unable to video beyond this point...line is under water." The facility provided a second invoice dated 2/1/13 from a different plumbing company. "Recommend call a Haz mat company to clean under building of waste water (grey water), and a flooring company to make a access on supflooring to get below building for plumbing company to get a proper proposal together and for Haz mat company to access to clean and disenfect area." There was no documented evidence the facility acted upon the recommendations. On 2/20/13 at 2:40 p.m. during a tour of the facility, it was observed there was a vent between Rooms 2 and 3 with a distinctive foul odor coming from the vent. There was also a foul odor noted coming from Nurse's Station 2 vent. On 2/20/13 at 2:48 p.m., during an interview Resident 2 stated that the toilet between Rooms 2 and 3 was unusable. Resident 2 stated the nearest restroom for her to use was in Room 4. According to the Minimum Data Set (MDS) assessment (tool used to determine the resident's abilities) dated 2/17/13 identified the resident as being cognitive, alert and oriented.On 2/20/13 at 3:10 p.m., during interview LN 1 stated he knew the toilet between Rooms 2 and 3 had a problem but the maintenance man could not fix it. LN 1 stated, "there was a sewage problem...this is an old building."On 2/20/13 at 3:15 p.m., during an interview at the Nurse's Station 2, LN 2 stated there were floor vents around the building connected underground. LN 2 indicated the vent located at the nurse's station (where the odor was coming from) which was covered partially by a trash can. On 2/20/13 at 3:30 p.m., during an interview, the Maintenance Supervisor (MS) stated sometime on the first week of January, the toilet and the floor in the bathroom between Rooms 2 and 3 were flooded when the toilet had clogged up. The MS stated, since then they had tried to do everything to fix it. They had tried to use a snake line several times to unclog it. They also had installed a new toilet bowl hoping it would solve the problem, but it did not. They finally turned off the water supply to the toilet and sink. The MS stated he had been in contact with their Regional Director of Facilities Maintenance at their corporate office about the problem on 2/20/13. On 2/20/13 at 3:40 p.m. during an interview, the Administrator (ADM) stated, the plumbing company had been contacted but they did not want to do the job because of the "hazardous waste." The ADM stated the plumbing company wanted the hazardous waste to be treated first and an open access to the flooring. The ADM and MS stated they she did not agree and did not like the idea of opening up the cement floor. The ADM and MS were interviewed, if the facility chose not to approve what would be their plan to resolve the hazardous waste problem? The ADM stated eventually they would have to do it and the corporate office would help them.On 2/20/13 at 4:15 p.m. during a telephone interview, the Complainant stated on 1/15/13, she observed the bathroom in Room 3A where Res 1 was staying had a sink full of black water that smelled so bad and the toilet had the toilet cover down with an orange cone on top. On 2/22/13 environmental specialist indicated the "crawl space has sewage." The specialist indicated he was at risk for respiratory problems during the clean up as indicated in the contract.On 2/22/13 at 9:10 a.m., an onsite observation was made by the Office of Statewide Health Planning and Development (OSHPD) representative. His Construction Advisory Report dated 2/22/13 included the following: "Patient rooms two and three and the staff break room are affected by this plumbing leak. The leak was caused by loose drain line supports...were compromised in the affected area which removed the slope and allowed water to pool in the drain pipe, resulting in accelerated corrosion in the affected area...The affected fixtures include patient rooms 2 and 3 and the ice-maker and hand wash sink in the break room." The OSHPD representative recommended "placing negative pressure air machine on crawl space, and suggested hiring an Industrial Hygienist to certify the affected area clean after mitigation has been completed." A recommendation was also made that the sewer be capped, negative air maintained, and/or clean up complete before restrictions be lifted. On 2/27/13 at 9:45 p.m. during an interview in Resident 1's room (3B), Resident 1's personal caregiver (PC) stated, since the day Resident 1 was admitted to the facility (1/9/13), the bathroom smelled and clogged. There was a potty chair in the bathroom for Resident 1's use. The PC stated, she visited Resident 1 on 2/15/13 at 9 a.m. and saw Resident 1 eating breakfast in her room. The PC stated she asked Resident 1 why she was eating in her room where the smell was so bad? She stated Resident 1 replied, "The food tray was left in my room, so I ate here." On 2/27/13 at 10 a.m. during an interview in Room 7C, Resident 5 stated on 12/24/12 and 12/25/12, the toilet at Room 2A (which she previously occupied) was clogged and the smell was so unpleasant. Resident 5 stated, "I have to put up with this, because this was the only facility where I can live."The facility's undated policy and procedure on Infection Control indicated ..." To maintain a safe sanitary, and comfortable environment for personnel, residents, visitors and the general public..." This violation had a direct or immediate relationship to the health, safety, or security of residents and therefore constitutes a Class "B" Citation. |
| 040000018 |
Golden LivingCenter - Chowchilla |
040011799 |
A |
27-Oct-15 |
XJ1E11 |
15621 |
Avalon Care Center - Chowchilla Complaint Number# CA00445939 Citation Number: _____________ CLASS A CITATION - ACCIDENTS 483.25(h) (2) - The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide supervision to prevent accidents for one sampled resident (Resident 1). On 6/8/15, Resident 1 was unaccounted for and unsupervised, for a period of one hour and 15 minutes (4:45 p.m. - 6:00 p.m.) during which time, she fell from her wheelchair while outside on the facility's designated smoking patio. As a direct result of her fall, and being allowed to lie unnoticed on the hot cement, Resident 1 sustained 2nd degree burns (involving the first two layers of skin causing redness, blisters, and loss of some skin) and 3rd degree burns (full tissue burn which permanently destroys the entire skin layers and extends into the tissues, muscles, or bones) to her left and right feet and to her right knee. This failure resulted in Resident 1's prolonged (over 3 months) hospitalization for treatment and subsequent amputation of both of her feet. On 6/10/15, an onsite visit was conducted to investigate CA00445939. Resident 1's Face Sheet indicated she was 70 years old and was admitted to the facility on 2/10/15, with diagnoses including a history of cerebrovascular accident (CVA) (a condition caused by lack of blood flow to the brain which resulted in loss of speech, confusion, or weakness), left-sided weakness, and chronic airway obstruction (poor air flow to the lungs causing shortness of breath, cough, and sputum production). Resident 1's Minimum Data Set (MDS) assessment (a federally mandated comprehensive assessment of residents in a skilled nursing facility to identify each resident's functional abilities and health problems) dated 5/24/15, indicated Resident 1 required extensive physical assistance by one staff person to move into standing position from her wheelchair, and limited physical assistance by one staff person when moving to or returning from off-unit locations. Resident 1's Plan of Care initiated on 2/11/15 and updated on 4/10/15, indicated Resident 1 had impaired mobility and required staff assistance to transfer and ambulate. Resident 1's Activities of Daily Living (ADL) documents dated 5/1/15 to 6/8/15, indicated Resident 1 was provided limited to extensive physical assistance by one person during transfers and off-unit locomotion. Resident 1's Fall Risk Evaluation dated 3/30/15, indicated Resident 1 was at high risk for falls (Score of 18 - where a score of 10 or higher indicated higher risk for falls) due to: multiple falls, visual impairment, loss of balance while standing, and decreased muscular coordination. Resident 1's Care Plan for falls dated 2/11/15, indicated, "Assist with transfers and ambulation, as needed..." Resident 1's Care Plan was revised on 2/13/15 to include, "Encourage resident to wait for assistance." On 6/10/15 at 10:15 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 was found unconscious on the ground on 6/8/15 at 6:00 p.m. The DON stated staff told her they did not know Resident 1 was outside on the smoking patio. The DON stated staff did not know Resident 1 had fallen or how long she had been on the ground. The DON stated, "It was too hot that day," and stated, "We should have supervised/ monitored her at all times, especially that day just because of the hot weather." When asked for the facility's standard of practice for resident care during extreme weather conditions (for example, hot summer weather), the DON stated, "We don't have the written policy but I can call another building to get one." During this interview, the DON was advised of the weather report for 6/8/15, per "http://www.localconditions.com/weather-chowchilla-california." The temperature at 5:53 p.m. was 104 degrees Fahrenheit.The DON was then informed of and was shown the California Department of Public Health's All Facilities Letter 15-11 (AFL 15-11) dated 6/1/15. This AFL reminded health care facilities to implement the Department's recommended precautionary measures, which included but not limited to, keeping susceptible and health compromised individuals indoors and out of the sun during the hottest parts of the day. On 6/10/15 at 10:15 a.m., during an interview, the DON stated during the facility investigation, LN 2 stated after LN 2 had returned from her break at the facility on 6/8/15, staff described finding Resident 1 outside on the ground at 5:30 p.m. LN 2 stated the CNA staff had noticed Resident 1 out of the window in the smoking area lying prone (face down) on the ground with her legs twisted in her wheels of the chair. Resident 1 was given a head-to-toe assessment, cool wet cloths were placed on her, and vital signs were taken. Staff had informed LN 2 Resident 1 had then started to wake up. Before Resident 1 had been taken to the hospital her vital signs were as follows: A pulse beat of 134 per minute (pulse - normal adult heart rate 60 - 100 beats per minute), Respirations were 24 per minute (respirations - normal adult breathing rate at rest is 12 - 16 breaths per minute), and Blood Pressure was 142/64 (blood pressure - normal adult blood pressure less than 120 mm Hg (millimeters of mercury) systolic (top number) over less than 80 mm Hg (bottom number) [120/80 or lower]. Resident 1's temperature was recorded as 102.9 (temperature - normal temperature 98.6 degrees Fahrenheit), and her oxygen saturation level was low at 90% (percent of blood saturated with oxygen - normal oxygen saturation is 95% - 99%). On 6/10/15 at 10:24 a.m., an interview was conducted with Resident 1's regular caregiver, Certified Nursing Assistant (CNA 4). CNA 4 stated when she came to work on 6/8/15 at 2:00 p.m., she saw Resident 1 at the Nurses' Station asking LN 2 for her (Resident 1's) cigarettes. CNA 4 stated, "I saw (Resident 1) again while I was on my break at 4:45 p.m. She was pushing her wheelchair past the Nurses' Station ... I was not sure if she was heading to the patio."CNA 4 stated dinner trays came out between 4:55 p.m. to 5:10 p.m. in the area of Resident 1's room. When asked if she had checked on or provided care to Resident 1 at any time from 2:00 p.m. to 6:00 p.m., CNA 4 stated she had not. On 6/10/15 at 11:08 a.m., a telephone interview was conducted with Licensed Nurse 2 (LN 2). LN 2 stated she saw Resident 1 at the Nurses' Station when she clocked in at 2:00 p.m. and again at 4:15 p.m. when she administered her medications. When asked if she had seen or checked on Resident 1 after she had taken her medications, LN 2 stated, "No, I did not." LN 2 stated she was out of the building for her break at 5:30 p.m. She stated when she came back at 6:05 p.m., she was told Resident 1 had fallen outside and was found unconscious on the ground. LN 2 stated Resident had fallen before (on 2/13/15 and 4/7/15), when she attempted to transfer herself and lost her balance. On 6/10/15 at 11:45 a.m., during an interview, CNA 3 stated Resident 1 had to be supervised, assisted, and monitored with activities of daily living (ADLs). CNA 3 stated Resident 1 was forgetful, had no safety awareness, and had fallen before because she was weak on her left side. When asked to describe how the facility monitored residents who smoked on the patio, CNA 3 stated, "Our policy is to bring them to the patio and stay with them even if they are independent. We help them put on their smoking apron and light their cigarettes for them."When asked to describe the facility's standard procedure for resident care during hot weather, CNA 3 stated, "We would encourage our residents to stay inside the building and if they insist, we should go out with them so they could be monitored." On 6/10/15 at 1:10 p.m. during an interview, CNA 1 stated that on 6/8/15 at 6:00 p.m., she was picking up meal trays in Resident 1's room when she noticed Resident 1's meal tray had not been touched. CNA 1 stated, "I peeked out from the blinds and saw (Resident 1) lying on the ground on the patio. I ran out of the room and called for help." CNA 1 stated she saw CNA 2 and they both ran to the patio followed by LN 1. CNA 1 stated Resident 1 was lying on the cement on her left side with her feet criss-crossed and stuck on the wheelchair's metal footrests. During the same interview, CNA 1 stated Resident 1's "eyes were closed" and she did not respond to verbal command or physical stimulation. She stated Resident 1's "Mouth was covered with slobber" (saliva or other type of fluid); "her skin was very hot to touch. Her feet were purple-bluish in color, and the skin on the upper part of her right knee was torn and bloody." She stated "the lower part" of Resident 1's right knee "was blistered." CNA 1 stated, "We took her back to her room and wiped her down with washcloth until she became responsive." She stated LN 1 had called 9-1-1 and Resident 1 was taken to the hospital on 6/8/15 at 6:30 p.m. When asked to describe Resident 1's overall condition and functional status prior to the incident, CNA 1 stated, "(Resident 1) was weak on her left side and had to be assisted during transfers from bed to chair and vice-versa." She stated Resident 1 "Had fallen before." CNA 1 stated Resident 1 "Was forgetful" and "Had poor safety awareness," for example, "She forgets to lock her wheelchair when standing up from the chair, and attempts to transfer herself without help." CNA1 stated Resident 1 had to be monitored or assisted to ensure she would not fall again. CNA 1 stated if she (CNA 1) hadn't looked out of the window, the staff may not have known Resident 1 had fallen on the ground, or that she was outside and alone in the heat. CNA 1 stated none of the three residents who smoked went out that day because of the extreme heat. CNA 1 stated, someone had given Resident 1 a cigarette and knew she was outside alone. CAN 1 stated the residents' cigarettes and lighters were kept in the medication room and only licensed nurses could access them.CNA 1 stated, "Whoever that is, we (CNAs) should have been told so we could check on the resident!" On 6/15/15 at 9:20 a.m., a telephone interview was conducted with Resident 1's responsible party (RP). The RP stated she had requested the facility to keep Resident 1 on the scheduled smoking social because she had been smoking excessively. The RP stated, "I told the Social Services my (family member - Resident 1) could not and should not smoke on her own whenever she wants it. She had to be supervised or monitored or else she would be smoking all day."The RP stated, "My (family member - Resident 1) is weak on her left side and had fallen before at the facility because she tried to transfer herself and she felt dizzy ... more reason to supervise her ...Staff did not supervise...my (family member - Resident 1) as I have asked them to do." On 6/19/15 at 1:42 p.m. during a telephone interview, LN 3 stated on 6/8/15 at 4:45 p.m., Resident 1 came to the Nurses' Station and asked for her cigarette. LN 3 stated she gave Resident 1 a cigarette and a lighter. LN 3 stated she did not warn Resident 1 that it was extremely hot outside; did not offer to accompany or assist her; did not inform any of the staff that Resident 1 was out on the patio so they could assist and monitor her; and did not check on Resident 1 prior to leaving the facility at the end of her shift at 5:30 p.m. LN 3 stated, "I did not follow through. (Resident 1)'s fall was preventable." On 8/6/15 at 8:00 a.m., during a telephone interview, Surgeon 1 stated Resident 1 was brought to the Emergency Department (ED) on 6/8/15, with 2nd degree and 3rd degree burns on her feet and right knee. Surgeon 1 stated Resident 1 told the ED physicians (upon her arrival), that she fell face first out of her wheelchair on the facility's patio, when she attempted to pick up her cigarette and lighter which she dropped on the ground. Surgeon 1 stated Resident 1 had prolonged exposure to extremely hot cement and her feet, toes, and right knee were "Pretty much cooked." Surgeon 1 stated Resident 1 underwent debridement (removal of dead tissues), skin grafting (a patch of skin is transplanted to another area), amputation (surgical removal of all or part) of the toes of the left and right feet, and would eventually undergo amputation of her feet. The acute hospital record indicated Resident 1 underwent the following surgeries and procedures: 1. 6/16/15: Excision (surgical removal by cutting) and debridement of bilateral lower extremities burns with wound vacuum placement (promotes healing through negative pressure to the wound). 2. 7/17/15: Burn excision of burns of the feet and right knee with transmetatarsal amputations (a surgical procedure to remove the forefoot in cases where the tissues in a patient's foot have been injured beyond repair) of toes 2 through 5 on the right foot and toes 1 through 5 on the left foot, with allografting (transplant of an organ or tissue from one individual to another) to the open wounds of both feet and right knee. 3. 7/23/15: Excision of bilateral lower extremity allograft with placement of autograft (transplant of tissue from one point to another of the same individual's body). 4. 8/5/15: Left foot wound excision and debridement with amputations of the tarsal bones (bones located in the midfoot and rear foot areas) and primary closure; right foot wound excision and debridement, amputation of the right great toe and all the metatarsal heads (the group of bones in the foot between the ankle and the toes) primary closure (skin edges of the wound sutured together to close wound); and, wound excision, debridement and partial closure of the right knee wound with application of a VAC (vacuum-assisted closure) dressing. The hospital document dated 9/1/15 titled, "Burn Service Note" indicated "...Remains in the hospital, now day 86. She still has open wounds, specifically on the right knee where there is some granulating tissue (connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process), but also some fibrous tissue (containing fibers), which would not be capable of holding a graft...continuing leak from her joints because of the depth of injury..." On 10/7/15 at 3:34 p.m., during a telephone interview, Resident 1's RP stated the resident remained in the Intensive Care Unit (ICU) of the hospital. The RP stated Resident 1's feet were "gone" and "her right knee" was "not healing." The RP stated per the physician's recommendation, Resident 1 was placed on hospice (for end-of-life comfort care only) and was at the time still in ICU. The facility failed to provide supervision to prevent accidents for Resident 1 on 6/8/15 when she was left unaccounted for and unsupervised for a period of one hour and 15 minutes (4:45 p.m. - 6:00 p.m.). During that time Resident 1 fell from her wheelchair while outside on the facility's designated smoking patio. As a direct result of her fall, and being allowed to lie unnoticed on the hot cement, Resident 1 sustained 2nd and 3rd degree burns to her left and right feet and to her right knee. Due to Resident 1's deep tissue burns on her feet and right knee, she required prolonged (over 3 months) hospitalization for treatment and subsequent amputation of both feet, placement in the ICU, and hospice (end-of-life) care.This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and therefore constitutes a Class 'A' Citation.1 |
| 040000018 |
Golden Living Center - Chowchilla |
040013178 |
B |
4-May-17 |
IFYI11 |
7857 |
F223 CFR 483.12 Abuse
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
On 10/11/2016 an unannounced visit was made to the facility to investigate Entity Reported Incident CA 00506149 regarding an allegation of resident sexual abuse.
The facility failed to protect the right of Resident 16 to be free from sexual abuse when Visitor 1, with a known sexual predator history, walked unescorted down the facility corridor on 10/7/16, knelt next to Resident 16 who was wheelchair bound and placed his right hand underneath and between Resident 16's leg and crotch. This failure resulted in the violation of Resident 16's right to be free of sexual abuse.
Review of Resident 16's clinical record titled, "Admission Record" (document containing resident personal information) indicated Resident 16 was admitted to the facility on XXXXXXX13 with diagnoses that included Alzheimer's disease (chronic disorder that affects cognitive and functional abilities in a progressive manner) and Anxiety (disorder causing feeling of uneasiness and apprehension). Resident 16's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool) assessment dated 9/14/16, indicated Resident 16 had severe cognitive (pertaining to reasoning, memory and judgement) impairment and was never or rarely able to make daily decisions. Resident 16's MDS assessment dated 9/14/16 indicated Resident 16 was rarely or never understood and was unable to understand simple commands. The MDS dated 9/14/16 indicated Resident 16 was not able to walk and required total staff assistance for bed mobility, transfers and to propel in her wheelchair. The MDS indicated Resident 16 required extensive assistance in almost all activities of daily living (ADL's) including dressing, toilet use, personal hygiene, and bathing.
Resident 16's "Progress notes," documented by Licensed Vocational Nurse (LVN) 6 dated 10/7/16 at 12:42 p.m., indicated, "[Certified Nursing Assistant] CNA [4] witnessed visitor groping resident between legs..."
On 10/11/16 at 11:38 a.m., during an interview, CNA 4 stated Resident 16 sat in her wheel chair in the main corridor the day of the incident, 10/7/16. CNA 4 stated she was working in another room when she recognized and observed Visitor 1 walk up to Resident 16, bend down and "grope her". When asked to clarify, CNA 4 stated Visitor 1 put his hand underneath and between Resident 16's legs. CNA 4 stated she then yelled across the room for him to stop and Visitor 1 stopped and removed his hand from Resident 16's crotch. CNA 4 stated she then went over to where Resident 16 and Visitor 1 were in the corridor. CNA 4 stated Resident 16 was unaware of what occurred. CNA 4 stated Resident 16 was fully clothed. CNA 4 stated once she knew Resident 16 was "ok" she then escorted Visitor 1 toward LVN 5 and together (LVN 5 and CNA 4) escorted Visitor 1 to the facility Administrator's (Adm) office. CNA 4 stated she described the incident between Visitor 1 and Resident 16 to the Adm who then called the police. CNA 4 stated she recognized Visitor 1 because his photo was on the wall of the breakroom. CNA 4 stated staff was aware of Visitor 1's sexual criminal record. CNA 4 stated Visitor 1 visited the facility daily between the hours of 10 a.m. and 12 noon. CNA 1 stated staff was told if staff was not directly with the visitor, they were to keep him in their line of sight at all times. CNA 4 stated, "He was not to be alone..."
On 10/11/16 at 11:45 a.m., during a concurrent interview and record review with the Social Services Director (SSD) and the Adm, the SSD stated Resident 16's clinical record indicated Resident 16 was unaware of her surroundings and could not respond verbally in a meaningful way.
On 10/11/16 at 4:32 p.m., during an interview, the Adm stated he was aware of the incident that occurred on 10/7/16 with Resident 16. The Adm stated he was in the facility at the time of the incident but did not observe it; he was in his office at the time of the incident. The Adm stated he was aware of Visitor 1's sexual criminal record and confirmed Visitor 1 was listed on Meagan's Law website (online national database for sex offenders). The Adm stated Visitor 1 was allowed to visit because his girlfriend (Resident 19) resided in the facility. The Adm stated the facility implemented a process by which Visitor 1 was allowed to visit daily between the hours of 10 a.m. and 12 p.m. (noon). The Adm stated Visitor 1 was required to check in at the business office window when he entered the building for each visit. The Adm stated staff was trained to be aware of Visitor 1 when in the building. The Adm stated that staff was trained to have a line of sight on Visitor 1 upon entry into the building. The Adm stated 'line of sight' meant Visitor 1 should be visualized by staff at all times. The Adm stated all staff was aware of the sexual criminal history of Visitor 1 and his photo was posted in the employee breakroom. The Adm stated, prior to the incident on 10/7/16 with Resident 16, Visitor 1 was not required to be in attendance with facility staff. The Adm stated in retrospect, the plan for Visitor 1 should have included being escorted and in attendance by facility staff at all times.
On 1/4/17 at 12:15 p.m., during an interview, LVN 5 stated she was working the day of the incident on 10/7/16. LVN 5 stated she recognized and was aware Visitor 1 was in the building on 10/7/16 when Visitor 1 walked past her. LVN 5 stated she heard CNA 4 yell "Stop!" and became aware CNA 4 was escorting Visitor 1 toward her. LVN 5 stated she did not witness the incident involving Resident 16 and Visitor 1. LVN 5 stated she and CNA 4 escorted Visitor 1 to the Adm's office and at that time CNA 4 described the incident to LVN 5 and the Adm who then called the police. When asked about the process when Visitor 1 was in the building, LVN 5 stated she was aware of Visitor 1's sexual criminal history. LVN 5 stated she was aware of Visitor 1 visiting the facility daily from 10 a.m. to noon. LVN 5 stated she was aware that Visitor 1 was to be in the line of sight of staff at all times.
Resident 16's "Police Report" Case Number 162221 indicated under Synopsis "[facility] reported a member of their care center [Resident 16] was sexually assaulted." The report indicated under the section Offenses "1. Violation/status 243.4(B)PC; Offense Description: Sex battery/institution for treatment..."
The facility policy and procedure titled "Abuse Policy" dated 9/26/16, indicated, "It is the policy of the company to take appropriate steps to prevent the occurrence of abuse...Definitions... Sexual Abuse: Sexual abuse includes, but is not limited to: Sexual harassment, Sexual Coercion, Sexual assault...Prevention...Education of employees, volunteers and others shall be conducted in an effort to heighten awareness of potential violations...Protections...If the suspected perpetrator is a family member, vendor, visitor or volunteer, the ED [Executive Director/Administrator] shall take all appropriate measures immediately to secure the safety and wellbeing of the resident..."
Therefore, the facility failed to protect Resident 16's right to be free from sexual abuse when Visitor 1, with a known sexual predator history, was allowed to walk unescorted through the skilled nursing facility, bend and kneel down next to Resident 16 and place his hand underneath and between Resident 16's leg and crotch. As a result of this failure, Resident 16 was subjected to a sexual assault which she could not comprehend or rebuff due to her severe physical and cognitive impairments.
This violation had a direct or immediate relationship to Resident 16's health, safety and security and thus constitutes a class "B" citation. |
| 040000018 |
Golden Living Center - Chowchilla |
040013181 |
B |
4-May-17 |
IFYI11 |
11890 |
F 223
483.12 (1)
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 11/29/16 at 4 p.m. an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Entity Reported Incident CA 00511997 regarding an alleged violation of sexual abuse.
The facility failed to ensure Resident 15 was free of sexual abuse when Resident 14 was found with his finger in Resident 15's vagina. Resident 15 was wheelchair bound and had known behaviors of wandering into other residents' rooms. Resident 14 was known by facility staff to have inappropriate sexual behaviors towards other residents that required direct visual monitoring of Resident 14's whereabouts within the facility by SNF staff every 15 minutes. On 11/23/16 Resident 15 wandered unobserved and unsupervised by facility staff into Resident 14's room. Sometime after Resident 15 wandered into Resident 14's room, Resident 14 was observed sitting on his bed next to Resident 15 with his hand inside Resident 15's brief and Resident 14's finger inserted into her vagina. The facility failed to prevent Resident 15 from wandering into Resident 14's room, unsupervised and failed to monitor Resident 14's whereabouts every 15 minutes. As a result of these failures, Resident 15 suffered sexual abuse and the violation of Resident 15's right to be free of sexual abuse.
Resident 15's face sheet (a facility form that contained resident identifying information on admission) indicated Resident 15 was admitted to the SNF on XXXXXXX14 with diagnoses that included Dementia (disorder resulting in memory loss, impaired thinking and poor judgement), Pain and history of upper and lower leg bone fractures (broken bones).
Resident 15's Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 11/10/16, indicated under the area of "Cognitive [pertaining to reasoning, judgement and memory] Skills For Daily Decision Making," Resident 15 had moderate cognitive impairment with poor decision making and required staff cues and supervision in making daily decisions. Resident 15's MDS dated 11/10/16 indicated Resident 15 required extensive to total staff assistance for activities of daily living including transfers, dressing, toileting, hygiene and bathing. The MDS indicated Resident 15 did not walk and utilized a wheelchair for mobility.
Review of Resident 15's clinical record titled, "Care Plan" dated 11/14/16 indicated, "She [Resident 15] gets up daily in her w/c [wheelchair] and wanders throughout the facility. She is disoriented, unaware of place and time." Interventions identified in the care plan for Resident 15's wandering did not include supervision of Resident 15's whereabouts for safety.
On 11/29/16 at 3:35 p.m., during a concurrent observation and interview, Resident 15 sat in a wheelchair in the hallway and held a teddy bear. Resident 15 became tearful and stated, "I've been bad." Resident 15 was unable to answer additional questions.
On 11/29/16 at 3:45 p.m., during a telephone interview, Certified Nurse Aide (CNA) 1 stated she was aware Resident 14 was on every 15 minute checks (staff observe resident every 15 minutes) due to his behaviors of touching residents and staff inappropriately. CNA 1 stated staff was to directly visualize Resident 14 and document every 15 minutes Resident 14's activities and whereabouts. CNA 1 stated on 11/23/16 around 4 p.m., she was across the hall from Resident 14's room and noticed the stop sign (a cloth with a red stop sign in the middle with Velcro on both ends that extended across the door opening) hung down one side of the door. (The absence of the sign going across the door would have allowed others to go in and out of the room without the presence of a visual barrier.) CNA 1 stated as she had entered Resident 14's room, Resident 15 sat in a wheelchair beside Resident 14's bed. CNA 1 stated Resident 14's hand was clearly on Resident 15's crotch with his middle finger of the left hand inserted into Resident 15's vagina. CNA 1 stated Resident 15's pants had been pulled down enough to access the brief (disposable underwear) which was pushed to one side. CNA 1 stated she pulled Resident 15's pants up, removed her from the room to the large dining room, and reported the incident to Licensed Nurse (LN) 1. CNA 1 stated the facility Administrator (ADM) then called her into his office where she provided a full verbal report on what she had observed during the incident between Resident 14 and Resident 15.
On 11/29/16 at 4:11 p.m., during an interview, CNA 2 stated Resident 15 was quieter than usual since the incident with Resident 14. CNA 2 stated she had worked two days with Resident 15 since the incident and had noted Resident 15 would "stare off" more and did not seem as happy as before the incident.
On 11/29/16 at 4:40 p.m., during a concurrent observation and interview CNA 2 stated Resident 14 was Spanish speaking and staff would provide a language interpreter. Through the interpreter Resident 14 was asked about the incident with Resident 15. Resident 14 stated he didn't know anything about the incident on 11/23/16. Resident 14 further stated he didn't know Resident 15.
Resident 14's face sheet indicated a diagnosis of Dementia.
Resident 14's MDS assessment, dated 11/6/16, indicated a Brief Interview for Mental Status (BIMS) score of 6 of 15 which indicated severe cognitive impairment.
On 11/29/16 at 6:05 p.m., during an interview, the facility Administrator (ADM) stated on 11/23/16, CNA 1 reported she had been across the hall from Resident 14's room and noticed the stop sign was down. The ADM stated CNA 1 reported she went into Resident 14's room and saw Resident 14 on his bed and Resident 15 in a wheelchair next to the bed. The ADM stated CNA 1 reported she observed Resident 14's hand down Resident 15's pants.
On 1/3/17 at 12:55 p.m., during a telephone interview, the Social Service Director (SSD) stated Resident 14 had a known behavior of inappropriate touching of others. The SSD stated she had been aware of Resident 14's sexual behaviors towards other residents and staff prior to the incident with Resident 15 on 11/23/16.
On 1/6/17 at 12:55 p.m., during a telephone interview, Resident 14's Primary Care Physician (PCP) 1 stated he was aware of the resident's long history of sexual behaviors.
On 1/13/17 at 3:50 p.m., during an interview, the SSD stated Resident 14 had a history of exposing himself and groping both staff and residents.
On 1/17/17 at 5:30 p.m., during an interview, LN 2 stated she was on duty when the incident between Resident 14 and Resident 15 occurred (on 11/23/16). LN 2 stated CNA 1 initially reported the incident between Resident 14 and Resident 15 to LN 1 and later repeated the report to both LN 1 and LN 2. LN 2 stated she, CNA 1 and CNA 2 went to Resident 15's room where she performed an assessment of Resident 15. LN 2 stated Resident's 15's cognition was impaired to the point where she was almost child- like and unable to recognize boundaries or danger. LN 2 stated Resident 14 was higher functioning than Resident 15 and knew right from wrong. LN 2 stated Resident 15 had become quieter with less rummaging and wandering behaviors since the incident. LN 2 stated Resident 15 sat in one spot for long periods of time staring into space after the incident, which was unusual for her. LN 2 stated the incident could have been prevented. LN 2 stated staff was aware of Resident 14's behaviors but over time staff became more "laid back" (less watchful) about monitoring Resident 14's behaviors. LN 2 stated Resident 14's care plan was not reviewed and revised in response to Resident 14's sexually inappropriate behaviors.
On 3/13/17 at 3:25 p.m., during a telephone interview, Resident 15's Family Member (FM) stated Resident 15 had dementia. The FM stated, "She [Resident 15] would never behave that way [would not have consented to sexual behavior if she was aware]." The FM stated the facility needed to look out for the welfare of all the residents in the facility that had dementia like Resident 15.
On 3/17/17 at 8:40 a.m., during an interview, the Director of Nursing (DON) stated for the last eleven months, Resident 14 had been on one to one monitoring by staff for his sexual behaviors. The DON stated the notes documented by the Interdisciplinary Team (IDT) (group of healthcare providers, including the DON and SSD, who meet to discuss and care plan resident problems) dated 11/5/15 and 3/11/16 did not address Resident 14's ongoing sexual behaviors or effectiveness of current interventions for the behaviors. The DON stated Resident 14's behaviors should have been addressed and care planned on 11/5/15 and 3/11/16 and were not The DON stated quarterly psychiatric evaluations for Resident 14 would have been appropriate, but were not done. The DON stated a psychiatric consult after every inappropriate physical contact with another resident by Resident 14 should have been done, but was not.
Resident 14's clinical record titled, "Progress Notes" dated 11/23/16 at 1:54 a.m., indicated, "...Remains on Q [every] 15 min. [minute] checks R/T [related to] adverse sexual Bx [behaviors]."
Resident 14's record titled, "Q (every) - 15 Minutes Visual Monitoring" dated 11/23/16, indicated, columns for time, "Activities/Observations," and staff initials. The columns timed from 2:15 p.m. to 3:45 p.m. did not indicate documentation of Resident 14's activities, and did not include staff initials to signify staff had made an observation of Resident 14 during those times.
Resident 14's nursing progress note dated 11/23/16 at 11:02 p.m., indicated, "Res (Resident 14) on alert charting for 15 min (minute) checks. Was an incident of sexual aggression today at 1515 (3:15 p.m.). A female resident (Resident 15) with dementia... they were found with his hand (Resident 14) in her crotch (Resident 15)..."
Resident 14's nursing care plan dated 6/18/16, indicated, "I sometime have behaviors which include episodes of depression m/b [manifested by] hypersexual behaviors, i.e. disrobing in public and inappropriate touching." Interventions for Resident 14's behaviors identified in the care plan dated 6/18/16 included, "One-on-one care provided for me 24 hours per day."
Resident 14's nursing care plan dated 9/9/16, indicated, "I sometimes have behaviors which include... hypersexual behaviors, i.e... inappropriate touching."
On 3/23/17 at 1:40 p.m., during an interview, the Medical Director stated he was not made aware of the incident with Resident 14 and Resident 15 until 12/14/16 (three weeks after the incident).
Resident 14's "Psychologist Consultation/Follow-up" form dated 6/29/16 indicated Resident 14 was on one-to-one monitoring for sexual behavior towards female peers.
Resident 14's "Psychologist Consultation/Follow-up" form dated 10/17/16, indicated under recommendations staff were to continue to monitor for sexually inappropriate behavior.
The facility policy and procedure titled, "Abuse Policy," undated, indicated, "It is the policy of the Company to prevent the occurrence of abuse..."
Therefore the facility failed to protect Resident 15's right to be free from sexual abuse when Resident 15 was allowed to wander unsupervised into Resident 14's room where Resident 14, who had known history of inappropriate sexual behaviors, sexually assaulted Resident 15. As a result of this failure, Resident 15 was subjected to a sexual assault which she could not comprehend or rebuff due to her severe physical and cognitive impairments.
This violation had a direct or immediate relationship to Resident 15's health, safety and security and thus constitutes a class "B" citation. |
| 050000049 |
Greenfield Care Center of Fillmore, LLC |
050009389 |
B |
09-Oct-12 |
O2VT11 |
3322 |
CLASS B CITATION -Financial Occurrence/Facility Not Self ReportedHSC Code 1421.1(a)(b)(2)(a)Within 24 hours of the occurrence of any events specified in the subdivision (b), the licensee of a skilled nursing facility shall notify the department of the occurrence. This notification may be in written form if it is provided by telephone facsimile or overnight mail, or by telephone with written confirmation within five calendar days. The information provided pursuant to this subdivision may not be released to the public by the department unless its release is intended to justify an action taken by the department or it is otherwise becomes a matter of public record. A violation of this section is a class "B" Citation(b) All of the following occurrences shall require notification pursuant to this section: (2) A financial institution refuses to honor a check or other instrument issued by the licensee to its employees for a regular payroll.During a complaint investigation on June 27, 2012, the Department determined the facility violated the above regulation. The facility failed to notify the department within 24 hours when a bank refused to honor regular payroll checks issued by the facility to its employees. The first instance, as verified with employees of the facility, a local store manager, and review of payroll checks returned for insufficient funds, occurred on August 19, 2011.The Department received an anonymous complaint on June 19, 2012, in which the complainant reported regular payroll checks for employees were being returned from the bank for insufficient funds. During an onsite visit June 27, 2012, beginning at 2:30 p.m., ten employees including nursing and support staff were interviewed. All ten employees confirmed they had received returned payroll checks, and associated penalty charges from the bank, due to insufficient funds.The employees explained that financial institutions and business establishments in the immediate community would not honor the facility's paychecks.During an initial interview on June 27, 2012 at 4 p.m., the facility administrator denied having knowledge of any payroll checks being returned for insufficient funds. However, in a subsequent interview on September 11, 2012, the administrator confirmed that she was aware that payroll checks were being returned for insufficient funds.An interview on June 28, 2012, with a store manager of a local grocery store, revealed the store does not accept any payroll checks issued by facility, due to a consistent lack of sufficient funds to cover the checks. Observation revealed posted signage stating payroll checks from the facility would not be honored.A review of documentation provided by the store manager verified that twenty eight employee payroll checks issued by the facility and dated August 19, 2011, were returned for insufficient funds. This information was verified in an interview on June 29, 2012, with the assistant manager of the bank used by the facility to issue employee payroll checks through. Although twenty eight employee payroll checks were returned for insufficient funds on August 19, 2011, the facility failed to ensure that the department was notified within 24 hours after a financial institution refused to honor the regular payroll checks issued by the facility to its employees. |
| 050000050 |
GLENWOOD CARE CENTER |
050011407 |
AA |
24-May-16 |
Z27N11 |
5990 |
Title 42 of the Federal Code of Regulations (h)(1) and (2) Accidents (h) The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide an environment free of accident hazards, and failed to provide adequate supervision, and assistance devices to prevent injury and death for Resident A. Resident A was assessed to be a high risk for falls, and had a history of attempted unassisted transfers from bed, removal the tab alarm (warning system when attempts are made to transfer self unassisted), and frequent manipulation of the remote bed control, but was not provided with alternative safety measures and supervision. As a result, Resident A was found on the floor with his head crushed between the bedframe. Resident A sustained blunt force trauma to the head and died. Resident A was an 84 year old male, initially admitted to the facility on 2/10/15 and was readmitted on 2/27/15 with diagnoses including dementia (decline in mental ability) and Parkinson's disease (progressive movement disorder).Review of Resident A's assessment dated 3/14/15 indicated, Resident A has impaired recall ability, impaired vision, and needed extensive assist with bed mobility and transfer. Review of fall risk assessment dated 2/27/15 revealed, Resident A was also identified as at high risk for falls. Review of the care plan dated 2/10/15, included interventions to have the bed in a low position and locked, use of side rails for bed mobility, and use of a tab alarm when in bed or the wheel chair.During an interview on 3/17/15 at 1:20 p.m., a registered nurse (RN) recalled, on 3/16/15 at 3 a.m., a certified nursing assistant (CNA 1) called for a nurse on the radio. RN saw Resident A lying on the floor, perpendicular to the bed, with his head between the bars of the frame of the bed. According to RN, Resident A had a "large gash down to the brain from middle of the eyebrow to past his ear", was not breathing and did not have a pulse. RN further observed that the tab alarm was on the bed and not connected to Resident A. RN stated Resident A was known for taking his tab alarm off. During an interview on 3/17/15 at 1:30 p.m. and 2:30 p.m., licensed vocational nurse (LVN 1) and CNA 1explained that prior to the date of this incident involving Resident A, they knew Resident A would remove his tab alarm.During an observation on 3/17/15 at 2:45 p.m., Resident A's room was located near the exit, at the end of the hall from the nurses' station. Resident A's bed was electric and contained a hand control device. The hand control device raised and lowered the entire bed, the head of the bed, and the knee. The bed contained a control panel located on the footboard with four lock buttons for each of the bed positions. During an interview on 3/18/15 at 10:20 a.m., LVN 2 explained on 3/15/15, (one day before the incident), Resident A was found "at least twice" to have his legs dangling over the side of the bed with the tab alarm intact but unclipped from his gown. LVN 2 explained Resident A would sometimes remove the gown from his body leaving the tab alarm clipped to the gown. According to LVN 2, this behavior happened on "several shifts."During an interview on 3/18/15 at 11:15 a.m., CNA 2 explained, that prior to the incident with Resident A, CNA 2 had knowledge that Resident A would remove the tab alarm and "always plays" with the bed control remote device changing the level of the bed. On 3/15/15 (one day before the incident), Resident A was seen "playing" with the bed control remote device and CNA 2 removed the bed control from Resident A's hands and placed it toward the end of the bed. During an interview on 3/18/15 at 1:45 p.m., the director of nurses (DON) explained, the facility uses the "24 hour report" document to report care issues to the next shift so care plans can be revised to meet the current needs of the resident. Concerns or changes can be filled out by anyone employed by the facility and these forms are read every morning during daily meeting. Any nurse can implement nursing measures such as a "bed pad sensor alarm" (alarms when a resident changes pressure on the bed when exiting the bed), or a "floor mat alarm" (detects when there is an unsafe bed exit). The DON indicated, "We even have a motion sensor alarm." Despite these alternative measures, there was no documented evidence these alternatives had been explored for Resident A.During an interview on 4/29/15 at 11 a.m. and concurrent review of the bed manufacturer investigative report dated 4/7/15, the bed manufacturer director of quality (DOQ) indicated, an alternate means of preventing the patient from rolling/climbing out of bed should be initiated if an individual is capable of self injury. Safety measures should be considered for patients identified as high risk for entrapment. The DOQ confirmed Resident A's bed was purchased by the facility with an override control panel at the foot of the bed. This control panel allows staff to override the bed hand remote control device and disable it, if needed. The medical examiner's autopsy report revealed the cause of Resident A's death was "Blunt Force Trauma of Head" with multiple skull fractures and laceration of the brain. The facility knew or should have known Resident A frequently removed his tab alarm, played with the bed control remote device, and attempted to exit the bed without the assistance of staff.The facility failed to disable the bed control remote device, or explore alternative measures to alert staff when Resident A was exiting the bed without assistance. This resulted in Resident A's death of blunt force trauma to the head, as a direct result of the fall from bed. The above violation presented an imminent danger to the resident and was a direct and proximate cause of the death of Resident A. |
| 050000049 |
Greenfield Care Center of Fillmore, LLC |
050012841 |
B |
12-Jan-17 |
TJGE11 |
1618 |
California Health and Safety Code 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: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. The Department determined the facility was in violation of the above statute by failure to post its overall facility rating (Five-Star Quality Rating) in areas used by residents for communal functions. During a relicensing survey observation on 12/8/16 at 8:40 a.m., the facility?s Five-Star Rating was not posted in areas used by residents for communal functions (dining, resident council meetings, and activities). During a concurrent interview, the facility?s Administrator acknowledged and confirmed, the facility?s Five-Star Quality Rating was not posted in any area used by residents for communal functions (dining, resident council meetings, and activities). The Five-Star Quality rating System was created by CMS to help consumers, their families, and caregivers compare nursing homes more easily. The ratings are based on health inspection rating, staffing, and quality measures. The facility?s failure in posting its star rating deprived consumers, their families, and caregivers valuable information in determining sound decisions for nursing home placement and continued stay in the nursing home. |
| 060000046 |
GORDON LANE CARE CENTER |
060009345 |
B |
30-May-12 |
T97Z11 |
9958 |
Gordon Lane Care Center CA00297884 Citation72311 (a)(1)(A) (B) (2) Nursing Service - General (a) Nursing Service shall include, but not be limited to the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care plan shall be based on this plan.The facility failed to ensure assessments of lung sounds were documented between 11/13/11 and 12/5/11 (23 days) for Patient A and failed to perform lung sounds assessments as part of the weekly assessments from 11/14/11 to 12/1/11The facility failed to develop a plan of care related to Patient A's risk for aspiration.The facility failed to implement the plan of care related to aspiration precautions for Patient A. Patient A was noted coughing while eating, continued on a regular diet for four days. Patient A was transferred to the acute care hospital emergency department and diagnosed with respiratory failure, severe sepsis and acute renal (kidney) failure due to septic shock (an overwhelming systemic infection) caused by aspiration pneumonia (inflammation of the lungs caused by breathing in food or liquids). Patient A was transferred to the ICU (Intensive Care Unit) at the acute hospital and placed on a ventilator (a machine which moves air in and out of the lungs). Findings:On 2/6/12, health record review for Patient A was initiated. Patient A was admitted to the facility on 11/11/11, and had a recent history of a subarachnoid hemorrhage (bleeding between the brain and the tissues that cover the brain), and aspiration pneumonia with respiratory failure. The MDS (an assessment tool) dated 11/18/11, showed Patient A had impaired memory and decision making skills and required assistance from staff for activities of daily living. In addition, he was nonverbal.The Nurses Weekly Progress Notes form (a weekly physical assessment conducted by a licensed nurse) dated 11/14, 11/21, and 11/24/11 and again on 12/1/11, showed no documented evidence of assessments of Patient A's lung sounds. The nurse's notes dated 11/13/11 through 12/5/11 showed no assessments of Patient A's lung sounds. The Nutritional Support Committee Assessment dated 12/1/11, showed Patient A had a "swallowing problem" and "coughs when swallows" and the patient was referred for a speech therapy evaluation. The assessment showed Patient A remained on a regular diet.The nurse's notes dated 12/2/11, showed Patient A was noted coughing during breakfast and lunch. Review of the care plans showed no care plan was developed related to Patient A's high risk for aspirating and swallowing difficulties, until 12/5/11.The Speech Therapy Evaluation and Plan of Treatment form dated 12/5/11, showed Patient A was referred for a speech therapy evaluation due to an exacerbation of decreased oral and pharyngeal (part of the throat) function, decreased safety during oral intake, coughing and choking during oral intake, and decreased functional activity tolerance, risk for aspiration, and decreased safety awareness. To facilitate safety during meals, the ST (speech therapist) recommended Patient A be closely supervised during oral intake. The ST also recommended alternating solids with liquids, monitoring of bite sizes and timing of bites, chin tuck swallowing (a technique used for safer swallowing) and maintaining an upright position during oral intake. The nurse's notes dated 12/6/11, showed the CNA (Certified Nursing Assistant) reported to the nurse that Patient A began to cough and choke after he drank. Patient A was assessed by the nurse and had rhonchi (course or loud gurgling lung sounds). Patient A continued to cough, and was suctioned with the removal of food particles and liquid. Patient A was nonverbal and his oxygen saturation rate was 88% (normal is between 95% and 100%). The physician was notified and ordered Patient A be transferred to the acute care hospital emergency department. The physician's order dated 12/6/11, showed to transfer Patient A to the acute care hospital emergency department.On 2/6/12 at 1515 hours, during an interview and health record review with RN (Registered Nurse) 3, RN 3 stated no care plan for Patient A's risk for aspirating food or liquids was developed upon admission or when staff noted the patient had difficulty swallowing on 12/2/11.RN 3 also stated auscultating (listening to the patient's lung sounds with a stethoscope) a patient's lung sounds is part of the weekly assessment the nurses conduct.On 2/6/12 at 1640 hours, during an interview and health record review with the DON (Director of Nursing), the DON stated assessing a patient's lung sounds should be part of a nursing assessment. The DON reviewed Patient A's health record and stated, licensed staff did not specify Patient A's lung sounds.On 2/13/12 at 1115 hours, during an interview with the ST, the ST stated he received an order for a speech therapy evaluation for Patient A. The ST conducted the evaluation on 12/5/11 (four days after the patient was noted with swallowing difficulty). The ST stated he recommended Patient A's diet be downgraded from a regular diet to a pureed consistency diet. The ST stated if a patient is coughing with meals, not tolerating their current diet, and at high risk for aspirating then the current diet should be evaluated. The ST stated licensed staff could initiate the process of downgrading a patient's diet if they were having difficulty swallowing while waiting for a speech and dysphagia (difficulty swallowing) evaluation to be done. On 3/6/12 at 0810 hours, during an interview and health record review with RN 1, RN 1 stated an order was received for Patient A to have a dysphagia evaluation because the patient had decreased oral intake, and food was spilling out around the side of his mouth. RN 1 stated listening to lung sounds is part of the respiratory assessment, and would be documented when done. When RN 1 was asked why there were no lung sounds documented on the weekly assessment she conducted on 11/24/11; the RN stated she "didn't do auscultation" for Patient A. On 3/6/12 at 0830 hours, during an interview with CNA 1, CNA 1 stated she was feeding Patient A breakfast and he was in bed, but the patient was sitting upright. When asked if she received any special instructions on how to feed Patient A, such as feeding Patient A at a slow rate, small bite sizes, chin tuck swallowing technique, double swallowing or alternating solids with liquids, CNA 1 stated no. On 3/6/12 at 1620 hours, during an interview and health record review with LVN (Licensed Vocational Nurse) 1, LVN 1 also stated listening to lung sounds is part of the respiratory assessment and would be documented when done. LVN 1 stated he conducted the weekly assessment for Patient A on 11/14/11 and 12/1/11. The LVN also stated the patient's lung sounds were not auscultated because the patient was not coughing at the time of the assessment and the patient looked like he was doing all right.On 3/7/12 at 0730 hours, during an interview and health record review with RN 2, RN 2 stated she conducted the weekly assessment for Patient A on 11/21/11 and stated she did not know why the patient's lung sounds were not documented on her assessment.Review of the acute care hospital's Emergency Room Report dated 12/6/11, showed Patient A was brought to the emergency room with worsening shortness of breath and severe respiratory distress. Patient A was hypoxic (low blood oxygen level), tachycardic (fast heart rate), tachypneic (rapid breathing) and hypotensive (low blood pressure). Patient A had food in his oropharynx (the middle part of the throat). Patient A had respiratory failure and hypoxemia (low blood oxygen) requiring emergent intubation (the insertion of a tube into the trachea) and the patient was transferred to the ICU. The Imaging Services reports dated 12/6/11, showed chest x-rays were done and Patient A had atelectasis (collapse of part of the lung) and bilateral lung infiltrates (a condition which occurs when something other than air enters the lungs).Review of the acute care hospital H&P (History and Physical) dated 12/6/11, showed Patient A had severe altered level of consciousness due to respiratory failure, acute renal failure, severe sepsis (a severe bacterial infection in the blood) and septic shock (an overwhelming infection which affects the body's organs, and can cause extremely low blood pressure and can lead to death). Review of the acute care hospital Pulmonologist's (a physician specializing in conditions and illnesses involving the lungs) Discharge Summary dated 1/4/12, showed Patient A was admitted to the hospital and maintained on a ventilator. Patient A was also treated with intravenous antibiotics and underwent a tracheostomy (a surgically created opening in the neck) and gastric tube placement (a flexible tube inserted into the stomach, through a surgically created opening). Patient A was diagnosed with respiratory failure due to pneumonia and aspiration pneumonia. The facility failed to assess Patient A's lung sounds, failed to develop a plan of care related to the patient's aspiration risk timely and implement the plan of care once developed.The violation of these regulations, jointly or separately, had a direct and immediate relationship to the health, safety and security of the patients. |
| 060001578 |
GROVE STREET HOME |
060010745 |
B |
04-Jun-14 |
YGY411 |
9845 |
W&I 4502 (d) - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (d) A right to prompt medical care and treatment. The facility failed to ensure the rights of Client A by failing to ensure her right to prompt medical care and treatment when the client fell on 4/5/14 and was not seen by the RN until 4/6/14. The client was not seen by a physician until 4/7/14, wherein the client was diagnosed with fractured clavicle from the fall.Findings: On 4/10/14, the Department received an ERI (Entity Reported Incident) indicating Client A fell in the bathroom on 4/5/14, and was diagnosed with a fractured clavicle. On 4/23/14, an unannounced visit at the facility was initiated to investigate the above ERI. Interview with the QIDP (Qualified Intellectual Disabilities Professional) confirmed Client A fell on 4/5/14, while in the bathroom with a DCS (Direct Care Staff). The QIDP stated Client A was on the toilet seat with a safety belt; however, when the DCS unbuckled the belt and turned to move the wheelchair, Client A got up and fell.Clinical record review was initiated on 4/23/14. Documentation in the clinical record showed the following: Client A was a 54 year old female with diagnoses that included organic brain syndrome and osteoporosis. The client is wheelchair bound. Per physical therapy evaluation dated 5/16/13, the client requires moderate assistance to transfer via standing pivot, needs the help of two people and a gait belt to walk, and wears a helmet (for seizures) when out of her wheelchair. The physical therapist also recommended using care when moving or transferring the client due to the diagnosis of osteoporosis.Documentation showed on 4/6/14, RN 1 (a fill in for facility RN who was on leave) came to the facility to assess Client A. RN 1 documented "res. complaints on a pain in R shoulder. Unable to assess the pain level because on all questions she just answers 'It hurts'. Receives Tylenol 650 mg Q 4 h for pain according to MAR. On assessment resident doesn't want to move or bring up her R arm because of the pain, plus she is spastic and keeps her arms flexed most of the time. Possible abnormalous [sic] or dislocation noted. R shoulder has a fresh bright bruise red - purpe [sic] - yellow on color. Want to bring resident to the nearest ER for X-ray, but couldn't do it myself, because she is wheelchair bonded [sic]. Tried to reach a driver, _____ (name), QIDP ____ (name) or house manager ____ (name) by calling and texting, but did not get any respond, because today is Sunday. Nobody was answering me. After a short consultation with RN ______ (name of facility RN out on leave), decided to continue to give Tylenol PRN and take the resident as soon as driver will come to ER for evaluation. VSS, no abnormal parameters. Will continue to monitor resident and give pain meds. 2 DCS people assigned to help her now."Documentation in the MAR (Medication Administration Record) showed Client A continued to take Tylenol 2 tablets for pain as follows:- On 4/5/14 at 1710 hours; - On 4/6/14 at 0700 hours; - On 4/6/14 at 1100 hours; and- On 4/7/14 at 0942 hours. On 4/7/14, RN 1 continued to document, "Res. was taken by a driver ___ (name) and me today around 10 am to ER _______ (name of hospital) for after fall evaluation. Res. is not complaining on pain, but her bruises on R shoulder and arm look worse. After a short eval. at ER ______ (name of hospital) and performing x-ray slides to R shoulder, ER doctor said that the res. has a small fracture of R clavicle." Review of the ER (Emergency Room) record showed the client was given a sling to position her arm and hydrocodone (a semi-synthetic opioid derived from codeine used orally as a narcotic analgesic) for pain. After being seen in the ER, documentation showed the client continued to take pain medication as noted in the MAR as follows: - On 4/7/14 at 2000 hours, took hydrocodone; - On 4/8/14 at 1000 hours, took hydrocodone; - On 4/9/14 at 1000 hours, took hydrocodone; - On 4/9/14 at 2000 hours, took Tylenol; - On 4/10/14 at 1600 hours, took Tylenol; - On 4/10/14 at 2000 hours, took hydrocodone; and - On 4/13/14 at 0800 hours, took hydrocodone. Review of an Out Patient Consultation Record dated 4/14/14, showed Client A was seen by an orthopedic (the branch of medicine that deals with the prevention or correction of injuries or disorders of the skeletal system and associated muscles, joints, and ligaments) physician. The physician documented "questionable hairline Fx distal end" and wrote an impression of fractured right clavicle. The physician continued the sling for comfort if needed and to use arm as tolerated. The client was released to go back to her day program. On 4/23/14, via telephone, RN 1 was interviewed. She verified all of the above. On 5/1/14, an unannounced visit was conducted at the facility to continue the investigation.On 5/1/14, Client A was observed to return home from her day program. She was sitting in her wheelchair with her right arm bent at the elbow and across her chest. She was not observed to use the right arm. She appeared sleepy. She sat at the table and ate crackers and had water to drink.The surveyor, QIDP and DCS all talked with the client; however, it was hard to understand the client. After the client was helped to her bed to rest, the surveyor again tried to interview Client A. However, the client was unable to answer any questions. Client A's right shoulder area was checked and no bruising was noted. On 5/1/14, per interview with DCS 1, Client A was sitting on a toilet chair with the seatbelt buckled on 4/5/14. Client A unbuckled the seat belt; however, the DCS saw her and was able to buckle it back. When the client was done in the bathroom, DCS 1 unbuckled the seat belt to help the client up; however, the client jumped up and fell on her shoulder. The DCS stated she tried to catch the client but was only able to get hold of her shirt. Another DCS was called to help DCS 1 get Client A up and into her wheelchair. The DCS immediately called the house leader and the nurse. Client A was given two Tylenol at 1710 hours for shoulder pain. On 5/1/14, per interview with DCS 1, QIDP and RN 2 (facility RN), Client A has had a decrease in her ability to communicate. The QIDP was also asked if she had received the phone call from the RN on 4/6/14. The QIDP stated she had not and she felt the RN must have dialed a wrong number as she had no missed calls on her cell phone on 4/5/14.On 5/1/14, the QIDP was asked for the facility's P&P for weekend coverage including transporting clients and when to call 911. The QIDP disclosed there was no P&P for weekend coverage or client transportation. However, the facility had an undated P&P titled First Aid Protocol Guide for ResCare County Group Homes. Fracture was addressed in page 2 of this undated P&P. It stated "Fractures are usually caused by a fall, blow, other traumatic event. Some fractures may be caused by disease that weakens the bones and can occur with little or no trauma. Osteoporosis, causes bones to thin and lose strength as they age.....", "IF YOU SUSPECT A FRACTURE, CALL 911 IMMEDIATELY." A continued review of the clinical record and the facility's incident reports showed Client A had fallen twice prior to the fall on 4/5/14. All three falls were in the bathroom. As noted in the nurse's notes in the clinical record, on 11/18/13, the RN documented "call from bathroom that I've fallen. DCS in bathroom with ______ (client name). Found sitting on floor along side commode next to shower. Denies any pain to legs, hips or body. States had a seizure and fell. Assessed to feet, no c/o (complaint of) pain. Able to walk with assistance. PERL, alert x 3 monitor for head injury." Further interview with the QIDP revealed the client had been put in the "wrong bathroom with no safety equipment" on 11/18/13. The QIDP stated she did an inservice the next day on 11/19/13 for all the DCS. Documentation of the inservice was noted. Also noted in the nurse's notes was documentation dated 2/19/14 for the following: "on 2-17-14 _____ (client's name) fell in bathroom and sustained a cut on forehead. Staff felt it was not deep and applied Band-Aid.", "On 2-18-14, cut is superficial, approximately 1 inch long as diagramed. Staff instructed to keep clean and dry." Per interview with the QIDP, Client A had asked to go to the bathroom on 2/17/14 and while helping to remove her pants, she fell and hit her forehead on the safety rail. On 5/4/14, DCS 1 was interviewed by telephone. She was asked what RN 1 replied to her when she called her after the fall of Client A on 4/5/14. The DCS stated RN 1 told her "that her shift was over and she would come the next day." DCS 1 stated RN 1 asked her to take the vital signs of Client A and call her back with them.The facility failed to ensure prompt medical care and treatment for Client A by the RN's failure to: assess the client for 17 hours following a fall when the client has risk factors (osteoporosis) for fracture; and follow facility policy after she assessed the client and suspected a fracture by not calling 911 for transport to a hospital thereby causing Client A to wait another 24 hours for diagnosis and treatment. The above violation has a direct relationship to the health of Client A. |
| 070000046 |
GREENHILLS MANOR |
070011214 |
B |
16-Jan-15 |
2TL111 |
4909 |
F226, 483.13(C) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their abuse policy for two residents (8 and 9). An alleged verbal abuse incident between two residents was not investigated, documented, and reported to the California Department of Public Health (CDPH) and the Ombudsman as required. There was no care plan developed for each resident and their physicians were not notified after the alleged verbal abuse incident.During a group meeting on 12/23/14 at 2 p.m., Resident 8 stated Resident 9 was "bossy" to other residents in the dining room and Resident 9 should not behave like a "boss." Review of Resident 8's Minimum Data Set (MDS, an assessment tool) dated 9/19/14 indicated Resident 8 did not have a cognitive impairment.Review of Resident 9's Social Work Progress Notes dated 12/8/14, indicated Resident 9 spoke to Resident 8 using the "F" word and the word "bitch". It indicated social services (SS) talked to Resident 9 regarding the use of inappropriate language. Review of Resident 8's clinical record indicated there was no documentation and no documented investigation by SS regarding the incident on 12/8/14.During an interview with SS on 12/23/14 at 2:35 p.m., SS stated she did not consider the use of inappropriate language as verbal abuse.During a concurrent review of Resident 8's clinical record with SS, it indicated there was no documented evidence Resident 8 was assessed and protected from abuse. Resident 8's physician and family member were not informed regarding the incident. There was no care plan developed and there was no follow-up documentation.During an interview with Resident 8 on 12/23/14 at 3:15 p.m., she stated Resident 9 yelled and called her a "bitch" with the "F" word in a hallway. Resident 8 stated she felt attacked and scared when she heard the inappropriate words from Resident 9. Resident 8 stated she did not feel good about the commotion and the inappropriate language made her nervous and uncomfortable. Resident 8 stated she still felt nervous after the commotion whenever she saw Resident 9.During an interview with Resident 9 on 12/29/14 at 8:40 a.m., Resident 9 stated he saw Resident 8 yelling at certified nurse assistant D (CNA D) in a hallway. Resident 9 shook his head and Resident 8 yelled at back at him about shaking his head. Resident 9 stated he said the "F" word to Resident 8. During an interview with the director of nursing (DON), who was the facility abuse coordinator, on 12/29/14 at 7:50 a.m., she stated the allegation of verbal abuse between Residents 8 and 9 was not investigated or reported to CDPH and the Ombudsman. The DON stated the allegation of abuse incidents should be investigated and reported to CDPH and the Ombudsman. Review of the CDPH's Intake Information dated 1/5/15, indicated the facility reported the allegation of verbal abuse between Residents 8 and 9 to CDPH on 1/5/15. During a telephone interview with Ombudsman E (OBM E) on 1/13/15 at 4:25 p.m., she stated she received the report of the allegation of verbal abuse between Residents 8 and 9 on 1/5/15, one month after the incident occurred. Review of the facility's policy "Abuse and Neglect Prohibition" dated 6/6/12, indicated verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Any employee who has knowledge, suspects or witnesses abuse must immediately notify the Ombudsman, CDPH within 24 hours of the alleged abuse and by written report sent within two working days. The resident's family or representative will be notified of any alleged violation and any assessment findings. The facility will conduct an investigation of an alleged abuse in accordance with state regulation. Reassure residents of their safety by visual monitoring. The DON will initiate a physical and mental assessment of the resident and document the findings. A care plan will be developed that reflects the resident's condition and will note measures to prevent recurrences. The attending physician will also be notified of the alleged violations and the results of the investigation.The facility failed to implement their abuse policy and procedure when they failed to investigate an allegation of verbal abuse, failed to notify CDPH and the Ombudsman program of the allegation, failed to assess the situation and document the findings including developing a care plan and notifying the physicians.This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 630012933 |
GATEWAY CENTER ICF 1 |
070011386 |
A |
29-May-15 |
UV7W11 |
7229 |
Welfare and Institutions Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure Client 1's right to be free from harm. On 3/8/15 at 1:00 p.m., Client 1 was left in the parking area unattended during a community outing. Client 1 fell with her wheelchair and sustained a fractured left clavicle (broken collarbone) and a left ankle fracture. Review of Client 1's medical record indicated she had diagnoses including moderate intellectual developmental disability (a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills), osteoporosis (a progressive bone disease that causes the bones to weaken and increases the risk of the bones breaking) and cerebral palsy (a group of permanent movement disorders). The Comprehensive Functional Assessment (CFA, an assessment tool) dated 11/6/14 indicated Client 1 used a wheelchair for mobility and could wheel herself quickly at times around the facility. She was responsive and cooperative.During the investigation on 3/23/15 at 8:15 a.m. in the facility, Client 1 was observed in a wheelchair. She was alert and pleasant; however, she could not maintain a conversation. Client 1's ankles were both swollen with more swelling in her left ankle than in her right ankle. She was observed moving her right arm spontaneously and when asked moved her left arm hesitantly.On 4/8/15 at 10:45 a.m. in the Day Program (DP, a community-based program that provides care to persons in need of personal services, supervision, or assistance essential for sustaining the activities of daily living) during an observation of Client 1, she was able to lock and unlock her wheelchair without a problem. A review of Client 1's X-ray report dated 3/8/15 from the acute care hospital where she was taken after the accident, indicated a fractured left clavicle, closed and left ankle fracture, closed.The facility incident report, dated 3/8/15, and the investigation report, dated 3/9/15, indicated Client 1 was waiting her turn to be loaded into the lift van. Direct support professional C (DSP C), who was caring for Client 1, prompted the client to put on the wheelchair brakes and the client complied. Then DSP C left Client 1 to assist a peer who was in a wheelchair "approximately twenty feet away in the line of sight from the parking area to the picnic table." Meanwhile, Client 1 wheeled herself away and fell with her wheelchair in the parking area across from the parked van. The same facility incident report indicated Client 1 fell on 2/16/15 while at a family visit at home hitting the footrest of the wheelchair with her back and the big toe on her left foot. The client was monitored for bruising (skin discoloration) and swelling when Client 1 returned to the facility.During an interview on 3/23/15 at 8:20 a.m. with DSP A, who was on the community outing, she stated she was securing another client inside the van when she heard another client yelling that Client 1 had fallen. DSP A saw Client 1 in her wheelchair on the ground in the parking area. DSP A stated she was not aware Client 1 was outside and parked beside the van.During an interview on 3/23/15 at 9:30 a.m. with DSP B, who was the lead staff member during the outing, he stated he was assisting another client who was transferring into the van when he heard a client yelling that Client 1 had fallen. He saw Client 1 on the ground in the parking lot. DSP B stated "the distance between the parked van and where [Client 1] fell was approximately twenty-five to fifty feet." DSP B stated he was not aware Client 1 was in her wheelchair parked beside the van where he was helping another client. He stated there was no specific staff member assigned to watch the clients while they were waiting to be loaded into the van. The staff was supposed to help each other. During a telephone interview on 3/23/15 at 10:30 a.m. with DSP C, who was assigned to Client 1, he stated he rolled Client 1 from the picnic table to the parked van and prompted Client 1 to wait while DSP C picked up another client who was still at the picnic table. DSP C stated he left Client 1 with another client. He then picked up a client when he heard a client yelling that Client 1 had fallen. He saw Client 1 on the ground on her left side. He also stated he did not tell anybody he parked Client 1's wheelchair beside the van. DSP C acknowledged that Client 1 was not supervised while she was waiting to be loaded into the van. During an interview on 4/8/15 at 2:20 p.m. with DSP D who was on the community outing, DSP D stated she was helping another client when she heard a client yelling that Client 1 had fallen. She saw Client 1 on the parking lot ground across where the van was parked. She stated the ground in the parking lot was uneven and slanted towards the end which can cause the wheelchair to roll faster. DSP D also stated Client 1can become excited and can wheel her wheelchair fast. During a telephone interview on 4/27/15 with the physical therapist consultant (PTC, consults with administrators, directors, physicians, public health nurses in planning, promoting, and conducting programs in physical therapy and rehabilitation), she stated before the injury, Client 1's left arm was her stronger arm because Client 1 tended to use her left arm often with activities. The PTC stated she planned objectives for Client 1 to strengthen her lower extremities. The PTC stated after the injury on 3/8/15 Client 1 could not perform her walking and standing objectives. Client 1 needed more help than she used too.Review of Client 1's Annual Assessment by Physical Assessment Notes dated 11/5/14 indicated Client 1 "continued to be limited by her heavy weak, weak legs and her weaker right arm." Review of the facility's undated policy, "Procedures for Loading and Unloading Clients Out of Vehicles", indicated all clients need to remain with at least one staff member at all times during the loading and the unloading process and at no time should clients be left out of the sight of a staff member during a community outing. The facility failed to ensure the client's right to be free from harm. The client was left at the picnic ground parking area unattended and fell causing a fractured left clavicle and a fractured left ankle. 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 for Client 1. |
| 070000085 |
GOLDEN LIVING CENTER - SAN JOSE |
070011582 |
B |
01-Jul-15 |
2MX111 |
2316 |
F241 - 483.14(a) DIGNITY AND RESPECT OF INDIVIDUALITY The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility failed to maintain Resident 1's dignity when on 6/13/15, certified nurse assistant A (CNA A) called Resident 1 "gago" which translated from an Austronesian language means "stupid" in English. This caused emotional distress and embarrassment for Resident 1. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 4/16/15 indicated Resident 1 was alert and oriented. The same MDS indicated Resident 1 required limited assistance with one person with his activities of daily living (ADL's) including hygiene and bathing. During an interview on 6/19/15 at 9:15 a.m., Resident 1 stated that on 6/13/15 he requested a towel. CNA A told Resident 1 he did not need towel as he was not taking a shower. Resident 1 admitted he reacted to the situation aggressively by yelling and cursing, and using some derogatory words. Resident 1 stated CNA A responded by calling him "gago" which translated from an Austronesian language means "stupid" in English. Resident 1 stated he felt embarrassed as this was verbalized in front of other staff. During an interview on 6/19/15 at 10:00 a.m., the administrator (ADM) stated she talked to CNA A regarding the incident and CNA A admitted using the word "gago." During an interview on 6/23/15 at 10:10 a.m., CNA A confirmed the 6/13/15 incident occurred with Resident 1. CNA A stated she admitted she responded inappropriately to Resident 1 by using the word "gago." Review of Resident 1's assistant program activity's progress notes dated 6/13/15 indicated Resident 1 experienced emotional distress and felt stressed about the incident.The facility's five day follow-up investigation report dated 6/23/15 indicated the facility concluded the incident was substantiated and CNA A was suspended for inappropriate behavior in response to Resident 1's request for a towel. The Department determined the facility failed to maintain Resident 1's dignity when CNA A called him "gago" which translated from an Austronesian language means "stupid" in English, which caused Resident 1 emotional distress and embarrassment. |
| 070000053 |
GOLDEN AGE CONVALESCENT HOSPITAL |
070012497 |
B |
11-Aug-16 |
STY411 |
6392 |
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 adequately supervise Resident 6 from elopement (leaving the facility without permission) and fall incidents. Resident 6 was found outside the facility twice and the alarm system did not alert staff to the resident leaving the facility unsupervised. Resident 6 fell four times and the interdisciplinary team (IDT, team members from different departments involved in a resident's care) did not assess the fall incidents and develop new interventions to prevent recurrences of falls. These failures resulted in Resident 6's elopement and recurrent falls and had the potential to injury of residents. Resident 6's clinical record was reviewed. The resident was admitted to the facility on 8/18/15 and her diagnosis included dementia (a brain disease which affects a person's ability to think and remember, influencing their daily functioning). Review of Resident 6's Minimum Data Set (MDS, an assessment tool), dated 3/1/16, indicated the resident was cognitively impaired, required supervision with walking, locomotion, and transferring from one surface to another without an assistive device i.e., walker or wheelchair, and wandered daily in the facility. Review of Resident 6's nurses notes dated, 10/14/15, indicated at 6:10 p.m., police informed the facility of Resident 6 walking outside the facility and staff was aware Resident 6 was missing. Review of Resident 6's elopement care plan, dated 10/14/15, indicated to monitor Resident 6 every 15 minutes for the resident's whereabouts and make sure the door alarm was working. There was no documented evidence Resident 6 was monitored every 15 minutes and the IDT discussed Resident 6's elopement. Review of Resident 6's nurses notes, dated 2/23/16, indicated at 10:40 p.m., Resident 6 was found sitting on the ground outside the facility. It indicated Resident 6 was bleeding on his nose, chin, right cheek, and right hand. During an observation and interview with the director of nursing (DON) on 7/26/16 at 5 p.m., when the DON opened the back exit door, the alarm did not sound. She stated the back exit door alarm should be working all the time. During an interview with registered nurse B (RN B), on 7/27/16 at 3:05 p.m., she stated Resident 6 was confused and walked in the hallway. RN B stated on 10/14/15, Resident 6 exited through the back door and the alarm did not work. RN B stated she found Resident 6 walking outside the facility on that day. RN B stated the 15 minute monitoring for Resident 6 was not consistently done. RN B stated on 2/23/16, Resident 6 left the facility through the back door and the alarm did not work. RN B stated she found Resident 6 sitting on the ground outside the facility, the resident had bleeding from her nose and cheek, and was transferred to an acute care hospital for evaluation. During an interview with the DON on 7/27/16 at 4:25 p.m., she stated Resident 6 left the facility twice and the alarm on the back door did not work. The DON stated staff used the back door, did not properly close the door, and the alarm did not sound. She confirmed the IDT did not assess Resident 6's risk of elopement and develop a care plan to prevent recurrences of elopement. Review of the facility's undated policy, "Wandering Residents", indicated all residents who are at risk for harm because of elopement will be assessed by the interdisciplinary care planning team. Interventions into elopement episodes will be entered onto the resident's care plan. A monitoring schedule will be implemented to ensure resident safety. Review of Resident 6's nurses notes, dated 12/15/15 at 6 p.m., indicated the resident tried to stand up but slid on the side of the bed, and landed on the floor. Resident 6 sustained a scratch on the right side of her back. Review of Resident 6's fall care plan dated 12/15/15, indicated to emphasize the safety precaution. There was no documented evidence the IDT discussed Resident 6's 12/15/15 fall. Review of Resident 6's nurses notes dated 1/23/16, at 1:30 a.m., indicated the resident was found sitting on the floor and had a bump, cut, and bleeding on the back of her head. Review of Resident 6's care plan dated 1/23/16, indicated there was no documented evidence the IDT assessed the root cause of the fall and developed or revised new interventions to prevent recurrences of falls. Review of Resident 6's nurses notes, dated 2/23/16, indicated at 10:40 p.m., the resident was found sitting on the ground outside the facility. Resident 6's nose, chin, right cheek, and right hand were bleeding. Review of Resident 6's fall care plan, dated 2/23/16, indicated Resident 6 had an unwitnessed fall. There was no documented evidence the IDT discussed the cause of the fall and no new interventions were developed or revised to prevent recurrences. Review of Resident 6's History and Physical from an acute care hospital dated 2/23/16, indicated Resident 6 was severely demented and had an unwitnessed fall sustaining abrasions to her nose and right hand. Review of Resident 6's nurses notes dated 4/4/16, indicated at 10:30 a.m., Resident 6 was found sitting on the floor and sustained skin discolorations on her left chin and a laceration on the right eyebrow. Review of Resident 6's fall care plan dated 4/5/16, indicated there was no new or revised care plan to prevent falls. During an interview with the DON on 7/26/16 at 3:30 p.m., she stated after the fall incidents, staff should develop new interventions to prevent recurrences. During an interview with the primary physician (PP) on 7/28/16 at 11:15 a.m., he stated he was aware Resident 6 had several falls and it would be beneficial for Resident 6 to do exercises to maintain and prevent Resident 6 from declining. Review of the facility undated policy, "Fall Assessment Policy and Procedure", indicated to assess residents for risk for falls, follow-up and evaluate all residents' falls in order to assess the individual condition, to identify the reason for the fall and to prepare a plan of care to reduce the potential for future falls. This failure had a direct relationship to the health, safety, or security of residents. |
| 070000040 |
GILROY HEALTHCARE AND REHABILITATION CENTER |
070013345 |
B |
17-Jul-17 |
FR2W11 |
9273 |
F309 - 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being
483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
The facility failed to ensure for Resident 2 received immediate and necessary treatment to prevent a decline in his medical condition. Resident 2 had a history of having a myocardial infarction (heart attack). From 6/15/17 to 6/18/17, he complained of increased chest pain, requiring the administration of seven doses of Nitroglycerin (NTG: a medication to provide immediate relief of chest pain) sublingual (under the tongue) tablets. On 6/18/17, Resident 2 fell out of his wheelchair and suffered a heart attack and a Code Blue (a code to alert the staff a resident had no pulse, respirations, or blood pressure and to start cardiopulmonary resuscitation [CPR: restore a pulse and breathing]) was called. The facility failed to notify Resident 2's physician of his increased chest pain, and failed to monitor his blood pressure and heart rate prior to administering the medication. These failures may have had a direct relationship in Resident 2's heart attack and hospitalization.
Lexicomp.com (a Web based Internet site) showed sublingual Nitroglycerin is used to treat the immediate onset of chest pain. A warning/precaution related to the effects of administration included a severe low blood pressure and a low heart rate.
Review of the facility's Policy and Procedure (P&P) titled "Cardiopulmonary resuscitation (CPR)" dated 8/14, showed documentation guidelines to include completion of a CPR Change of Condition Form, notification of the physician and resident's family/responsible party.
Clinical record review for Resident 2 was initiated on 6/27/17. Resident 2 was admitted to the facility on XXXXXXX 13, with diagnoses including congestive heart failure (the heart can no longer pump blood as efficiently), atrial fibrillation (irregular heart beat) and a history of a myocardial infarction (heart attack).
Review of Resident 2's Minimum Data Set (MDS: an assessment tool) dated 5/30/17, showed he was alert and able to make his needs known.
Review of Resident 2's physician order dated 5/30/16, showed he was a full cardiopulmonary resuscitation status (to be resuscitated in the event his heart or breathing stopped).
Review of the Resident Medication Administration Record (MAR) indicated his medications included:
a. Amiodarone HCL 200 milligrams (mg) twice a day for the treatment of an abnormal heart rhythm;
b. Digoxin 125 mcg by mouth every day for the treatment of heart failure;
c. Isordil 30 mg by mouth once a day for the treatment of angina (chest pain);
d. NTG 0.4 mg sublingual every five minutes as needed for chest pain x three doses, if no relief call the physician.
Resident 2 received a NTG tablet 0.4 mg sublingual every five minutes as needed for chest pain x three doses, if no relief call the doctor on the following days:
a. On 6/3/17 - one dose (10:09 a.m.);
b. On 6/9/17 - one dose (6:01 p.m.);
c. On 6/15/17 - two doses (0:05 a.m., and 10:56 p.m.);
d. On 6/16/17 - two doses (4:21 p.m., and 5:06 p.m.);
e. On 6/17/17 - one dose (9:37 p.m.); and
f. On 6/18/17 - two doses (10:07 a.m. and 10:12 a.m.), received approximately 90 minutes before the resident was found on the ground.
Review of Resident 2's Verification of Incident Investigation/Administrative Summary form dated 6/18/17 at 11:20 a.m., showed Licensed Vocational Nurse (LVN) A documented Resident 2 was in the smoking patio face down. The resident had an irregular heartbeat and was non-responsive. LVN A documented Resident 2 was sent to the emergency room via 911.
Review of Resident 2's Change of Condition Evaluation dated 6/18/17 at 11:56 a.m. showed he was found face down on the patio, unresponsive and had a two centimeter (cm) x two cm laceration to his right cheek. Resident 2 had a slow irregular (abnormal) heart rate of 45 beats per minute (normal heart rate: 80-100 beats per minute), 911 was called and he was transferred to the emergency room.
Review of Resident 2's Paramedics report dated 6/18/17 showed at 11:13 a.m., Resident 2 was found on the patio at the facility, unresponsive and moaning. An examination revealed he was cyanotic (bluish in color), cool and diaphoretic (sweating). Resident 2's heart rate was 37 beats per minute and his electrocardiogram (EKG: machine to show the electrical activity of the heart) showed he was in 3rd degree heart block (a condition where none of the electrical signals where performing accurately) requiring external pacemaker paddles (paddles placed on the chest to stimulate the heart to beat).
Review of Resident 2's emergency Transcription Report dated 6/28/17 showed Resident 2's primary diagnoses included severe bradycardia (slow heart rate), and a heart attack. He was intubated (a plastic tube inserted into the throat to help breath) and admitted to the Intensive Care Unit in critical condition.
During an interview on 6/27/17 at 12:17 p.m., the nursing supervisor stated on 6/18/17, Resident 2 was having chest pain in his room before the resident went outside to the smoking patio. She stated she was unable to locate if vital signs (pulse, blood pressure and respirations) were taken prior to the administration of the Nitroglycerin tablets.
During a follow-up interview on 6/27/17 at 12:40 p.m., the nursing supervisor was unable to locate documentation to show Resident 2's physician was notified of his increased chest pain episodes from 6/15 to 6/18/17, requiring the administration of NTG (seven doses). In addition, she was unable to locate documentation to show a complete investigation was conducted when Resident 2 was found on the ground (who found the resident, interviews with staff members/residents related to this incident and what ambulance company transported the resident to the emergency room).
On 6/27/17 at 1:16 p.m., a telephone interview was conducted with LVN A. He stated he did not know who found Resident 2 face down on the ground in the patio. He stated when he entered the smoking patio he found Resident 2 face down on the ground, unresponsive and with shallow, labored breathing (difficulty breathing). LVN A stated when Resident 2 stopped breathing for "a quick second" he then called a Code Blue. In addition, LVN A stated he did not document Resident 2's vital signs (heart rate or blood pressure) when he administered the NTG. He stated he would notify the doctor if the NTG was ineffective, and/or if the resident had a new onset of chest pain. No documentation was available to show Resident 2's physician was notified of his increased need of NTG.
During an interview on 6/27/17 at 1:45 p.m., Resident 3 stated he was on the patio when Resident 2 fell out of his wheelchair. He stated Resident 2 told him he had been having chest pain during the night and did not feel good. Resident 3 stated Resident 2 wheeled himself back into his room to get a NTG tablet and then returned to the patio. He stated Resident 2 had his hands across his chest and was rocking back and forth prior to leaning forward and falling out of his wheelchair. Resident 3 stated he went back into the hallway and was yelling for the staff to help Resident 2.
During an interview on 6/27/17 at 1:55 p.m., Resident 4 stated on 6/18/17, Resident 2 had told her he had not been feeling well for three days. She stated Resident 2 was talking to other residents on the patio when he suddenly fell forward out of his wheelchair.
On 6/27/17 at 2 p.m., a follow-up interview was conducted with the nursing supervisor. She was unable to locate documentation of Resident 2's vital signs prior to the administration of NTG. When the nursing supervisor was asked for documentation related to the Code Blue called for Resident 2 on 6/18/17, she stated the facility had no code blue sheets or any documentation of the code.
This violation had an immediate relationship to the health, safety, or security of the resident. |
| 080000032 |
Grossmont Post Acute Care |
080011035 |
B |
30-Sep-14 |
QY8W11 |
3174 |
Health and Safety Code 1289.4 A theft and loss program shall be implemented by the long-term health care facilities within 90 days after January 1, 1988. The program shall include all of the following:(a) Establishment and posting of the facility's policy regarding theft and investigative procedures. Class B Citation issuedThe facility failed to investigate the loss of Patient A's hearing aids.As a result, the patient went without hearing aids for 86 days. Patient A was admitted to the facility on 2/6/14, with diagnoses which included dementia (a disease process of the brain which interferes with thinking, mood and behavior), per the facility Face Sheet. On 4/4/14 at 9 A.M., Resident A's clinical record was reviewed.Per the resident's Inventory of Personal Effects dated 2/6/14 (the date of admission), there was one set of hearing aids, both left and right documented on the inventory sheet. There was an additional notation on the inventory sheet dated 2/25/14 (the date of discharge), "Hearing Aid (rt and lt) right and left missing 2/15 and 2/16. The resident's Inventory of Personal Effects was signed by facility staff and the patient's daughter at the time of admission and discharge.Per the Nursing Progress Notes dated 2/16/14 at 9:08 P.M., LN (Licensed Nurse) 1 documented, "pt (patient) lost both lt (left) and rt (right) hearing aids per pt's (patient's) family, daughter to discuss with case manager/social worker regarding hearing aids."On 4/4/14 at 10:15 A.M., the Director of Staff Development (DSD) was interviewed concerning Patient A's lost hearing aids.The DSD stated, a search of the linen, trash, and floor of the resident's room was done, "We turned the room upside down and could not find the hearing aids. I reported right away to the Customer Services Liaison or the Social Worker. I did not report this to the Administrator or fill out any paperwork." According to the DSD, this was contrary to the facility's policy and procedure.The DSD then provided a 3" x 5" sheet of paper on which she had jotted down notes, stating this was the investigation. The 3" x 5" sheet of paper did not contain dates, times, or the names of the residents involved. There were no interviews with residents or staff members.On 4/4/14 at 11:30 A.M., the Administrator stated the system for lost items was to, "Report the loss to the staff, search for lost item, then report to the Customer Services Liaison, and the Social Worker. The Social Worker or the Customer Services Liaison would follow up with the family, then inform me."The Administrator further stated, "There is no formal process of investigation." Per the facility's undated policy and procedure titled, Theft and Loss Policy, "...7. All reported cases of theft or loss will be investigated and a report completed if the item is not located in a reasonable amount of time..."Resident A went 61 days from the loss of the hearing aids until the audiologist appointment on 4/18/14, and on 5/12/14, a total of 85 days later, Resident A had not received replacement or compensation for the lost hearing aids.This violation had a direct relationship to the health, safety or security of the resident. |
| 090000086 |
Granite Hills Healthcare & Wellness Centre, LLC |
090009016 |
A |
20-Mar-12 |
NSY123 |
5600 |
K 67 42 CFR 483.70 (a) Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications.19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 NFPA 101, Life Safety Code, 2000 Edition 19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1. 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.NFPA 54, National Fuel Gas Code, 1999 Edition 4.1.5 Detection of Leaks and Defects. (a) The piping system shall withstand the test pressure specified without showing any evidence of leakage or other defects. Any reduction of test pressures as indicated by pressure gauges shall be deemed to indicate the presence of a leak unless such reduction can be readily attributed to some other cause. (b) The leakage shall be located by means of an approved gas detector, a noncorrosive leak detection fluid, or other approved leak detection methods. Matches, candles, open flames, or other methods that provide a source of ignition shall not be used. Where leakage or other defects are located, the affected portion of the piping system shall be repaired or replaced and re-tested. [See 4.1.1(c).]NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition 2-3.4.2Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection devices(s) within. 2-3.4.5 Openings is walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs. 3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct systems. 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 5-1.2 Records shall be maintained on acceptance test results and shall be available for inspection.The facility failed to maintain their gas utility in accordance with NFPA 101, NFPA 54 and NFPA 90A. They facility failed to immediately respond to a suspected gas leak and failed to maintain their heating and air conditioning system by testing their smoke/fire dampers. This affected eight of eight smoke compartments located in the facility. On January 30, 2012, a nurse evaluator (CDPH Staff 1) reported a possible gas leak to the Housekeeping Supervisor.On January 31, 2012, at 8:30 a.m., CDPH Staff 1 reported the gas leak to the Life Safety Code Evaluator.At 10 a.m., the water heater room was observed. The Housekeeping Supervisor was interviewed and asked if she had reported the gas leak to anyone. She stated that the last time she reported a gas leak was approximately 2 years ago.At 11:10 a.m., the manufacturer's instructions for the water heater were requested from the Housekeeping Supervisor. The document titled "MODELS BTR(C) 120 THRU 400A - COMMERCIAL GAS, GLASS-LINED, TANK-TYPE WATER HEATER? was reviewed. The document had the following instructions: " WARNING: If the information in these instructions is not followed exactly, a fire or explosion may result causing property damage, personal injury or death ... What to do if you smell gas ...Immediately call your gas supplier from a neighbor's phone. Follow the gas supplier's instructions. " At approximately 12:30 p.m., the Maintenance Supervisor was asked if he had contacted the utility company to report a gas leak. He stated that he had not contacted the gas company but would contact them soon because of the evaluator's concerns.At 2:30 p.m., the utility company technician was onsite and was interviewed. He stated that a small fizz leak was identified in the piping for the water heater. During a tour of the facility with the Housekeeping Supervisor, on January 18, 2012, fire/smoke dampers were observed in the facility. Testing documents were requested from the Housekeeping Supervisor at 3:02 p.m. She reported the facility did not have records for fire/smoke damper testing.The Housekeeping Supervisor stated that she had no knowledge that the dampers had been tested or inspected.During review of the previous Life Safety Code surveys, this finding was identified on August 18, 2011. The facility Plan of Correction (POC) indicated that they would complete damper testing. This finding was identified on the LSC survey during a re-visit on December 5, 2011. The facility failed to test the smoke/fire dampers to ensure they would function in the event of a fire. The facility?s failure to maintain the physical plant of the building and ensure the heating, ventilation, and air conditi8oning systems complied with the provisions of NFPA 101, 9.2, 19.5.2.1, 19.5.2.2.2, and NFPA 90A, adversely affected the health and safety of all residents in the facility. A gas leak could result in an increased risk of an explosion or fire and failure to maintain the smoke dampers could result in the spread of smoke or fire, in the event of a fire. These facility?s failures presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 090000086 |
Granite Hills Healthcare & Wellness Centre, LLC |
090009017 |
A |
20-Mar-12 |
NSY123 |
7146 |
K 147 42 CFR 483.70 (a) Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 NFPA 70, National Electrical Code, 1999 Edition 110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. (C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating. 110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts. 384-17. Panelboards in Damp or Wet Locations. Panelboards in damp or wet locations shall be installed to comply with Section 373-2(a). 400-8. Uses Not Permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following: (1) As a substitute for a fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors. (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces (5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors (6) Where installed in raceways, except as otherwise permitted in this code 410-3. Live Parts. Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact.Exposed accessible terminals in lampholders, receptacles, and switches shall not be installed in metal fixture canopies or in open bases of portable table and floor lamps. 517-20. Wet Locations. (a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system is such interruption cannot be tolerated. The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70. This was evidenced by a panelboard and high voltage equipment in an area with standing water on the floor. The facility failed to provide a ground-fault circuit-interrupter (GFCI), in a wet location. There were damaged electrical receptacles in some areas. The facility had an open light socket and was using multi-outlet adapters to provide additional electrical outlets in place of fixed wiring. On January 31, 2012, at 9:40 a.m., standing water on the floor in the boiler room was observed. The room contained high voltage equipment that included an electrical circuit switch panelboard and a compressor. The water was approximately 31-inches from the panelboard and 12-inches from the compressor. There were wet rags and a basin full of water on the ground underneath the piping to the boiler system.At 9:43 a.m., the Maintenance Supervisor reported that the water leak had existed for some time.At 9:45 a.m., damage around the ground port of the red electrical outlet in the corridor by the clean linen laundry room was observed. There was a gap in the cover plate that exposed energized parts. The gap measured approximately 1/4-inch. At 10:10 a.m., a small compressor was placed in a wet location underneath a sink in the kitchen. The cable to the compressor ran through the wall and was plugged into a multi-outlet adapter. A juice machine was plugged into the same adapter. The receptacle wall outlet, providing power to the multi-outlet adapter, was not protected by a Ground Fault Circuit Interrupter (GFCI). An ice machine was plugged into the second port of the wall outlet. The switch at the electrical panel box was labeled 8 & 10, for the receptacle wall outlet in the kitchen. The switch was not equipped with a GFCI. On January 18, 2012, at 3:39 p.m., a broken faceplate cover on the light switch in the kitchen, by the corridor door was observed. From 4 p.m. - 4:25 p.m. damaged electrical outlets in several areas of the facility were observed. The electrical outlets for Bed 2 and Bed 3, in Room 11, were damaged around the ground port. The red electrical outlet, in the corridor adjacent to Room 11, was damaged around the ground port. The electrical outlet for Bed 2 and the outlet by the television in Room 13, were damaged around the ground port. One electrical outlet was damaged around the ground port, on the north wall in the Admissions Office.On January 18, 2012, at 4:26 p.m., observation revealed that the ceiling light fixture had an open light socket, in the inner storage area, in the Activity Storage Room.From 4:29 p.m. ? 5:02 p.m., damaged electrical outlets were observed in the facility. The red electrical outlet, in the corridor adjacent to the laundry room, was damaged around the ground port.Three of four electrical outlets in the Staff Lounge were damaged around the ground port. Eight of eight electrical outlets in the main dining room were damaged around the ground port. Six of six electrical outlets in the TV Room were damaged around the ground port.Two of four electrical outlets in the Director of Staff Development Office, were damaged around the ground port. The red electrical outlet, in the corridor adjacent to Room 31, was damaged around the ground port. The electrical outlet for Bed 3, in Room 31, was damaged around the ground port. The electrical outlet for Bed 2, in Room 25, was damaged around the ground port. The red electrical outlet, in the corridor adjacent to Room 25, was damaged around the ground port.Five of seven electrical outlets observed in the Main Lobby were damaged around the ground port.At 5:04 p.m., four medical devices connected to a multi-plug adapter, in Room 44, Bed 1 were observed. A bed, an air mattress pump, an oxygen concentrator, and a feeding pump were connected to the adapter.During review of the previous Life Safety Code survey and re-visit, on August 18, 2011 and December 5, 2011, a deficiency was cited for K147 which cited damaged outlets. The facility failed to replace the damaged outlets and make electrical repairs identified on the surveys. The failure to correct the electrical hazards could result in an increased risk of electric shock or an electrical fire, resulting in severe injury to residents, visitors, or staff.The facility?s failure to maintain the physical plant and electrical safety of the building, adversely affected the health and safety of all residents in the facility. These failures presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm could result. |
| 090000086 |
Granite Hills Healthcare & Wellness Centre, LLC |
090009097 |
B |
08-Mar-12 |
IC8211 |
17195 |
Safeguards for Patients' Monies and Valuables. 72529 (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance. All of these records shall be maintained at the facility for a minimum of three years from the date of transaction. At no time may the balance in a patient's drawing account be less than zero. (B) Records of patients' monies and other valuables entrusted to the licensee for safekeeping shall include a copy of the receipt furnished to the patient or to the patient's authorized representative. Each item of patient property entrusted to the licensee shall be clearly identified as belonging to that patient. (3) Patients' monies not kept in the facility shall be deposited in a demand trust account in a local bank authorized to do business in California, the deposits of which are insured by the Federal Deposit Insurance Corporation, or in a federally insured bank or savings and loan association under a plan approved by the Department. If a facility is operated by a county, such funds may be deposited with the county treasurer. If a facility is operated by the State, such funds may be deposited with the State Treasurer. All banking records related to these funds, including but not limited to deposit slips, checks, cancelled checks, statements and check registers, shall be maintained in the facility for a minimum of three years from the date of transaction. Identification as a patient trust fund account shall be clearly printed on each patient's trust account checks and bank statements. (4) A separate list shall be maintained for all checks from patient funds which are, or have been outstanding for 45 days or more as reflected on the most recent bank statement. Bank statements shall be reconciled monthly with copies of the reconciliation maintained by the facility. Any checks on such accounts written off or un cashed shall result in an addition to the appropriate patient's account. (6) A person, firm partnership, association or corporation which is licensed to operate more than one health facility shall maintain a separate demand trust account as specified in (3) above for each such facility. Records relating to these accounts shall be maintained at each facility as specified in (2) above. Patient funds from one facility shall not be mingled with funds from another facility.(8) Upon discharge of a patient, all money and valuables of that patient which have been entrusted to the licensee and kept within the facility shall be surrendered to the patient or authorized representative in exchange for a signed receipt. Monies in a demand trust account or with the county treasurer shall be made available within three normal banking days. Upon discharge, the patient or authorized representative shall be given a detailed list of personal property and a current copy of the debits and credits of the patient's monies. (9) Within 30 days following the death of a patient, except in a coroner or medical examiner case, all money and valuables of that patient which have been entrusted to the licensee shall be surrendered to the person responsible for the patient or to the executor or the administrator of the estate in exchange for a signed receipt. Whenever a patient without known heirs dies, written notice within five working days, shall be given by the facility to the public administrator of the county as specified by Section 1145 of the California Probate Code and a copy of said notice shall be available in the facility for review by the Department. The facility failed to have a system in place to ensure that the money entrusted to them on behalf of patients in the patient trust account was maintained and safeguarded in accordance with state regulatory requirements. The facility was unable to provide evidence that the trust account funds had been deposited in a local banking institution. There was no evidence that quarterly account statements had been provided to patients or their responsible parties in over a year. There was no evidence that the facility refunded balances in the trust account after a patient was discharged from the facility, instead money just sat in the account for years as opposed to being refunded to the patient or their family members. The facility received a Class B citation on 9/23/09 for failing to safeguard patient monies held in the patient trust account. A plan of correction was done with the assurance that the violations of the regulations would not happen again. The citation was corrected on 9/30/2009 under the premise that systems would be in place to protect money held in the patient trust account. The facility failed to put into place the structure and processes to ensure regulatory compliance with a patient trust account. The Department formally requested that a financial audit be conducted by the Department of Health Care Services , Audits and Investigation Program, San Diego Financial Audits Branch.The Department began a licensure survey on 8/8/11 at the facility to determine compliance with state licensure regulations. During the survey a complaint was received that the facility did not have an accounting system to manage the resident trust account. The trust account was reviewed in response to the complaint allegations and licensure survey.On 8/10/11 at 1:45 P. M. an interview and document review was conducted with the administrator. The administrator presented a document entitled, "Trust Fund Balance Report" with a list of patients that had various amounts of money listed. The administrator stated that the list was generated by him. The administrator further stated that he used a personal-finance-software program to generate the list. The administrator stated that he was the person that maintained the individual patient trust account. When the administrated was asked to present the trust account banking statements and individual ledgers, he stated that he did not keep them at the facility.On 8/11/11 at 10:00 A.M. an interview was conducted with the administrator. The administrator stated that he had changed banks. He named three different banking institutions and continued to state that he would have to go to each one to obtain individual patient's records. The administrator stated that he had not done quarterly accounting of the patient individual trust accounts or provided statements to the patients. The administrator stated that he thought quarterly account statements went out "Sometime in 2010."On 8/11/11 at 3:45 P.M. the administrator provided a document that did not represent a bank, however, indicated it was a "resident trust account" for the facility. The document had various amounts listed, a balance and deposits. An interview was conducted with the administrator at this time. The administrator stated the document "should satisfy the need for any more inquires of patient's trust fund monies." The administrator stated that he was unable to obtain the residents individual trust fund accounts from the banking institutions. The administrator further stated that the individual accounts were unavailable. Based upon interviews with the facility's administrator and the unavailability of the patient trust account records, bank statements and individual ledger statements; a formal request for a financial audit to be completed by the Department of Health Care Services, Audits and Investigations Program was done. The San Diego Financial Audits Branch was given the responsibility to complete the audits for compliance with state regulations regarding the patient trust account.On 8/12/11 auditors from the San Diego Financial Audits Branch began to audit the facility's patient trust account. The period of review was from 12/1/06 to 8/12/11. The summaries of findings are as followed.1. The administrator had sole control of the trust fund without separation of duties and without oversight control of the trust fund. This situation made it possible to commit an inappropriate transaction.The auditors found that the trust funds records were manipulated for getting approval for Medi-Cal eligibility. The patient ledger cards showed an ending balance over $2,000. This was one practice that was being used by the administrator to easily manipulate the existing system for inappropriate purposes.There were several patient accounts that were above the $2,000 Medi- Cal property limits. The administrator's explanations included that he would change the status of a patient from Medi- Cal to private and then use the surplus money towards the patient account with the facility. The administrator stated that he did not notify the patients when their balances reached $200 less than the eligibility property limitation. 2. The administrator did not perform bank reconciliations. There was not any bank reconciliation prior to 6/09. The last reconciliation dated 12/31/10 indicated errors. A running balance on the checkbook was not maintained. The printouts of the control account (patient statements generated by the administrator) created at different times showed different balances for the same period.The control account balance shown as the support for the bank reconciliation as of 12/31/10 did not reconcile to the control sheet printed on 8/12/11. The sub-account (individual patient accounts) total balance shown as the support for the bank reconciliation as of 12/31/10 did not reconcile to the control sheet printed on a 08/12/11. The administrator did not provide the patients with quarterly accounting.3. Supporting documentation was requested but never provided. The administrator did not maintain supporting documents such as receipts, bank statements and deposit slips at the facility. The administrator did not issue a receipt for the Social Security checks deposited to the patient trust funds.4. Reconciliation of sample bank reconciliation furnished by the administrator was for the 12/31/10. The evidence indicated that there was a discrepancy from the reconciled bank balance and the administrator's control account report ending balance of $1,755.81. There was no interest distributed to the patient from 12/10 to 7/11. The last know distribution of interest was completed in 9/09 of a total $3,226.14. When the administrator was asked how the interest was distributed, he replied that he took the difference of the bank account and the control account to make the calculation. The administrator stated , " it's not the most accurate way to distribute the interest, because the interest is from prior years and patients who are no longer there, it was easier to just distribute the interest to those who were there and move on."5. The control balance shown as the support for the bank reconciliation as of 12/31/10 did not reconcile to the control sheet printed on 8/12/11. 6. The sub-account total balance shown as the support for the bank reconciliation as of 12/31/10 did not reconcile to the control sheet printed 8/12/11. 7. The auditor's reviewed the issue of the patients' monies returned within 3 normal banking days, the following was noted. There were several accounts in which the patient monies had not been returned for more than 9 years. Some of the checks that were written to return the patient monies had not been cleared by the bank. The Department made a return visit to the facility on 9/26/11 after receiving the written auditor's report.On 9/26/11 at 10:30 A.M., an interview and record review of the trust fund was conducted with the administrator. The document titled "Trust Fund Balance" dated 8/8/11 was reviewed. There were a total of 9 patient accounts that were recorded as "active" with monitory balance. Patients 1, 2, 6, 7 and 8 had died and the monies in the account had not been returned within the 30 days as required by the regulation. The Trust Fund Balance Report dated 8/8/11 indicated the status of the accounts were as follows: Patient 1 died on 4/11/11. The active balance was $9900. Patient 2 died on 3/01/11. The active balance was $2268.18. Patient 6 died on 9/09/10. The active balance was $1352.90 Patient 7 died on 12/11/10. The active balance was $781.57 Patient 8 died on 12/9/10. There was an active balance $20.01Patients 3, 4, 5 and 9 were discharged from the facility yet their money had not been returned within 3 normal banking days as required by the regulation.The Trust Fund Balance Report dated 8/8/11 indicated the status of the accounts were as follows: Patient 3 was discharged to a general acute care hospital on 5/12/11. The active balance was $1570.00 Patient 4 was discharged to a general acute care hospital on 6/12/09. The active balance was $35.00. Patient 5 was discharged to home on 5/27/11. The active balance was $285.00 Patient 9 was discharged 5/27/11. The active balance was 65 cents.The administrator stated on 9/26/11 that he knew the monies had to be given back but he had "not gotten around to it."A follow-up visit was made to the facility on 12/5/2011 to review the trust account again to see if any corrective action had been taken.On 12/05/11 at 1:30 P.M. an interview and joint document review was conducted with the administrator. The administrator identified a document as the residents' Trust Fund Balance Report. The administrator stated that "nothing had changed" since the August 2011 survey. On 12/6/11 at 1:35 P.M. another interview was conducted with the administrator regarding the status of the patient trust account. The administrator stated he still did not have the current bank statements. He stated that he still had not generated any quarterly statements for the residents with trust fund balances. Again, the administrator stated that the accounting materials and documents were not available at the facility.A third follow-up visit was made to the facility to review the status of any corrective action taken by the facility regarding the patient trust account. On 1/30/12 at 12:30 P.M. a meeting was conducted with the administrator. A request was made of the administrator to provide all documentation related to the trust account which included current bank statements and individual patient ledger balances. Again, the administrator stated that documentation was at the corporate office. The administrator stated he "did not have a current bank statement of the resident's trust funds because he had changed banks from Bank A to Bank B the early part of January and "it took time."On 2/1/12 at 9:35 A.M. a random sample of discharged patients who still had active money balances in the trust account were reviewed. Patient 10 was discharged from the facility on 12/2/11. Patient 10 still had an active patient trust account balance of $3318.12.On 2/1/12 at 9:35 A.M. an interview was conducted with the administrator who stated "I know" monies are to be returned in a timely manner. The administrator said that he had not sent checks and the checkbook was at the corporate office. He stated that he had not taken any corrective action since the August 2011 survey to resolve the trust account irregularities.Patients and families deposit money into the facility's trust account with the expectation that their funds will be properly safeguarded. Patients use this money for their personal needs while they are patients in the skilled nursing facility. Patients and their families expect an accurate accounting of their money. Patients and families also expect that their money will be returned to them.The facility's administrator had sole responsibility to manage and protect money entrusted to him. From August 2011 until February 2012, a period of sixth months the facility's administrator failed to take any corrective action regarding the patient trust account. The accounting practices that the facility's administrator engaged in,lent to fiscal abuse which presented a substantial probability that money was misappropriated or lost forever. The above violations jointly, separately or in any combination have a direct or immediate relationship to patient health, safety or security. |
| 090000061 |
Golden Hill Subacute & Rehabilitation Center |
090009427 |
B |
02-Aug-12 |
CZNW11 |
4416 |
72637 (c) General Maintenance All buildings, fixtures, equipment and spaces shall be maintained in operable condition. The facility failed to maintain the side rail of 1 of 2 sampled patient's (A) bed. As a result, when the certified nursing assistant turned the patient onto the rail, the rail gave way causing the patient to fall out of bed with the certified nursing assistant onto the floor. The patient sustained mild bleeding from biting her tongue from the fall.Patient A was admitted to the facility on 11/11/10, with diagnoses that included acute respiratory failure, obesity and attention to tracheostomy (tracheal opening for breathing) was connected to equipment per the Admission Information Sheet. The minimum data set (MDS) assessment dated 3/5/12, indicated that Patient A was in a persistent vegetative state/no discernible consciousness and was totally dependent on staff for activities of daily living, transfers, toileting and personal hygiene.A tour of the facility was conducted on 1/13/12 at 10:00 A.M. with the director of nurses (DON). Patient A was observed in bed turned on the right side with both eyes closed. The side rails of the bed were observed in the up position, a tracheostomy was connected to equipment for breathing and a gastrostomy (abdominal opening) tube feeding was infusing via feeding pump.A review of the clinical record for Patient A was conducted on 1/13/12 at 10:20 A.M. The Licensed Nurse's Notes dated 10/18/11, at 2:20 P.M. indicated, "CNA was turning the patient to her side to get the padding when the bedrail went down and the resident fell with the CNA assisting her holding head onto the floor. Assisted back to bed with a hoyer lift, changed bed to bariatric bed. Some mild bleeding when the patient bit her tongue, no further bleeding noted. Notified the physician. Will continue to monitor." A phone interview was conducted on 1/13/12 at 10:30 A.M. with certified nursing assistant (CNA) 1. CNA 1 stated, "The side rail was up and I turned Patient 1 to change the padding. After turning her, she coughed. When she coughed, she rolled over towards me and she fell on top of me onto the floor. The side rail gave up, that's how she fell on top of me. I did not have any problem with the bed rails before. Her bed was too small for her." A phone interview was conducted on 1/24/12 at 11:00 A.M. with the respiratory therapist (RT) 1. RT 1 stated, "I was with Patient A's roommate when the fall incident happened. I heard CNA 1called for help. I saw CNA 1 and Patient A on the floor. The side rail malfunctioned and I saw it on the floor. We helped Patient A back into bed. I put her trache collar back. She was on blowby (a tube placed on the tracheal area that aids in the delivery of oxygen in to the respiratory system)." An interview was conducted on 1/24/12 at 11:10 A.M. with CNA 2. CNA 2 stated, "I went in to help. I saw the side rail on the floor. Patient A was on the floor with her face down and I noticed bleeding coming out from her mouth." An interview was conducted on 3/19/12 at 11:10 A.M. with the maintenance supervisor (MS). The MS stated, "Patient A is now on a new bed. The old bed was thrown away. I remember it had a different side rails. It did not come with the bed." An interview was conducted on 3/9/12 at 5:40 P.M. with the licensed nurse (LN) 3. LN 3 stated, "I was called in to Patient A's room when she fell on top of the CNA. Yes, Patient A was transferred into a bariatric bed soon after the fall incident. The side rail was on the floor when I walked in to the room. Maintenance took the old bed away. I noticed Patient A had some bleeding from the mouth from biting her tongue when she fell. The physician was notified."It is critical that side rails to patients' beds be maintained in good repair. Side rails are used for positioning while facility staff renders personal care in their beds to prevent risks for falls and patients becoming injured. Failure of the facility to maintain the side rail of this patient's bed caused the rail to drop to the floor. The sudden movement caused the patient to fall from the bed on top of the CNA onto the floor with sufficient force to immediately cause the mouth to bleed from a tongue bite and not being able to breathe without the trach collar in place.A violation of this regulation had a direct or immediate relationship to the health, safety, and or security of this patient. |
| 090000086 |
Granite Hills Healthcare & Wellness Centre, LLC |
090012381 |
A |
22-Nov-16 |
HLAG11 |
22865 |
Final draft A Citation Granite Hills - CA00429012 Title 22, 72311(a)(B)(C)(2) Nursing service - General Nursing service shall include, but not be limited to, the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (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. (2) Implementing of each Resident's care plan according to the methods indicated. Each Resident's care shall be based on this plan. Title 22, 72501 (e) Licensee - General Duties (e) The Licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision. Findings: On 2/11/15 at 3:00 P.M., a complaint reported event was investigated regarding a Resident who choked while eating breakfast. Based on interview and record review, the facility failed to ensure that Resident A was provided with supervision during breakfast. In addition, the facility failed to ensure that a plan of care for Dysphagia (difficulty of swallowing) was implemented. A review of Resident A's clinical record revealed that Resident A was readmitted to the facility on 8/4/14 with diagnoses that included dysphagia-oropharyngeal (abnormalities of muscles, nerves or structures of the oral cavity, pharynx, and upper esophageal sphincter), and encephalopathy (abnormal brain function or brain structure). This made it difficult for Resident A to swallow food. There was no evidence that the facility developed a method or mechanism, such as supervision during meals to ensure the implementation of interventions in the nursing care plan for dysphasia, to prevent choking or aspiration, were established. According to the licensed nurses notes dated 1/1/15, "At 6:45 A.M., Resident A was standing by room door waiting for breakfast. Resident A stated that he had a good sleep. No respiratory distress notes.", "At 0750, I was summoned in patient's (Resident A's) room by the CNA (certified nursing assistant) who was picking up the breakfast tray to check on patient's condition. Upon assessment, patient was laying in bed unresponsive, skin pale and clammy, unable to obtain B/P (blood pressure), no pulse (absence of heartbeat) was palpated...Per CNA, patient was last seen sitting on the side of the bed at 0730 eating breakfast. Tray by the side of the bed noted to be empty of food..." On 1/1/15 at 7:30 A.M., there was no documented evidence that Resident A was supervised and given assistance (over-sight, encouragement or cueing) during his breakfast meal. Resident A was served his breakfast tray in his room. Resident A was known to have high risk of choking, as well as, behaviors where he ate food fast and did not chew his food well. According to Resident A' plan of care for "Dysphagia", updated on 11/4/14, Resident A would receive a mechanical soft diet as ordered, maintain an upright position for all meals, use small portions (bites) and small sips, do not let resident gulp liquids, control distractions in environment (TV off, etc.), Resident A to remain upright 30 minutes after meal, monitor for s/s (sign and symptoms) aspiration- SOB (short of breath), respiratory distress, congestion, temperature elevation, notify MD (physician) promptly if s/s occur. The recapitulated physician's orders, dated December 2014, indicated that Resident A was on a mechanical soft (regular diet is modified in texture to a soft, chopped or ground consistency), NCS (non- concentrated sweets) fortified, large portions, thin liquids diet. There was no written physician's order to not serve the following foods that Resident A was allergic to: milk, eggs, and pineapple. The H&P (history & physical) by the physician dated 9/3/14 indicated that Resident A had an aspiration risk (choking risk). The physician's orders indicated, "Continue aspiration precaution, small bites/sips; do not talk with food in mouth..." The History and Physical Examination (H&P) by the physician, dated 8/5/14, indicated that Resident A could make needs known but could not make medical decisions. According to the facility's menus for "New Year's Day - 1/1/15", Breakfast for Ground or Mechanical Soft Diet, Large Portion, the diet prescribed for Resident A, included the following: - 2 Egg Muffin Sandwiches - make with ground ham - No Parsley - High Fiber Juice 4 oz (ounce) - Hot Farina Cereal 3/4 cup - Milk 8 oz The facility's recipe for "Egg Muffin Sandwich", was documented as: - Portion size: 1 sandwich = 1 egg + 1/2 oz ham + 1/2 oz chesses (2 oz protein) - English muffins, lightly toasted & buttered Grounds - Grounds: May serve but grind ham - 1/2 oz. Option: May serve on lightly toasted and buttered wheat bread. According to the Admission Nutritional Screening & Data Collection Form completed by the registered dietician and dated 8/5/14, Resident A was allergic to milk, eggs and pineapple. On 4/6/16 at 2:50 P.M., the dietary supervisor was interviewed. She stated that she worked on 1/1/15 but she did not remember if Resident A's English muffins were toasted or not. She requested to review the facility's recipe. She reviewed the facility's recipe and stated that "Probably followed a recipe, so I think we used the lightly toasted wheat bread and butter." She was not sure if the facility served Resident A milk and eggs, which he was allergic to. The facility's policy entitled Regular Mechanical Soft Diet, dated 2015, indicated that "...Regular Mechanical Soft Diet: Description: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below." The foods listed include: meats, poultry and fish, which should be ground with meat juices or moist meatloaf, and to avoid whole or chopped meat, dry meat, (chopped meat only allowed when order by Speech Therapy). Additional foods listed include: breads, cereals, which should be soft, and to avoid "[b]reads with hard crusts. ... English Muffins..." The facility served Resident A either two English muffins or wheat toast, on 1/1/15 according the facility's menu. Resident A was edentulous (toothless) and did not have dentures which increased his risk of choking on 1/1/15. Resident A sat at the side of his bed in his room and ate his breakfast by himself, without supervision by the staff. The speech therapist (ST) recommended, and per the physician's instructions, dated 9/3/14, the staff were supposed to remind Resident A to use chin tuck (postural exercises for combating neck pain and strengthening the muscles that pull the head back into alignment), take small bites of food and sips of liquid, and sit upright during meals. As a result, on 1/1/15 at 7:50 A.M. the certified nurse assistant (CNA) found Resident A lying on his bed, unresponsive. Resident A was transferred to the acute care hospital via ambulance in response to a 911 call and died four days later at the hospital on 1/5/15. Per hospital's Emergency Service Report, dated 1/1/15, the "OG (Orogastic) tube (a tube place through esophagus) was placed. During that time, the patient (Resident A) was noted to have a large amount of meat (ham) in his posterior pharyngeal area (behind the oral opening in the area that's commonly called the top of the throat) that was removed at the time of OG placement." According to the Physician's Consultation Note from the hospital, dated 1/21/15, "He (Resident A) was sitting at the bedside and eating breakfast yesterday morning (1/1/15); 15 minutes later when nurse returned to his room, the patient (Resident A) was found down next to the bed, pulseless and panic, CPR (Cardiopulmonary resuscitation) apparently initiated by the nursing staff at the nursing home... The patient (Resident A) was brought in to the Emergency Room (ER) of hospital and code was continued by the ER physician for a total of about 25 minutes with significant amount of food material suctioned out from his airway in the ER." The speech therapists (STs) were contracted by the facility from an outside agency. The STs who wrote the Evaluation and Plan of Treatment was no longer employed by the contracted company and unavailable for interviews. The Speech Therapy (ST) Evaluation and Plan of Treatment (Treatment Record) was reviewed on 2/11/15. The STs notes, dated 8/7/14, indicated, "...Strategies included small bites/sips + clearing oral cavity before next bite. Pt (Patient) required mod (moderate) verbal cues for safety..." The ST notes dated 8/13/14 indicated, "...utilizes large bites and drinks without cues...Pt able to repeat strategies of small bites/sips and chin tuck to therapist..." The ST Treatment Record notes, dated 8/14/14, indicated that "...Very impulsive self-feeding with decreased awareness of need for safety. Pt utilizes very fast rate with large bite size and incomplete swallow prior to new bite. Max (maximum) cues provided for slow rate, small bite, and solid/liq (liquid) alternation. Patient A (Resident A) had intermittent coughing throughout meal during mastication secondary in cohesive bolus particles spilling into airway. Pt would benefit from supervision at meals to assist with use of strategies..." The ST Treatment Record notes, dated 8/15/14, indicated that "Resident A...still takes large bites. Educ [education] with CNA, need supervision [s with a circle around the s] at meals to use strategies. Wrote out visual reminders." The ST Treatment Record notes, dated 8/27/14 indicated that "...Very impulsive and needs constant supervision to utilize precautions..." The ST Treatment Record notes, dated 9/1/14 indicated that "...Pt highly distracted & required mod/max cues to attend to eating. Pt. with large bolus, pocketing & verbal output with bolus in oral cavity. Min (minimum)/mod cues for swallow safety to ensure tolerance & safety..." The ST Discharge Summary, dated 9/3/14, indicated that "Long Term Goals: Patient (Resident A) will safey swallow least restrictive diet level utilizing swallowing w/o [without] s/s [sign and symptoms of] aspiration 90 %. Comments: Currently patient able to consume mech [mechanical] soft diet 90 % with min [minimum] s/s [signs and symptoms] dysphagia. Skill: Pt (Resident A) and Caregiver Training: chin tuck, small bites/sips, upright position, inconsistent follow 2' [secondary] cognitive status; staff training completed. Discharge Status and Recommendation: Prognosis: Maintain CLOF [current level of function] = Good with consistent staff follow-through. Functional Outcomes: Swallowing Abilities = Distant Supervision. Intake Protocol: Swallow Strategies/Positions: chin tuck, small bites/sips. Sit upright, Supervision for Oral Intake = Occasional supervision, Distant supervision." There was no evidence in the record which indicated that the ST referred Resident A to the RNA program (Restorative Nursing Assistant program referrals are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy to promote the resident's ability to adjust to living as independently and safely as possible). There was no documentation of how to supervise Resident A in the discharge summary of ST recommendation. The plan of care for Resident A was not fully developed to ensure that an aspiration protocol was implemented. The minimum data set assessment (MDS), Section C, Cognitive Patterns, dated 12/14/14, was reviewed on 2/11/15. It indicated Resident A's BIMS (Brief Interview for Mental Status) was coded (score) 9 (according the Resident Assessment Instrument (RAI) 3.0 manual for MDS indicated that score 8-12 was moderately impaired). Resident A's functional status for eating, Section G, indicated that Resident A required supervision with oversight, encouragement or cueing during eating meals and required meal setup by the staff. The same MDS sheet indicated that Resident A did not have any dental problems such as missing natural teeth or difficulty with chewing. However, the family member reported to the California Department Public Health (CDPH or Department) on 1/28/15 at 11:35 A.M., that Resident A did not have teeth, and the family member requested that the facility get the Resident's dentures resized because the set the Resident had did not fit. The family member called to the CDPH 12 days after Resident A was deceased. On 2/10/15 at 12:46 P.M., a second interview with the family member was conducted, she repeated the same story. There was no documentation in Resident A's medical record that the family had requested resizing dentures. The Department was not able to determine if Resident A had a set of dentures, according to the facility's documentation. During the course of the investigation, multiple inconsistent documentations and interviews were found as follows: * The Nutritional Screening & Data Collection Form reviewed by the Registered Dietician on 8/5/14, indicated that Resident A had his own teeth, and Resident A did not have chewing or swallowing problem, and did not have missing teeth, or dentures. * The Resident Admission Assessment by the licensed nurse (LN) on 8/4/14, indicated that there was no assessment for oral/dental conducted by the LN. This section was left blank. * The History and Physical Examination by the physician on 8/5/14, indicated that the primary physician did not assess Resident A's oral cavity and teeth. * The Inventory of Personal Effects sheet by the facility staff on 8/4/16, indicated that Resident A did not have dentures. * A denial notice letter from the Dental-Cal (California Medi-Cal Dental Program), dated on 11/17/14 indicated that the dentist examined Resident A for dentures on 8/12/14. There was no documentation that the social service department followed up with the dentures for Resident A after the TAR (Treatment Authorization Request) denial. * The Nursing Care Plan for no teeth was developed by the licensed nurse on 8/14/14 and re-assessed on 11/4/14. * The Investigative Report by the Medical Examiner on 1/8/15, indicated that "The upper and lower teeth are absent." * On 2/12/15 at 12:45 P.M., the director of nursing (DON) was interviewed and stated that Resident A did not have dentures. * On 2/12/15 at 2/12/15 P.M., LN 1 was interviewed and stated that Resident A's dentures were broken and Resident A threw them away. * On 2/12/15 at 3:05 P.M., an interview with the social services worker was conducted. She stated that the resident's sister stated the resident had dentures, and then she followed up with the resident and he told her he did not have dentures. The weekly summaries [Nursing Assessment sheets], the section for ADL (Activities of Daily Living), dated 11/25/14 - 12/1/14; 12/8/14 - 12/15/14; and 12/22/14 - 12/29/14, indicated that Resident A required supervision. The CNA -ADL Tracking Form, "section eating", dated 12/2014, indicated that Resident A required supervision (oversight) with setup help only during AM shift, and Resident A required one person limited physical assistance with one person during PM shift. The Weight Variance Committee Weight Loss/Gain Assessment sheet, dated 11/3/14, under the section "feeding ability" indicated that Resident A required supervision during eating. Resident A's Nursing Care Plan was reviewed on 2/11/15. The Nursing Care Plan for Dysphagia developed on 8/14/14, updated on 11/4/14, indicated that "...Problem: Dysphagia (difficulty in swallowing), risk for choking, aspiration (draw in or out using a sucking motion) or aspiration risk..." The Care Plan's "interventions" indicated, "... speech therapy, diet as ordered - mechanical soft, upright position for all meals, use small portions and small sips. Do not let resident gulp liquids, resident to remain upright 30 min (minutes) after meal and monitor for s/s (signs and symptoms of aspiration)..." These interventions were not implemented by the staff with supervision/assistance on 1/1/15. There were no evidence of how the facility would ensure that the intervention or the care plan would be implemented, so that Resident A complied with the intervention relating to teaching and provided support when the resident ate alone in his room. The Nursing Care Plan for Risk of Weight Loss, developed on 8/5/14 and updated on 11/5/14, indicated that "Problem: Risk of weight loss, depression, cognitive impairment...encephalopathy and risk for asp (aspiration) PNA (pneumonia)..." The Care Plan interventions indicated, "...Approach: ...offer assistance as necessary, allow sufficient meal time, allow sufficient time to chew and swallow..." These intervention plans were not implemented by the staff with supervision/assistance on 1/1/15. On 2/12/15 at 12:45 P.M., an interview and a joint medical record review for Resident A was conducted with the Director of nursing (DON). She acknowledged that the staff did not make sure that the Nursing Care Plans were implemented for Resident A. She acknowledged that Resident A was not supervised by the staff and Resident A did not have dentures during breakfast on 1/1/15. On 2/12/15 at 12:55 P.M., an interview with the licensed nurse (LN) 1 was conducted. She stated that Resident A was seen by speech therapy with a diagnosis of dysphagia. She stated, "I just reminded him to eat slowly and no talking while eating." She stated that she did not read the speech therapy notes. She stated she was unaware what speech therapy recommended. She acknowledged that the facility staff did not supervise Resident A during breakfast on 1/1/15. On 4/7/16 at 1:56 P.M., an interview with the current SLP was conducted. The SLP read the previous SLP assessments and weekly summaries and stated that the facility should have put Resident A into the Restorative Nursing Assistance (RNA) program with close supervision. She stated that the Resident A should not have eaten alone in his room without the facility staff present. She acknowledged that the previous SLP did not place Resident A on the RNA program at the time of discontinuation of the formal ST therapy in August 2014. The facility's policy and procedure, dated 1/1/12, titled "Feeding the Resident" indicated, "Policy: II. Trays are delivered by the Dietary staff to each nursing unit for residents not able to eat in the dining room. III. Resident who are able to eat outside their rooms are served in the dining areas...VI. Nursing Staff will: A. Be observant during the feeding process. Watch for signs of choking or anything unusual. B. Do not leave the resident unless it is an emergency. C. Continue feeding until the resident has had enough food or until the meal is finished..." The facility's policy and procedure, dated 1/1/12, titled "Restorative Nursing Program Guidelines", indicated that "Policy: A resident may be started on a Restorative Nursing Program when upon admission the facility with restorative needs, but not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy. Generally, Restorative Nursing Programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy..." The facility's policy and procedure, dated 1/1/12, titled "Eating and Swallowing" indicated that "...Purpose. To improve or maintain the resident's self-performance in feeding oneself food and fluid, or activities used to improve or maintain the resident's ability to ingest nutrition and hydration by mouth...Policy. Eating activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. Information will be provided to residents that teach techniques to improve the resident's safety and independence during mealtime...II. Techniques for Eating and Swallowing. A. The resident may need to be provided with frequent verbal instructions before and after each bite such as "chew," "suck," "hold your breath," "chin down," "swallow," "tilt your head forward," and so on..." The acute care hospital's discharge summary, dated 1/13/15, indicated that "... Cause of Death: 1. Acute cardiopulmonary arrest secondary to possible upper airway mechanical obstruction from food particle. 2. Aspiration pneumonitis (caused by inhaling materials such as vomit, food, or liquid). 3. Severe anoxic encephalopathy (brain tissue is deprived of oxygen and there is global loss of brain function). 4. Ventilatory (mechanical ventilatory support when the ventilatory and/or gas exchange capabilities of their respiratory system fail).-dependent respiratory failure ...Resident apparently eating and he choked on some food particle. The Resident was found unresponsive...abundant amount of food particle suctioned and dislodged from the upper airway. The Resident needed intubation and mechanical ventilation...hypoxemic (deprived of adequate oxygen) injury of the heart due to cardiopulmonary arrest...The Resident was made comfort care...Resident expired..." The Medical Examiner's External Examination Report, dated 1/8/15, indicated, "...Investigator's Report, on 1/1/15, [Resident A] was eating his breakfast. Minutes later he was found unresponsive. He was transported to the hospital where significant amount of food was suctioned from his airway. He remained unresponsive and possibly suffered a myocardial infarction (heart attack)...Based on the external examination findings and the circumstances surrounding the death, as currently understood, the cause of death is anoxic encephalopathy, due to choking (aspiration of food)..." The facility failed to ensure that Resident A was supervised and monitored when eating his breakfast on 1/1/15. The physician's H&P indicated Resident A was an aspiration risk (choking). The physician's orders indicated to continue aspiration precautions. The facility also failed to provide Resident A with a mechanical soft diet as required by Resident A's plan of care. As a result, on 1/1/15 at 7:50 A.M. a CNA found Resident A was lying on his bed and unresponsive. His skin color was pale and clammy, and he was pulseless. Resident A was transferred to the acute care hospital via 911 and died 4 days later at the hospital on 1/5/15. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical hard would result. |
| 090000061 |
Golden Hill Subacute & Rehabilitation Center |
090013028 |
B |
13-Apr-17 |
FLSB11 |
7000 |
Federal Regulation, Long Term Care Facilities F 323, section 483.25 (h) Accidents.
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
Based on observation, interview, and record review, the facility failed to ensure that the facility was free of accident hazards and that a safe environment was provided for one of three sampled residents (Resident 2). An uneven level of two adjoining (touching) surfaces, a concrete pavement and a sand pit, in the patio was a hazard to residents. This failure resulted in Resident 2 sustaining serious injuries to include a fractured femur (thigh bone), a fractured cervical vertebra (neck bone), and a head laceration (deep cut).
Findings:
On 10/13/16 at 8 A.M., an entity reported incident was investigated regarding Resident 2, who had a fall on 10/4/16.
Resident 2 was readmitted on XXXXXXX 16 with diagnoses which included a history of falling and difficulty in walking, per the facility's Admission Record. The minimum data set assessment (MDS), Section C, Cognitive Patterns, dated 10/14/16, was reviewed. It indicated Resident 2 had a BIMS (Brief Interview for Mental Status) coded (score) of 15. According to the Resident Assessment Instrument (RAI) 3.0 manual for MDS, a score of 13-15 indicated that the resident was cognitively intact.
An interview with the director of nursing (DON) was conducted on 10/13/16 at 8:30 A.M. The DON stated Resident 2 fell while smoking on the patio on 10/4/16 at 3:35 P.M. She stated the housekeeper supervisor (HS) witnessed Resident 2 trip, fall forward, and hit her head on the pole. The DON stated Resident 2 was sent out of the facility on 10/4/16 by calling 911. The DON stated Resident 2 returned to the facility on 10/7/16 after she had surgery and now wore a neck collar. The DON further stated, "We put a fence now to prevent the problem." The DON acknowledged that the uneven level of the two adjoining surfaces, a concrete pavement and a sand pit in the patio was an accident hazard.
An observation of Resident 2 was conducted on 10/13/16 at 9:10 A.M. Resident 2 sat in a wheelchair and propelled herself out onto the smoking patio. She wore a neck collar.
A concurrent interview and observation of the smoking patio was made with the DON on 10/13/16 at 9:12 A.M. The smoking patio had a cement porch, a fence, and just beyond the fence a lower level of sand, not even surface level. The lower level of sand area was accessible, by walking around the fence, which was done with the DON while touring the area. The porch also had four poles which supported an awning (covering that provided shade). The DON acknowledged that the facility's environmental hazard of an uneven level of the two adjoining surfaces, a concrete pavement and a sand pit, was not fenced off to prevent an unnecessary/avoidable accident, on 10/4/16.
An interview with the HS was conducted on 10/13/16 at 9:20 A.M. The HS stated that on 10/4/16 around 3:20 P.M., Resident 2 asked for another cigarette. She was standing in the sand area trying to step up to the cement porch area, tripped, and fell. The HS stated Resident 2 hit her head on the left front steel pole of the porch awning. The HS stated that Resident 2 complained of hip pain and her head was bleeding. The HS stated two licensed nurses arrived to the patio and tended to Resident 2.
An interview with licensed nurse (LN) 1 was conducted on 10/13/16 at 9:40 A.M. LN 1 stated that on 10/4/16, during change of shift report, HS 1 called the nurse's station and said someone fell. LN 1 stated, "I and another nurse, (LN 2's name), went to smoking patio. (Resident 2's name) was on the floor. There's an overhang/pole and she was holding her upper body up using the pole. Her whole body was around the pole. Her lower body was completely on the floor, but upper body up 'cause she was holding on to the pole. There's a dirt pit. She said she was trying to walk around the pole... she said she slipped off of the pavement. She was bleeding on her forehead... She didn't initially complain of pain but started holding her neck. She didn't have facial grimacing. She later complained of hip pain. She was brought to her room. Charge nurse notified and received order from doctor to send her out."
An interview with LN 2 was conducted on 10/13/16 at 10 A.M. LN 2 stated, "It was during change of shift, 3 o'clock or so (on 10/4/16). I was giving a report. Charge nurse let, I believe (LN 1's name) was charge, me know an incident happened downstairs and needed help. (LN 1's name), I, and an oncoming nurse (name), went to smoking patio. I saw (Resident 2's name) sitting to her right side on edge of cement/dirt area. I saw bleeding on forehead."
An observation and interview with Resident 2 on 10/13/16 at 12:50 P.M. was conducted. Resident 2 was lying in bed in her room. She was observed with a sutured cut on the top center part of her forehead. Resident 2 stated she was getting a cigarette and stepped off of the (patio) platform into the sand area. She stated when she came back to step onto the (patio) platform, she misjudged the depth and fell. Resident 2 stated she broke her neck, femur, and had a head laceration (deep cut) with seven to nine stitches. Resident 2 stated she was sent to the hospital and went to surgery.
The clinical record review for Resident 2 was conducted. A care plan for Resident 2, dated 4/25/16, indicated "This resident is (Moderate) risk for falls." Per the care plan a goal for the resident was to "be free of minor injury." The Progress Notes for resident 2, dated 10/4/16 at 3:59 P.M., indicated "Resident stated she fell on pavement/edge next to sand pit located next to smoking area while she was trying to walk around the pole. Resident stated "if that ledge wasn't there, I wouldn't of tripped" Resident expressed frustration on depth of sand pit next to pavement..." The Assessment Summary Notes for Resident 2, dated 10/4/16 at 4:16 P.M., indicated "IDT (interdisciplinary team) Fall Investigation notes ... Resident did not see the step off at the end of concrete sidewalk, leading to sandy patch. Conclusion (Including new interventions)... Smoking participants will be reminded of smoking break safety and need to stay within smoking area (not beyond awning pole). Sandy patch area next to concrete sidewalk will be filled so that sand is leveled with pavement so that there is no step off..."
The hospital discharge summary for Resident 2, dated 10/7/16, indicated "diagnosis- fall, fracture of femur, and cervical spine fracture... head laceration (deep cut) sutured on 10/4/16."
The facility's policy and procedure titled Fall Management, dated 7/08 was conducted. This policy indicated, "Policy: It is the policy of SNF (skilled nursing facility) that our physical environment remains as free of accident hazards as possible." |
| 090000086 |
Granite Hills Healthcare & Wellness Centre, LLC |
090013196 |
B |
24-May-17 |
N2VH11 |
8691 |
Federal Regulation, Long Term Care Facilities F 323, section 483.25 (h) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility failed to ensure the environment was safe for one of two sampled residents (1), when Resident 1 was hit in the head with a glass light bulb cover (fixture) by another resident (2). This failure resulted in Resident 1 obtaining a laceration (deep cut) to her head which affected her health and well-being.
Findings:
On 9/22/16 at 2:15 P.M., an entity reported incident was investigated regarding a resident to resident physical altercation. The Department received two reports from the facility. The first report of suspected dependent adult/elder abuse was completed by the director of nursing (DON). The report indicated that Resident 1 pulled Resident 2's hair on 9/19/16 at 10 P.M. The second report indicated that Resident 2 hit Resident 1's head on 9/20/16 at 2:15 P.M.
Resident 1 was admitted to the facility on XXXXXXX12 with diagnoses that included dementia (impaired memory and thinking that interferes with daily functioning) and major depressive disorder (brain disorder in which a person has a loss of interests that affects daily life) per the facility's Face Sheet. A review of Resident 1's history and physical, dated 4/27/16, was conducted. This document indicated, "does not have capacity to understand and make decisions."
Resident 2 was admitted to the facility on XXXXXXX16 per the facility's Face Sheet. There were no diagnoses indicated. A review of Resident 2's hospital records, dated 9/14/16, was conducted. The hospital's face sheet indicated, "...Service Psychiatric...Reason for visit Bipolar (mood disorder in which a person has depressed lows and manic highs). The psychiatric evaluation indicated, "...The patient admitted on an emergency basis for one of numerous psychiatric hospitalizations after being placed on a 5150 (authorization to involuntarily confine a person suspected to have a mental disorder that is a danger to self or others), danger to self as per (name of doctor)... Diagnostic Impression: Axis I (one): Schizoaffective disorder (mental illness that affects a person's ability to think, feel, and behave clearly and mood disorder symptoms)... depressed (brain disorder in which a person has a loss of interests that affects daily life) with psychosis (mental disorder in which a person has a disconnection from reality)..."
An interview with director of nursing (DON) 1 was conducted on 9/22/16 at 2:15 P.M. DON 1 stated certified nursing assistant (CNA) 1 heard a loud noise in a resident's room on 9/20/16. She stated CNA 1 checked Resident 2's room and saw blood on Resident 1's face. DON 1 stated an attempt to interview Resident 1 was made, however Resident 1 could not remember what happened. DON 1 stated Resident 2 was interviewed and Resident 2 admitted she hit Resident 1. DON 1 stated Resident 1 was currently in her room and Resident 2 was no longer in the facility. She stated CNA 1 was not available because CNA 1 was not scheduled to work.
An observation and interview of Resident 1 was conducted on 9/22/16 at 2:25 P.M. Resident 1 was observed lying in bed in her room. She had a laceration with stitches (sutures- holds the skin together while a wound heals) on her head. Resident 1 stated she did not know of an incident where another resident hit her, but that she had pain on her head.
A concurrent observation and interview with the Administrator (Admin) and the maintenance staff (MS) was conducted on 9/22/16 at 2:30 P.M. The room where the incident took place was observed. The Admin acknowledged the light bulb cover above the sink in the residents' room was glass [breakable] and stated it could be unscrewed [unsecured, anybody can access and remove it]. The light bulb cover was unscrewed by turning the cover by hand and the MS stated, "You just unscrew it."
An interview with the MS was conducted on 9/22/16 at 3:15 P.M. The MS stated, "I plan to put a screw, so the fixture cannot be taken off by turning (by hand)."
A telephone interview with CNA 2 was conducted on 12/8/16 at 3:45 P.M. CNA 2 stated she was with her assigned resident when she heard a glass break. CNA 2 further stated, "My other co-worker checked to see what happened. I heard my co-worker yell for me... I walked into the resident's room." CNA 2 stated Resident 1 was standing right in front of the sink with blood running down her face. She further stated Resident 2 was a few feet away, next to the restroom door. CNA 2 stated, "(Resident 2's name) said (Resident 1's name) talks to herself in the mirror and wouldn't move. (Resident 2's name) said she unscrewed the light bulb fixture and hit (Resident 1's name)... I heard they got into an argument the day before. I was never assigned to those patients however."
A concurrent interview and record review with LN 1 was conducted on 2/10/17 at 8:48 A.M. LN 1 stated she was at the nurse's station on 9/20/16 at 2:15 P.M. She stated, "I heard glass breaking. So, I went to the room (resident's room). Two CNAs were already there (CNA 2's name) and possibly (CNA 1's name). I think (CNA 1's name) was assigned... The CNAs were looking at blood coming from (Resident 1's head). I said what happened? (Resident 2's name) was in bed and said she (Resident 2) unscrewed the light fixture and told me she hit (Resident 1's name) on the head. "LN 1 further stated she did not recall Resident 1 pulling Resident 2's hair on 9/19/16.
A concurrent interview and record review with CNA 1 was conducted on 2/10/17 at 9:11 A.M. CNA 1 stated, "9/20/16 during report I was told by (LN 1's name) of the pulling of the hair incident the night before (between Resident 1 and Resident 2). I was told to really focus on the patients, but we already do q (every) 15 minute checks (visualizing and documenting the location of a resident). (Resident 1's name) wanders into other rooms. So, I was told to monitor and try to catch her if/when we see her." CNA 1 further stated after the hair pulling incident, a room change was done but Resident 1 was use to her original room. CNA 1 stated on 9/20/16, she was walking out of the nurse's station and heard glass breaking. CNA 1 further stated she started checking rooms and saw Resident 1 and Resident 2 pulling each other's hair, in (Resident 1's original room number) near the bathroom door. CNA 1 stated, "I tried to separate (Resident 1 and 2), saw (Resident 1's name) bleeding from the head. Yelled for help. (CNA 2's name) came to help. She ran out to get (LN 1's name)." CNA 1 stated Resident 1 was sent out to the hospital and she did one-to-one supervision of Resident 2. CNA 1 stated she spoke to DON 1 that day about the incident, but not again after that.
A review of Resident 1's hospital discharge summary, dated 9/20/16, was conducted. This document indicated, "...Chief Complaint: ...HEAD LAC (laceration)..."
A review of Resident 2's transfer record, dated 9/20/16, was conducted. This document indicated. "Resident had angry outburst, hit another resident (with) a glass vase to the head resulting in major injury. Police were called. Resident will need psych (psychiatric) eval (evaluation) & (and) tx (treatment)... Transferred to (name of hospital)..."
An interview with the Admin was conducted on 3/29/17 at 10:11 A.M. The Admin acknowledged the environment should be safe for residents.
A review of the facility's policy and procedure titled Safety Committee- Composition and Duties, dated 1/1/12, was conducted. This policy indicated, "...Maintain Facility grounds in a manner to allow for the safety of resident and Facility staff..."
The facility failed to ensure that their written policy and procedure pertaining to Safety Committee duties and responsibilities was implemented by maintaining an environment safe for residents, especially those residing on the secured unit where residents have impaired cognition and mental illness diagnoses. This failure resulted in Resident 1 being hit by Resident 2 with a glass light bulb cover in which Resident 1 sustained a serious injury of a head laceration. Resident 1's health was compromised and her highest level of well-being was not maintained.
The above violations, either jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and potentially for other residents at the facility. |
| 010000024 |
Granada Rehab & Wellness Center, LP |
110008826 |
B |
02-May-12 |
6LI111 |
4921 |
1418.91(a) Health and Safety Code (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) Health and Safety Code (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of resident abuse (Resident 1) to the State survey and certification agency, with the potential for continuing abuse towards Resident 1. Resident 1's clinical records were reviewed on 12/22/10, 4/23/11, and 12/7/11. She had diagnoses including dementia, depression, and anxiety. Nurses notes, dated 12/9/10, indicated that at 12 noon, Family Member A pointed out bruising on Resident 1's right arm and a skin tear between the resident's left thumb and first finger. Family Member A "stated they were not there last night @ 8 p.m. when she left" the resident. The notes indicated that the resident's aide "said she did not see them (bruises and skin tear)" on the resident when she assisted the resident to the bathroom earlier in the morning.Nurses notes, dated on the evening shift of 12/10/10, indicated the resident returned to the facility with Family Member A. Nursing "noted bruises of R (right) hand and R forearm. Also noted some bruising on L (left) hand." Additional notes, dated 12/10/10, indicated that it had been reported Resident 1 was hitting her aide that morning. "This fact should be considered as one possible explanation for pt. (patient's) bilateral hand bruising." Documentation, received 12/10/10, indicated Resident 1 had bruising on the outside of both hands, partial bruising up to the elbow on the right hand, and possible finger indentation bruising on the right arm. During a telephone interview, on 12/21/10 at 11:45 a.m., Ombudsman B stated that Resident 1's family member contacted her, on 12/10/10, with concerns about care at the facility leading to the bruising. Family Member A told Ombudsman B that there had been no bruising on Resident 1 on the previous evening (12/8/10) but there was bruising present at noon on 12/9/10, when the family member took the resident home for a visit. The family member told the Ombudsman that she was fearful to take the resident back to the nursing home. Ombudsman B visited Resident 1 at the family member's home on 12/10/10. Ombudsman B stated the resident's hands were "very, very bruised. The right hand was bruised up to the elbow, pretty black. The right side of the left hand was very black.The portions between the thumbs and fingers of both hands were the worst. It looked like she had been grabbed."Ombudsman B stated that she spoke to the administrator on 12/10/10 and told her of the following concerns: a. It looked like the resident had been grabbed. b. The family member was concerned that perhaps staff was doing this to the resident. c. Family Member A refused to return the resident to the facility because of fear that staff was mistreating Resident 1. During a telephone interview, on 12/28/10 at 9:20 a.m., Family Member A stated that she was a frequent visitor and on the evening of 12/8/10, Resident 1 had no visible bruising, but the resident's hands were bruised when she took Resident 1 home for a visit on 12/9/10 at noon. "They were black. All up her arms." Family Member A stated that when she asked staff what had happened, staff did not know. "Nobody knew what happened and that scared me more than anything." Family Member A suspected that the bruises were caused by staff and stated that she was "fearful" to take the resident back to the nursing home and kept her overnight. She stated she spoke with Ombudsman B, who visited Resident 1 at Family Member A's home, on 12/10/10, and pictures were taken of the bruising. Review of the photographs, received 12/30/10, revealed: a. Bruising between the thumb and forefinger of the right hand and two bruised and depressed areas on the underside of the right wrist resembling finger marks. b. Bruising between the thumb and forefinger of the left hand and bruising on the left inner hand near the wrist. c. Bruising on the back of the right hand and multiple bruised areas above the right wrist, some appearing depressed and resembling finger pressure areas.During interview, on 12/7/11 at 4:05 p.m., the administrator stated that it was the facility practice to report allegations of abuse and injuries of unknown origin to the State licensing and certification agency. She stated that the facility did not report the Ombudsman's allegation of suspected abuse regarding Resident 1 to the State licensing and certification agency. The facility failed to to report the allegation of abuse, towards Resident 1, to the State licensing and certification agency, with the potential for continuing abuse. Under Health & Safety 1418.91, failure to report abuse results in a Class B citation. |
| 010000646 |
GENEVIE DREAM HOME, INC. |
110009367 |
B |
27-Mar-14 |
IJN711 |
10387 |
A008 Welfare & Institution Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure one client (Client 1), was free from harm and neglect, when the facility failed to provide care and services to prevent the development of a Stage IV (4) decubitus ulcer (pressure sore), which resulted in hospitalization. This failure led to the need for multiple surgeries and wound treatment. The facility is a six bed Intermediate Care Facility for the Developmentally Disabled-Habilitative, licensed to provide care and services to people with varying degrees of developmental disability and mental retardation. Client 1 was dependent upon the facility for her basic health care needs, including skin care. On 2/27/12, review of an, "Special Incident Report," dated 2/24/12, and received from the facility on 2/27/12, indicated that the facility nurse was notified of a, "sore" on Client 1's buttocks, on 2/21/12, and indicated that the Physician Assistant recommended further medical attention, as there was necrotic (dead) tissue at the wound base. The Physician Assistant started Client 1 on, "Cephalexin," an antibiotic. On 3/1/12, a complaint was faxed to the Department which indicated Client 1 was admitted to a long term care facility with a stage IV (four) pressure ulcer on her left buttock, which had required surgical intervention. On 2/29/12 at 3 p.m., during a telephone interview, Facility Nurse C stated that staff was supposed to do daily skin checks, and that staff did not point the sore out to him until it was a small ulcer. Facility Nurse C stated that in the last few months, Client 1 had become wheelchair dependent, and was deteriorating fast. Facility Nurse C stated that he thought the staff was not trained for the level of care that Client 1 needed. During an interview, on 2/29/12 at 3:20 p.m., DCS (Direct Care Staff) A stated that after Client 1 developed the pressure sore, staff knew that they should turn Client 1 every two hours. DCS A stated that when staff tried to lift Client 1, Client 1 yelled a lot, did not want to be moved, and liked to stay in one spot. DCS A stated that staff did body checks every morning, when the clients' bathe, and that he saw the pressure sore first when he transferred Client 1 to the toilet. DCS A stated that it [the sore] was about two inches wide and round, and he took a picture and text it to the nurse. DCS A stated the sore had peeling skin, and in the middle of the sore was black tissue.During an observation and interview, on 2/29/12 at 3:25 p.m., DCS B brought out a vinyl, gray wheelchair which DCS B stated was used by Client 1. There was no padding or cushion on the wheelchair.During an interview, on 2/29/12 at 3:27 p.m., DCS A stated that another client had padding on the wheelchair but not Client 1. DCS A stated that after the bedsore developed, they placed a pillow and a pad on the wheelchair.During an interview, on 2/29/12 at 3:30 p.m., DCS B stated that in the last year, Client 1 started to go downhill, and maybe for a little more than four months Client 1 had been in a, "house wheelchair." DCS B stated there was no padding in the wheelchair. Review of the Nursing Progress notes, dated 2/21/12, indicated that staff had informed the facility nurse that Client 1 developed a lesion on her left buttock, and on 2/27/12, Client 1 was taken to the acute care hospital for more extensive wound care. The notes indicated that the left buttock pressure sore was greater than one inch in circumference, with thick scales in the center of the wound. The 2/27/12, notes indicated that Client 1 was admitted to the hospital for evaluation and treatment of the left buttock decubitus. Review of the, "Health Care Plan," dated 12/15/11, confirmed that the plan did not include skin integrity, however there was a, "Short Term Health Care Plan," dated 6/23/11, with interventions to change positions every two hours at night, and during the day Client 1 should stay up and be moved at least every two hours and use the wheelchair only when absolutely needed. The plan indicated to keep Client 1 walking to her full extent. The care plan indicated that Client 1's skin was clear from breakdown on 7/15/11. There was no new care plan developed or revised for the prevention of skin breakdown, since the short term care plan was developed on 6/23/11. During an interview, on 6/15/12 at 11:15 a.m., the House Manager stated that staff had overlooked the skin ulcer because of where it was located, and also stated that Client 1 yelled and screamed when staff moved her because she was scared. The House Manager stated that in the past year, Client 1 did not want to get out of the wheelchair. The House Manager stated that the decline in her condition was discussed with the physician and caseworker. The House Manager stated that Client 1 was in her wheelchair most of the day, did not feel like getting up, and it freaked her out if staff tried to move her. The House Manager indicated that the nurse told staff to turn Client 1 every two hours, and that staff did a body check two times a day. The House Manager indicated he thought staff missed seeing the pressure sore.During an interview, on 3/30/12 at 11:30 a.m., Acute Care Hospital Nurse D stated that Client 1 came to the hospital with a Stage III (three), possible Stage IV (four) pressure ulcer and had to have three surgeries, under anesthesia, to treat the buttock wound. Review of the, "Admitting History and Physical," dated 2/27/12, indicated that Client 1's chief complaint was a left buttock ulcer, that had developed into a Stage three or four ulcer, which was not treatable in an office setting. The report indicated that Client 1 had been weak, not eating or drinking well, and the note indicated that Client 1 had a, "smoldering," problem in her left buttock now for some time and the, "duration was unclear." The note indicated that Client 1 needed admission for further evaluation and treatment of this problem, such as surgical debridement, under possible anesthesia. Review of the operation reports indicated that on 2/28/12, there was necrotic tissue down to the bone, which was excised from the left buttock decubitus. Another debridement (removal of necrotic tissue) for the ulcer was done on 3/5/12, with packing of the wound, and a physician dictated report on 3/12/12, indicated another debridement was done for residual necrotic tissue for the stage IV decubitus ulcer.During an observation and interview, on 3/30/12 at 12:05 p.m., Acute Care Hospital Nurse D prepared to do a dressing change on Client 1's left buttock wound. The wound on Client 1's left buttock appeared to be red, with a center area that contained a whitish colored material. Acute Care Hospital Nurse D measured the wound and stated that the wound was 3 cm deep by 5.25 cm in length and 3.5 cm in width. Acute Care Hospital Nurse D stated that there was a whitish slough in the middle of the wound, and that the ulcer was deep, down to the bone. Acute Care Nurse D stated that they did a wet to moist dressing change three times a day as part of her treatment, as she had a chronic infection. During a telephone interview, on 6/15/12 at 11:40 a.m., the QMRP (Qualified Mental Retardation Professional) stated that the facility was not prepared for how soon Client 1 deteriorated, and that the facility was not a nursing facility that could handle the care she needed. On 6/15/12, review of, "Integumentary or Skin Care - Pressure Sores," facility in-service material, undated, located in the staff in-service book, indicated that one of the most serious threats to skin integrity was pressure, especially for the immobile client. The in-service material indicated that the pressure sores began by redness of the skin caused by impaired circulation to an area, usually over a bony prominence like heels, elbows or hips. The in-service material indicated that if left untreated, the site would gradually blister and spread to deeper tissue and finally ulceration and necrosis (death of tissue). The in-service material indicated that it was not uncommon for untreated pressure sores to erode the tissue to the bone. Review of the, "Individualized Contractor Agreement," signed 5/20/03, by the facility nurse, indicated that the facility nurse provided nursing service in accordance to the needs of the client, which included training of staff in personal hygiene and developing and implementing a written care plan for each client. Review of the Disability Rights California (DRC) protection and advocacy agency report, dated August 2003, titled, "Abuse and Neglect of Adults with Developmental Disabilities," indicated that individuals with developmental disabilities were members of a vulnerable population, less able to defend themselves against abuse or neglect. The victims had cognitive deficits and were unable to recognize their rights to safety and protection. This population were dependent on others to assist them with activities of daily living and personal care. Neglect was defined as failure of person caring for a dependent adult to assist with personal hygiene, provide medical care for physical and mental health needs, and to protect the client from health and safety hazards. The failure of the facility to ensure the basic needs of Client 1, including skin care and skin breakdown preventive care, led to neglect and harm. Client 1 was prone to skin breakdown, and this failure affected Client 1's health and welfare, when she developed a stage IV pressure ulcer, requiring surgical intervention and hospitalization. This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000646 |
GENEVIE DREAM HOME, INC. |
110009619 |
B |
13-Mar-14 |
74K211 |
14210 |
A008 Welfare and Institution Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure that one of six clients (Client 1) was free from injury, when Client 1, who had a history of falls, had three falls in one month, 11/5/10, 11/13/10, and 11/17/10. Client 1 sustained a fractured pelvis as a result of the 11/17/10 fall. The facility failed to provide substantial investigations of the cause of Client 1 falls, develop and implement policy and procedures, regarding protection of clients who were at risk for falls, and develop and implement plans of care, with measurable interventions, which potentially could have prevented Client 1 from sustaining a pelvic fracture as a result of the 11/17/10, fall.The Department received a self-reported notice that on 11/17/10, Client 1 had fallen in the bathroom. On 11/18/10, Client 1 was taken to a local acute care hospital for evaluation. X-rays taken indicated Client 1 sustained an acute pelvic fracture, and three vertebrae were also fractured.Client 1's clinical record was reviewed, and indicated Client 1 was admitted with diagnoses that included mildly developmentally delayed and Parkinson's Disease. A physician's assessment, dated 8/25/11, was included in Client 1's record, indicating that Client 1 was able to walk, but was reported to have an unsteady gait. Client 1's clinical record review included her Comprehensive Functional Assessment (CFA), completed on 8/2/10, by the QMRP (Qualified Mental Retardation Professional). The assessment indicated Client 1 had a history of falls, and based on a physical therapy evaluation, Client 1 had a hard time turning and getting up from a seated position. "The staff have encouraged her to tell one of the staff when she is about to get up." The, "toileting," assessment indicated Client 1 had to be watched closely in the bathroom, and staff was to remind her to be careful. Client 1 was also evaluated by an eye physician, who indicated she had, "drug induced cataracts," had glaucoma (a common cause of blindness), and was to wear +3.00 reading glasses for vision, and that she had recently been prescribed fosamax (to prevent osteoporosis - a brittle bone condition). A Monthly Nursing Review, dated 10/21/10, and signed by the Licensed Nurse, indicated that Client 1 required supervision to prevent falls and injuries. Client 1's record, regarding the self- reported incident of 11/17/10, indicated that Client 1 had also sustained an injury in the evening, on 11/5/10 and 11/13/10. A physician's note indicated that on 11/5/10, Client 1 got up from her bed during the evening, opened the facility door to the lower level of the house, and fell down a flight of stairs. The stairs were approximately ten steps. Client 1 was examined by her attending physician. The report indicated she had abrasions to her right shin, right foot, and upper-mid back, along with ecchymosis (bruising) to her left thigh. An Injury Investigation form, dated 11/5/10, indicated Client 1, "fell on stairs," and the investigation indicated, "injury was accidental, no evidence of abuse." An Injury Assessment form, dated 11/5/10, indicated Client 1 had numerous superficial abrasions on both lower legs, and her back had bruises. There were also two bumps on her scalp, but no evidence of fractures. The report also indicated there had been a power outage. Client 1 had been assessed by the Licensed Nurse, who reported no serious injuries. Although a form titled, "Injury Investigation," was completed, there were three individuals interviewed, regarding the fall, the results of the interviews were not documented and the information documented was inconclusive of the time of the injury, who was available to assist the client at the time of the injury, if the injury was witnessed and whether or not the client was being monitored or supervised. The report also failed to provide documentation regarding the attempts to determine why the client approached the wrong door, which led to the fall. There was no documentation to support why Client 1 was not being monitored or supervised to ensure her safe well-being in spite of Client 1's medications, conditions, and history of multiple falls. On 6/3/11 at 2:55 p.m., the House Manager was interviewed. He stated that the staff who were present during Client 1's falls were no longer working at the facility. He stated a staff member stayed on the couch upstairs to assist any client who might need help at night. The couch was approximately 20 feet from Client 1's bed, and the bathroom was across the hall from Client 1's bedroom. The House Manager stated he was called at 9 p.m., the evening of 11/5/10, with news that there was an electricity outage. He indicated that he was not at the facility when Client 1 fell, and stated Client 1 got up from her bed, went to the wrong door, fell down the stairs, and sustained bruises. There were no investigative procedures performed to determine what could be done in the future, to prevent this from recurring. There was no intervention plan to monitor or supervise Client 1 during her sleep hours to protect her safety and prevent further falls.Client 1's clinical record contained an Unusual Occurrence Report, dated 11/17/10, which indicated that Client 1 had fallen again in the bathroom and a new bruise was noted on her lower abdomen. Client 1 complained of pain in the right buttocks area. An appointment with her physician was made for the following day, on 11/18/10. The record indicated that upon examination of Client 1, the physician referred her to the local acute hospital's Emergency Room. X-rays were taken and revealed Client 1 sustained a pelvic fracture. The X-rays also revealed Client 1 had compression fractures of Lumbar 1, Lumbar 3, and Lumbar 4, with undetermined age. The acute care hospital's Discharge Summary, dated 12/15/10, indicated, "She [Client 1] also is very non-compliant with safety instructions and is considered to be at high risk for further falls." Client 1 was discharged and transferred back to the facility on 12/15/10. On 10/11/12 at 9:15 a.m., the Licensed Nurse was asked for the facility's policy regarding clients' fall prevention. In a letter, dated 10/15/12, addressed to the Department, the Licensed Nurse indicated, "We do not have a fall policy since the only person prone to falls has been [Client 1's name]." Although an Unusual Occurrence Report was completed by the Licensed Nurse for the 11/17/10 fall, the report did not contain interviews, the location of where Client 1 had fallen in the bathroom, and in what position she fell, to possibly determine the cause of the fall and possibly prevent recurrent falls. The Licensed Nurse stated he had not done an investigation after the 11/17/10 fall.Client 1's Health Care Plan, for the period of 12/15/09, and signed by the Licensed Nurse on 12/15/09, indicated an identified health concern for potential for injury due to unsteady gait and muscle weakness. The Health Care Objective indicated that Client 1 would not sustain injuries due to falls, or if she did sustain an injury, she would be medically evaluated within a reasonable period of time. The, "Interventions," included: 1) That Client 1 would be assisted, as necessary, by staff, when she appeared to be unsteady on her feet. Staff would instruct her to, "be careful," when she was walking in an unsteady manner; 2) If she fell, staff would observe for any injury including minor abrasions, bruises, and complaints of pain. If staff noted any type of injury, they would notify the RN Consultant. If serious injury was suspected, and the RN Consultant was not immediately available, they would attempt to notify the physician or the Emergency Department; and 3) Client 1 would receive physical therapy evaluations on an as-needed basis, on the recommendation of the physician. The care plan failed to mention that Client 1 was having falls during sleep hours. There were no interventions on how the facility staff would monitor or supervise Client 1, to prevent falling during those hours of her sleep, if she decided to go to the bathroom. Although a door alarm was installed next to her bed, Client 1 would not always use the alarm. The facility's Health Care Plans (HCP) policy, revised 5/07, indicated that the HCP would identify the medical and emotional needs of each client and specify interventions to be utilized, in the event signs or symptoms of an identified health concern arose. The Health Care Plans would be written by the RN Consultant at any time during the clients' residence, should their health status change, to show immediate knowledge of the problem and the implementation of nursing care to overcome it. "It will be the responsibility of the RN to communicate with direct care staff any special concerns or changes in health status to assure client's needs are met." Client 1's Health Care Plan, dated 12/15/09 was not revised until 12/15/10, after the 11/17/10, fall which caused her to fracture her pelvis.At 8:45 a.m., the QMRP was interviewed about Client 1 having an unsteady gait, and whether or not Client 1 had any Physical Therapist recommendations regarding her falls. Although the CFA, dated 8/2/10, indicated that Client 1 had been referred for physical therapy assessment on 11/19/08, due to concerns about her unsteady gait, there was no Physical Therapy report in Client 1's record. The QMRP confirmed Client 1 did not have any physical therapy prior to the 11/17/10 fall. The facility thought it had her falls managed, and that by teaching her to use the alarm button, she could learn that responsibility.On 11/15/10, the Safety Committee Minutes, dated 2/3/11, were reviewed and indicated that on 11/18/10, Client 1 had been sent to the acute care hospital due to a fractured pelvis, and the recommendations were to continue to monitor her due to her fall risk. On 11/15/12 at 8:55 a.m., the QMRP was asked what the responsibilities of the Safety Committee were. He stated they discussed things that needed fixing, repair work, special incidents, injury logs, and anything that related to the safety of the clients. He stated he did not think the facility had a policy on what the Safety Committee's responsibilities were. The Human Rights Committee meeting minutes, dated 2/3/11, indicated that a lock had been placed on the door leading to the downstairs, to prevent any injury to the clients who may attempt to walk downstairs, and also indicated that Client 1 was now using a wheelchair and a seatbelt while seated in her wheelchair. The minutes failed to contain any discussion regarding how the facility would protect Client 1 from future falls.On 11/15/12 at 8:50 a.m., the QMRP was questioned why there was not any discussion in the Human Rights Committee meeting regarding the safety of Client 1. He stated that during the Human Rights Committee meetings, those present discussed issues and topics of what was going on, and they really did not determine what to do in detail. The facility's undated policy, regarding the Human Rights Committee, indicated, "It is the facility's policy to establish and support a Human Rights Committee that is responsible for assuring that client rights, as specified in the Welfare and Institutions Code, Sections 4502 through 4505 and Sections 50500 through 50550, Title 17, California Administrative Code, are safeguarded." The policy further indicated the committee would meet quarterly to, "review treatment modalities used by the facility where the client human rights or dignity is affected;" On 11/15/12 at 8:55 a.m., the Licensed Nurse was asked if the facility had a policy on how the facility would ensure the safety of the client. He stated this was in the client's bill of rights. Copy of the facility's, "Patient bill of Rights," indicated in paragraph 4502, that the patient has a right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.On 10/11/12 at 10:10 a.m., the Licensed Nurse was questioned what the facility had done after Client 1's 11/17/10 fall, to prevent future falls. He stated Client 1 was in a wheelchair and would probably not fall, and then stated that she was still at risk especially at night. An Injury Investigation, dated 11/27/11, in Client 1's record, indicated that Client 1 had another fall in her bedroom early in the morning, attempting to go to the bathroom. Client 1 lost her balance, fell to the floor, and hit her face on the carpet.Client 1's high risk for falls, due to a history of multiple falls, had been ongoing during her stay at the facility. Without development and implementation of facility policy's to protect the clients, it was difficult for the facility to provide appropriate interventions to protect the safety of clients. The facility's policy regarding care plans, and Human Rights had not been followed, and the facility had no policy for prevention of falls for their clients. Although the facility staff were completing forms titled, "Injury Investigation," the forms did not contain sufficient documented information required to determine the circumstances surrounding the cause of a fall, and therefore staff were unable to provide interventions necessary to protect the clients from harm. Failure to have interventions in place to prevent Client 1 from sustaining a pelvic fracture, as a result of the fall of 11/17/10, had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000034 |
Golden Living Center - London House Sonoma |
110009712 |
B |
06-Feb-13 |
VHOX11 |
1946 |
1418.21 (a)(1)(B) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (B) An area used for employee breaks. 1418.21(b) Health & Safety Code 1418 (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2. The facility violated the regulation when the facility failed to post the facility's overall rating in an employee's break room used by the facility staff. This failure resulted in the potential for staff not being informed of the facility's overall rating. Findings: During concurrent observation and interview with Administrative Staff A on 1/8/13 at 4:35 p.m., the facility's overall rating could not be located in the employee break room. Administrative Staff A confirmed the posting was not in the break room. Administrative Staff A stated he would check with "the payroll girl" who does the postings on facility bulletin boards. During an interview on 1/8/13 at 4:50 p.m., Administrative Staff A stated the payroll employee had left for the day and he would ask her about the posting the next day. Administrative Staff A stated, "Is it required in the break room? I couldn't find that in the SOM." Administrative Staff A was told that the requirement could be found in the California Health & Safety Code. During an environmental tour on 1/9/13 at 10:20 a.m., the overall facility rating was not observed in the employee break room. |
| 110000077 |
Greenfield Care Center of Fairfield |
110010906 |
B |
26-Sep-14 |
553511 |
5007 |
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.The facility failed to report an allegation of employee to resident abuse to the Department within 24 hours, with the potential for ongoing abuse of the resident. Resident 1 was 91 years old and had diagnoses that included dementia, English was Resident 1's second language. A Fall Risk Assessment, dated 5/1/14 indicated Resident 1 was at high risk for falls due to intermittent confusion, poor safety awareness and balance problems when standing and walking. During an interview, on 7/23/14 at 10:45 a.m., Licensed Staff A stated that on 7/19/14 about 10:45 or 11 a.m., he heard yelling in a foreign language coming from the dining room. Licensed Staff A stated when he entered the dining room Resident 1 was shouting in her native language, and he heard Management Staff T tell Resident 1 she had to leave the dining room. Licensed Staff A stated he saw Management Staff T grab Resident 1's walker to guide Resident 1 out of the dining room. When Licensed Staff A assisted Resident 1 back to her room, Resident 1 said (Management Staff T) was mean and treated her like a baby. When Licensed Staff A spoke with Management Staff T, she said Resident 1 was spitting on the dining room floor so she had to leave.Licensed Staff A stated when Administrator stopped by the facility that afternoon; he informed the Administrator that Management Staff T had been rough with Resident 1. The Administrator told Licensed Staff A to write a report. Licensed Staff A stated on 7/20/14 after lunch, he heard Resident 1 screaming. He observed Resident 1 was with Management Staff T in the dining room. Licensed Staff A stated he heard Management Staff T say to Resident 1 that she had to leave because she had spit on the floor. Licensed Staff A observed Management Staff T pushing on the handle of Resident 1's wheeled walker as Resident 1 walked. Licensed Staff A asked Management Staff T to step away but Management Staff T continued to hold onto Resident 1's walker, and appeared to be trying to drag her from the room. Licensed Staff A again asked Management Staff T to step away. Licensed Staff A stated Management Staff T looked so angry he was concerned that she might hurt Resident 1.During an interview, on 7/25/14 at 8:40 a.m., Certified Nurse Assistant N, (CNA N), stated on 7/19/14 at 11 or 11:30 a.m., she was standing outside the dining room. CNA N stated an activity was going on in the room when she heard a resident yelling. CNA N stated she saw Management Staff T place her hand on Resident 1's shoulder as Resident 1 walked with her walker, and push Resident 1 out of the dining room. Resident 1 was yelling back at Management Staff T in her native language. CNA N stated Licensed Staff approached and led Resident 1 away. Review, on 7/24/14, of an Event Report dated 7/22/14, authored by Licensed Staff A, indicated Licensed Staff A reported the 7/19/14 incident to the facility physician on 7/19/14 at 11:30 a.m. and to Resident 1's responsible party on 7/19/14 at 11:45 a.m. by phone. A progress note, dated 7/22/14, indicated the facility Administrator was notified on 7/19/14 and again on 7/20/14 of the incidents. Review of the progress note indicated the physician and responsible party had also been notified on 7/20/14 During an interview, on 7/23/14 at 9:45 a.m., the Administrator stated she was informed by Licensed Nurse A of the incident on 7/19/14 when she stopped by the facility. The Administrator stated Licensed Staff A called her at home, after dark, on 7/20/14 to inform her that "it happened again". The Administrator stated she told Licensed Staff A to write a report and leave it under the door of her office. Review, of the SOC 341, Report of Suspected Dependent Elder/Adult Abuse, dated 7/22/14, received by facsimile by the Department on 7/22/14 at 1357, (1:57 a.m.), indicated that a telephone report had been made by the facility to the local Ombudsman, however the date and time of the call was not noted on the SOC. The SOC indicated that a written report was faxed to California Department of Public Health, (CDPH), on 7/22/14, 3 days after the initial incident, no other reports were noted. Review, on 7/24/14 at 9:30 a.m., of the facility policy and procedure titled Prevention of Abuse, last reviewed and revised on 12/16/11, indicated the facility Administrator would, "report all incidents of alleged or suspected abuse to DHS (Department of Health Services, [CDPH]), within 24 hours", and noted that failure to report was subject to a class B citation. The facility failed report an allegation of employee to resident abuse to the California Department of Public Health within 24 hours, with the potential for ongoing abuse of the resident. This failure had a direct or immediate relationship to the health, safety, or security of the residents. |
| 010000024 |
Granada Rehab & Wellness Center, LP |
110010946 |
B |
27-Jan-15 |
2ULI11 |
4584 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of verbal abuse to the Department of Public Health, State Licensing and Certification Agency in a timely manner. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay, had the potential for Resident 1 and other residents to be exposed to further abuse and likely continued to cause fear and anxiety to residents who had heard or witnessed the incident and saw that the perpetrator was not removed from resident care immediately following the incident. The Department's intake information form, dated 8/12/14, revealed that the facility reported an allegation of employee to resident abuse that occurred on 8/5/14. Resident 1's face sheet (admission record) indicated that Resident 1 was a 81 years old male, who was admitted to the facility on 11/8/13 with multiple medical diagnoses including generalized pain, difficulty in walking, and dementia (A term refers to cognitive deficit and memory impairment) without behavioral disturbance. A written statement by Unlicensed Staff F, signed and dated on 8/6/14, indicated that Unlicensed Staff F witnessed the incident: "On 08/05/2014 I was in a Resident's room on Side One when I witnessed Charge Nurse [Licensed Staff C] Say to Resident [Resident 1] ...'If you ever f***ing touch me like that again, I will Break your f***ing Neck. Do you Understand me?' The Resident did respond in anger but I wasn't able to hear his response." The facility's investigation report titled "Summary of incident", dated 8/11/14, indicated that on 8/5/14, at approximately 11 a.m., Resident 1 became physically aggressive towards Licensed Staff C while Licensed Staff C was helping another resident in front of Resident 1's room. The report also indicated that in the afternoon at approximately 3 p.m., Unlicensed Staff F witnessed that Licensed Staff C said to Resident 1 "If you ever F***ing touch me like that again, I will break your f***ing neck. Do you understand me?" The facility investigation resulted in the termination of Licensed Staff C's position. During an interview on 8/19/14, at 1:50 p.m., regarding reporting the allegation of the abuse that occurred on 8/5/14, Administrative Staff A stated that she did not know about the incident until 8/7/14. She stated that Licensed Staff C was suspended on 8/7/14 and was terminated on 8/11/14. She also stated that she reported the incident to the Department on 8/12/14 (7 days after the incident).When asked the reason for the facility to take seven days to report the incident to the Department, Administrative Staff A stated that at first she did not believe the incident constituted abuse.Administrative Staff A stated that after her investigation, she considered the incident to be abuse and reported the incident to the Department and Ombudsman on 8/12/14. She stated that she reviewed the facility policy and procedure and knew that an allegation of abuse should be reported to the Department within 24 hours. The facility policy and procedure titled "Reporting Abuse," dated 9/1/13, indicated "...If the reportable event relates to an incident other than physical abuse, including sexual abuse, emotional or psychological abuse, neglect, abandonment, financial abuse, or self-neglect, that occurred at the Facility, a telephone report and a written report will be made to the local Ombudsman or to the local law enforcement agency within twenty-four hours..." The Department's investigation identified that the facility failed to report an allegation of verbal abuse to the Department of Public Health, State Licensing and Certification Agency in a timely manner. This resulted in the Department's inability to independently investigate the abuse allegation without delay. This practice had the potential for Resident 1 and other residents to be exposed to further abuse and likely continued to cause fear and anxiety to residents who had heard or witnessed the incident and saw that the perpetrator was not removed from resident care immediately following the incident. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 010000033 |
Golden Living Center- Santa Rosa |
110011047 |
B |
13-Oct-14 |
G6HR11 |
7368 |
B845 T22DIV5 CH3ART3-72311(a)(3)(B) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The facility violated the regulation by failing to accurately identify adverse side effects of lithium toxicity and digoxin toxicity. These failures resulted in Resident 1 exhibiting altered mental status, a heart rate of 52 beats per minute, acute renal failure aggravated by lithium toxicity and prolonged encephalopathy caused by lithium toxicity. Lithium is a type of mood stabilizer, also called an anti-mania medication, used to treat bipolar disorder. Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Digoxin is a medication used to treat irregular heartbeats. Resident 1 was admitted on 7/19/12, to the facility with a history of bipolar disorder. After Lithium medication was initiated during Resident 1's stay at the facility, the Resident developed altered mental status and a toxic blood level of Lithium and digoxin.Resident 1's July, August, and September medication administration records (MAR's) indicated that a daily, bedtime dose of Lithium 300 milligrams was initiated on 7/26/12, and that that dose was continued until 9/5/12. On 9/5/12, the daily Lithium dose was increased to 1200 milligrams. There was no documented evidence that Lithium levels were obtained prior to initiation of treatment or after treatment progressed.The nursing plan of care dated 7/31/12, indicated that potential for drug related complications associated with use of psychotropic medications related to bipolar disease. The interventions were to: 1) Monitor for side effects and report to physician side effects of the medication that included sedation, drowsiness, urinary retention. 2) Staff were to monitor closely for lithium toxicity as lithium toxicity can occur close to therapeutic levels. The facility was to start treatment only if prompt accurate lithium serum levels were available and could be determined. The goal was to be free of psychtropic drug related complications. Resident 1's August and September "Side Effects Monthly Flow Sheet," for 2012 indicated that Resident 1 exhibited no side effects of sedation/drowsiness from lithium medication.During an interview on 10/4/14 at 3:00 p.m., Licensed Nurse A was asked what are side effects of Lithium and how do you monitor Lithium levels, Licensed Nurse A stated that you have to look at the nursing plan of care at the beginning of the shift and the weekly summaries when we review the nursing plan of care.The medication administration record for the month of July 2012 showed that Resident 1 received Digoxin 0.25 mg by mouth daily and to hold for heart of less than 60 beats per minute. The laboratory results dated 7/23/12, indicated that Resident 1's digoxin levels were 1.0 (normal range 0.8-2.0) and on 7/30/12 were 0.9. There was no digoxin levels obtained after these dates. The nursing plan of care dated 7/31/12 for impaired cardiovascular status related to atrial flutter indicated that interventions included observe for restlessness, and signs of fatigue and change of condition such as stamina and endurance and report changes. The interventions were that staff was to obtain lab work as ordered by physician. The goal was will maintain therapeutic laboratory values and will not have a decline in function related to cardiac condition. During an interview on 10/12/12 at 3:15 p.m., Licensed Nurse B was asked what the nursing implications for digoxin are. Licensed Nurse B replied that you need to make sure the patient's blood levels are within the therapeutic range. You need to look at the laboratory results to make sure they are within the therapeutic range. Lithium and digoxin both have narrow therapeutic ranges and you have to watch for toxicity There were no nurses notes provided after 9/18/12 of Resident 1's nursing assessment. During a telephone interview on 10/3/12 at 2:00 p.m., the complainant stated that the complainant had noticed a deterioration in Resident 1's physical and mental status, during the complainant's visits to the facility, beginning on 9/19/12 and continuing to 9/21/12. The complainant stated that Resident 1 was unresponsive and could not sit up on 9/19/12, had visible oral secretions and failed to recognize the complainant on 9/20/12, and, on 9/21/12, appeared corpse-like. On 9/21/12, the complainant arranged for emergency transportation (called '911') to a hospital emergency room, because of the facility's failure to respond to the complainant's repeated requests for more timely physician contact, or treatment, of Resident 1's condition.The hospital's emergency room report dated 9/21/12 showed Resident 1 was admitted with altered mental state, a heart rate of 52 beats per minute and had a strong urine odor. The acute care hospital's discharge summary indicated that Resident 1 was admitted with lithium toxicity and digoxin toxicity. Resident 1's lithium level was 4 (normal range 0.8 to 1.2). Resident 1 had acute renal failure aggravated by lithium toxicity. Resident 1's digoxin blood level was 2.4 (normal range 0.8 -2 ng/ml). Resident required parenteral fluid hydration, forced diuresis. On this regimen, Resident 1's lithium level returned to a therapeutic level and no additional lithium was given. Resident 1's digoxin level normalized and the patient was no longer given digoxin for the supraventricular arrhythmias. Resident 1 had prolonged encephalopathy secondary to the lithium toxicity as well as the psychotropic drugs. Resident 1 remained encephalopathic (brain malfunction) and rigid. Steroids were administered and Resident 1's muscles became flaccid (relaxed) and he was able to move. Resident 1 became conversant, which was not available previously and appeared to be less encephalopathic.The 28th edition of the Nursing Drug Handbook (a popular and respected drug handbook for nurses) indicated that "determining the [blood] drug level is crucial to safe use of [Lithium] . . . [and to] . . . monitor level 8 to 12 hours after first dose, the morning before second dose is given, two or three times weekly for the first month, and then weekly to monthly during maintenance therapy." In addition, the drug handbook indicated that dosage increases should be "based on blood levels to achieve optimal dosage." The 28th edition of the Nursing Drug Handbook indicated that Digoxin blood levels were to be monitored. The therapeutic ranges were 0.8- 2 ng/ml. Excessively low pulse below 60 beats per minute may be a sign of digitalis toxicity. Withhold and notify the prescriber. Toxic effects on the hear may be life threatening and require immediate attention. Therefore, the facility violated the regulation by failing to accurately identify adverse side effects of lithium toxicity and digoxin toxicity. These failures resulted in Resident 1 exhibiting altered mental status, acute renal failure aggravated by lithium toxicity and prolonged encephalopathy caused by lithium toxicity. The violation of this regulation had a direct relationship to the health, safety, or security or patients. |
| 010000024 |
Granada Rehab & Wellness Center, LP |
110011158 |
A |
27-Jan-15 |
2ULI11 |
8823 |
?F223 483.13(b), 483.13(c)(1)(i) Free From Abuse/Involuntary SeclusionThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to afford the right to be free from verbal and mental abuse to Resident 1 when Licensed Staff C directed abusive language towards him and threatened his physical safety. This failure negatively impacted the resident's psychosocial well-being when he became fearful about going down the hallway by himself, likely impacted the sense of safety of other residents who heard the threats and likely continued to cause fear and anxiety to residents who heard or witnessed the incident and saw that the perpetrator was not removed from resident care immediately following the incident. Resident 1's face sheet (admission record) indicated that Resident 1 was a 81 years old male, who was admitted to the facility on 11/8/13 with multiple medical diagnoses including generalized pain, difficulty in walking, and dementia (A term refers to cognitive deficit and memory impairment) without behavioral disturbance. During a review of the clinical record for Resident 1 on 8/14/14, at 8:50 a.m., the quarterly Minimum Data Set (MDS, an assessment tool), dated 5/8/14, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. A written statement by Unlicensed Staff F, signed and dated on 8/6/14, indicated that Unlicensed Staff F witnessed the incident: "On 08/05/2014 I was in a Resident's room on Side One when I witnessed Charge Nurse [Licensed Staff C] Say to Resident [Resident 1] ...'If you ever f***ing touch me like that again, I will Break your f***ing Neck. Do you Understand me?' The Resident did respond in anger but I wasn't able to hear his response." The facility's investigation report titled "Summary of incident", dated 8/11/14, indicated that on 8/5/14, at approximately 11 a.m., Resident 1 had exhibited physical aggression towards Licensed Staff C while Licensed Staff C was helping another resident in front of Resident 1's room. The report further indicated that in the afternoon at approximately 3 p.m., Unlicensed Staff F witnessed that Licensed Staff C said to Resident 1 "If you ever F***ing touch me like that again, I will break your f***ing neck. Do you understand me?" The facility investigation resulted in the termination of Licensed Staff C's position. During an interview on 8/13/14, at 3:45 p.m., Administrative Staff A stated that Resident 1 did not get along with Licensed Staff C since January or February, 2014 because Resident 1 believed that his son hired Licensed Staff C to watch him. Administrative Staff A stated that the facility had separated Licensed Staff C and Resident 1; Licensed Staff C did not take care of Resident 1 at all in the last two to three months. Administrative Staff A further stated that on 8/5/14, after Resident 1 punched Licensed Staff C in the morning, she spoke with Licensed Staff C and he went back to work.During an interview on 8/14/14, at 12:50 p.m., Licensed Staff D stated that on 8/5/14, at approximately 11 a.m., Licensed Staff C and another resident were in front of Resident 1's room. Licensed Staff D stated that he did not see the entire incident, but he heard Licensed Staff C said to Resident 1 "Get your hands off me." Licensed Staff D stated that on 8/5/14, Licensed Staff C had the resident assignment which included Resident 1. He stated that Licensed Staff C continued to work with the same assignment after the morning incident. Licensed Staff D further stated that he knew Resident 1 did not get along with Licensed Staff C. When asked the reasons for Licensed Staff C to have the resident assignment including Resident 1, Licensed Staff D stated there was no specific reason but that was Licensed Staff C's primary assignment. Licensed Staff D stated that Licensed Staff C did not have to take care of Resident 1 because Resident 1 did not take any medication and treatment. Review of Resident 1's clinical record revealed that he needed to be assessed for pain and had orders that included pain medication that needed to be given to him as needed if the assessment indicated that he was in pain.During a concurrent observation and interview in a conference room on 8/13/14, at 4:20 p.m., Resident 1 was sitting in a wheelchair and was able to propel himself. Resident 1 stated that on 8/5/14, in the afternoon, near a nurse station, Licensed Staff C said to him included "Next time, if you put your hands on me again, I will break your fucking neck."Resident 1 stated that he was fearful and hesitated to go to the hallway by himself following this threat.The facility clinical document titled "Weekly Summary (weekly resident assessment)," dated 7/22/14 and 8/4/14, revealed that Licensed Staff C signed Resident 1's weekly summary forms for completion. Also, the nurse's note dated 7/13/14 at 10 a.m., revealed that Licensed Staff C wrote a note on Resident 1's behavior.During an interview on 8/14/14, at 11:05 a.m., Administrative Staff A was asked "If [Licensed Staff C] did not take care of [Resident 1] at all, how could he write the nurse's note and weekly summary?" Administrative Staff A later verified that Licensed Staff C was writing the weekly summaries and nurses notes for Resident 1 including assessments.Administrative Staff A verified the assignment with staffing personnel and stated that the staffing personnel did not take Licensed Staff C off the resident assignment which included Resident 1. The document titled "Background Screening Report," dated 4/17/13, indicated that Licensed Staff C was convicted for misdemeanor of disturbing the peace - loud/unreasonable noise on 7/19/11. During an interview on 8/14/14, at 11:35 a.m., Administrative Staff A was asked about Licensed Staff C's conviction on the background screen report. Administrative Staff A stated that she did not know about the conviction. She stated if she knew the conviction, she should have investigated the conviction before hiring Licensed Staff C.During an interview on 8/14/14, at 12:25 p.m., Administrative Staff B stated that he knew about Licensed Staff C's conviction on the background screening report and talked to Licensed Staff C. Administrative Staff B stated that he accepted Licensed Staff C's explanation of the conviction and gave Administrative Staff A the information. The facility then decided to hire Licensed Staff C.During a review of Resident 1's clinical record on 8/14/14, at 8:50 a.m., the chart did not contain any nurse's notes, social service notes, and care plan regarding the verbal abuse and threat incident that occurred 8/5/14.During an interview on 8/14/14, at 11:05 a.m., Administrative Staff A reviewed the chart and confirmed that there were no nurse's notes, social service notes or care plan for the incident. She stated that the incident should be care planned and the nurses should document their assessment and monitor Resident 1 for 72 hours.When asked for facility policy and procedure for protecting and monitoring resident after the abuse incident, Administrative Staff A stated the facility had the policy and procedure for protection of the resident. During an interview on 8/14/14, at 11:40 a.m., Social Service Staff E stated she had knowledge about the incident but did not document anything about it in Resident 1's clinical record.The facility policy and procedure titled "Abuse - Prevention Program," dated 1/1/12, indicated "The Facility does not condone any form of resident abuse, neglect and /or mistreatment, and...maintain an environment free from abuse and mistreatment...The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents...The Facility assists or rotates Facility Staff working with difficult or abusive residents..." The Department's investigation identified that the facility's failure to afford Resident 1 the right to be free from verbal and mental abuse including physical threats Licensed Staff C directed towards him. This practice negatively impacted the resident's psychosocial well-being when he became fearful about going down the hallway by himself. It likely impacted the sense of safety of other residents who heard the threats and likely continued to cause fear and anxiety to residents who heard or witnessed the incident and saw that the perpetrator was not removed from resident care immediately following the incident. 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. |
| 010000001 |
Golden Livingcenter Petaluma |
110011264 |
A |
11-Feb-15 |
PCOK11 |
9614 |
Nursing Service - General T22DIV5CH3ART3-72311(a)(1)(C)(a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to re-evaluate and update Resident 1's, "At Risk for Injury," Care Plan, relative to Resident 1's non-compliance, to include additional interventions for monitoring Resident 1, who was admitted from an acute care hospital after having a left hip arthroplasty (surgical procedure that restores joint movement) due to a fall at his home; was assessed as being a high risk for falls; had a diagnosis of delirium (severe confusion and disorientation) and had two unwitnessed falls within 15 days of admission. Resident 1's last fall resulted in a hospital readmission, due to his left hip hardware loosening, requiring a second surgery. Findings: On 8/28/14, the Department received an incident report indicating that on 8/17/14, at 8:55 p.m., Resident 1 had an unwitnessed fall in his room while attempting to self-transfer. The report indicated that on 8/25/14 (eight days later), Administrative Staff A noted that, post-fall, Resident 1's lower left extremity had an unnatural angle and Resident 1 had increased pain. X-rays were ordered, which indicated a left hip internal hardware loosening. On 8/26/14, Resident 1 was transferred to the hospital for an additional left hip surgery. On 9/10/14, at 9:45 a.m., the Admission Record, dated 7/29/14, indicated that Resident 1 was admitted to the facility from an acute care hospital with diagnoses that included: Hip joint replacement and history of falls, delirium, anxiety, cataract (closing of the lens inside the eye that leads to decrease in vision), hypertension (high blood pressure), and pain. The Nursing Admission Assessment, dated 7/29/14, indicated Resident 1 had a fall risk score of 21, meaning that he was at high risk for falls. The Fall Risk Care Plan, dated 7/30/14, indicated interventions that included: Bed in low position, call light... in easy reach ....observe for medication side effects, and therapy referral as needed. An At Risk for Injury Care Plan, dated 7/29/14 (revised 8/29/14), indicated that Resident 1 had difficulty following directions related to a diagnosis of Psychosis and Delirium, and had, "multiple attempts to transfer self without assistance." However, there was no evidence that this care plan had been updated after Resident 1's first fall on 8/3/14.During a review of the Nurses Progress Notes, dated 8/3/14, at 11:46 p.m., it indicated that at 7:20 p.m., Resident 1 had sustained a previous unwitnessed fall, in the facility, when Resident 1 was sitting on the floor in front of his wheelchair at bedside. The care plan interventions, dated 8/4/14, included to apply Dycem (a non-slip material) to his wheelchair cushion and to offer rest periods and assist him back to bed as needed. The Post Fall Analysis Plan, dated 8/3/14, at 7:20 p.m., indicated that Resident 1 had impaired safety awareness and judgment, poor insight into limitations, and intermittent confusion. Even though Resident 1 had fallen at home (the reason for his recent hip surgery and subsequent admission to the facility), the box indicating a history of falls was unchecked.Review of the Nursing Assessment, dated 8/3/14, at 11:46 p.m., indicated that vital signs were done, neurological assessments were initiated, and Resident 1 denied pain and injuries related to the fall. On 8/7/14, Resident 1 had an x-ray of his left hip that indicated the prosthesis was still intact. During a review of the Nurses Progress Notes, dated 8/17/14, at 11:08 p.m., it indicated that at 8:55 p.m., Resident 1 had sustained a second unwitnessed fall, in the facility when the resident attempted to ambulate, lost his balance, and fell. The care plan interventions, dated 8/18/14, included: Order bolsters for air mattress, and apply floor mat alarm at bedside. There was an intervention for moving Resident 1 closer to the nursing station, but it had been canceled. The Post Fall Analysis Plan, dated 8/17/14, at 8:55 p.m., indicated that Resident 1 had impaired safety awareness.Review of the Nursing Assessment, dated 8/17/14, at 11:08 p.m., indicated that vital signs were done, neurological assessments were implemented, family and physician were notified, and that Resident 1 denied pain and injuries related to the fall. On 8/25/14, Resident 1 had an x-ray of his left hip, indicating internal hardware loosening. On 8/28/14, Resident 1 returned from the hospital, and the Nursing Admission Assessment indicated that Resident 1 was at risk for falls; with a total score of 18 (a total score of 10 or above deemed residents at risk for falls).During a review on 9/10/14, at 12:30 p.m., the Minimum Data Set (MDS - an assessment tool) dated 8/6/14, indicated that Resident 1 required two persons to physically assist him with activities of daily living (ADL's), such as for bed mobility, transfers, dressing, and bathing. The MDS further indicated that Resident 1's gait was not steady but he could stabilize himself with the assistance of staff when moving from a bed to a wheelchair and for toileting. The MDS also indicated that Resident 1 was able to express ideas and wants and had the ability to understand others. Resident 1's brief interview for mental status (BIMS - an assessment that measures cognition ability), indicated that Resident 1 had a score of 13 out of 15, which meant his cognition was intact. During a review of the Nurses Progress Notes, dated 8/11/14, at 1:16 a.m., Licensed Staff H indicated, "Pt. [Resident 1] was non-compliant with repositioning due to confusion."During an interview on 9/10/14, at 12:30 p.m., Administrative Staff A stated that the facility was set up for failure when Resident 1 was admitted for rehabilitation due to his non-compliant behavior.During an interview on 9/10/14, at 2:55 p.m., Administrative Staff C stated that there was no care plan for Resident 1's behavior because Zyprexa (Antipsychotic medication) was discontinued on 8/28/14, and the care plan was considered resolved.During an interview on 9/10/14, at 3:30 p.m., Administrative Staff A stated that, in regards to the care plan intervention of moving Resident 1 closer to the nursing station, this was canceled because Resident 1 was not compatible with the new roommate. When asked what interventions the facility initiated for non-compliant residents, Administrative Staff C stated that anytime a resident could not be redirected, the facility would put the resident on 1:1 (one staff member supervising one resident). Administrative Staff A stated that 1:1 supervision was not provided for Resident 1.During an interview on 9/11/14, at 9:59 a.m., Unlicensed Staff D stated Resident 1 became more confused after the first fall so the plan was to keep his bed in a low position and to monitor the floor mat and the clip-on/floor alarms. Unlicensed Staff D stated that Resident 1 was combative as he would curse at staff and slap staff on the wrist. Unlicensed Staff D stated that there was less staff working at night and residents got more confused, and that the falls could have been prevented if Resident 1 had 1:1 supervision. During an interview on 9/11/14, at 11 a.m., Licensed Staff E stated that Resident 1 would demonstrate he could use the call light but would call out by yelling. Licensed Staff E stated that when a resident could not be redirected, staff needed to get approval for 1:1 intervention. For Resident 1, the one thing that could have prevented his falls was 1:1 interventions. The facility policy and procedure titled, "Falls Management Clinical Guidelines," dated 2013, indicated that during preadmission intake, the center determined if the potential resident had a history of falling or unsteady gait and ensured that the appropriate fall interventions were in place prior to the resident's admission. Following a resident's fall, appropriate interventions were implemented and the care plan was updated.The facility policy and procedure titled, "Change in Condition Report-Post Fall Investigation Summary Guidelines for Completion," dated 1/2011, indicated that the purpose of the policy was to assess individual condition after a fall occurs and to identify the reason and/or risk factors for the fall, in order to prepare a plan of care to reduce the potential for future falls. Under the procedure section, Item 2- Objective indicated: ".....identify any pertinent disease or diagnosis, any medications that could contribute to falling, history of pervious [sic] falls, and evidence of impaired safety judgment.....Evaluate for causative factors including.....psychosocial issues including changes in mood or roommates.....Attempt to establish what the resident was doing / attempting to do prior to the fall...Care Plan Developed/Revised as indicated: Identify if the care plan was updated and new approaches to be implemented."Therefore, the facility failed to update the care plan to specifically address Resident 1's behavior of non-compliance, with interventions to prevent Resident 1 from falling a second time, requiring a second surgical intervention.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. |
| 010001139 |
Greenfields III ICF-DDN |
110011340 |
B |
23-Apr-15 |
M85Z11 |
7961 |
WELFARE AND INSTITUTION CODE 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to prevent harm to Client 1, when Client 1's wheelchair brakes were not locked properly, and Client 1's wheelchair rolled forward over the curb, and toppled over on top of Client 1. Client 1 was strapped into the wheelchair, and fell onto the street surface face first, with the wheelchair on top of Client 1. Client 1 sustained a bleeding laceration to her lip that required sutures and an abrasion to her forehead.The facility is a 6 bed Intermediate Care Facility for the Developmentally Disabled - Nursing licensed to provide care and services to people with varying degrees of developmental disability. Client 1 was dependent on the facility for basic needs. During an interview on 7/17/14 at 9:30 a.m., Day Program Staff A (DPS A), stated that he was the aide assigned to assist Client 1 on 7/1/14. DPS A stated that he was assigned 2:1 with another client as well as Client 1, that day. DPS A stated that another aide, Day Program Staff B (DPS B), took Client 1 to the curb to meet her bus that day. DPS A stated that he was closer to the building, attending to his other client, when he heard DPS B shout out Client 1's name. DPS A stated that he looked over towards the commotion and saw Client 1's wheelchair going over the curb. Client 1 was strapped into the wheelchair, and fell to the ground, with the wheelchair on top of Client 1. DPS A stated that they all ran over to assist Client 1 at that point. DPS B asked DPS A to assist in lifting Client 1's wheelchair back up. DPS A stated that it was then when they saw that Client 1 was bleeding from her face, mouth and forehead. DPS A stated that they assessed Client 1, and determined that Client 1 was able to be transported in the wheelchair to the nurse. They then, took Client 1 into the building to be examined by the nurse. DPS A stated that the nurse and Day Program Manager C (DPM C) gave Client 1 first aide and called 911. During an interview on 7/17/14 at 9:50 a.m., DPS A was asked if he had received any prior training in the proper techniques used to transport clients using wheelchairs for mobility. DPS A stated that he had been trained to: 1.) Make sure that the wheelchair brake is locked; 2.) Make sure that we don't leave the client in their wheelchair unattended. During an interview on 7/17/14 at 9:55 a.m., DPS B stated that she had set the brake on Client 1's wheelchair, the one in the back of the wheelchair, then went to reach for the ramp controls to the right of the ramp, and Client 1 rolled away to the left. DPS B stated, "Evidently I hadn't pushed on her brakes hard enough."During an observation and interview on 7/17/14 at 9:55 a.m., Client 1 was brought to the anteroom of the Day Program Nursing Office, where DPS B demonstrated how she applied the brakes on Client 1's wheelchair. DPS B explained that Client 1 was wearing her wheelchair transport harness at the time of her fall, which kept Client 1 from falling out of the wheelchair as it tipped over onto the ground. Client 1 still had one small scab, approximately 1 cm X 1/2 cm in size, on her upper lip. Client 1 also had one red mark, approximately 1 cm X 1 cm, on her forehead.During an observation on 7/17/14 at 10:00 a.m., DPM C pointed out the location where the accident involving Client 1 occurred. DPM C demonstrated, using a colored folder for a marker, the area of sidewalk where Client 1's wheelchair had been parked, while DPS B lowered the lift mechanism, in preparation to load Client 1 onto the Day Program bus. DPM C stated that DPS B parked Client 1 in her wheelchair at the curb, to the left of the Day Program van lift, and while DPS B reached away to the right to operate the lift mechanism. DPM C stated that during this maneuver, Client 1 strapped into her wheelchair, rolled away to the left, away from DPS B, and over the curb. Client 1 fell forward, face-first and sustained an abrasion to her forehead, and a cut on her lip which were bleeding profusely. Photographs were obtained to establish the location of the site of the incident. (Refer to Photography Report.) During an interview and record review on 7/17/14 at 11:20 a.m., Direct Care Staff D (DCS D) stated that there was a reminder checklist posted on the inside of the front door reminding facility staff of all the steps necessary to equip each of their clients for safe wheelchair transport each day. As proof of her statements, DCS D provided a copy of the facility's posted reminder. The posted reminder indicated that each client using a wheelchair for transportation, would have their wheelchair and all necessary equipment for their day ready to go onto the bus, and that all of those items should be retrieved back from the p.m. bus driver, it said nothing about checking the brakes on each client's wheelchair before and after van access. During an interview and record review on 7/17/14 at 11:40 a.m., HM F, the facility house manager, brought copies of the Check-list Reminder posted on the inside of the front door, and the facility Shift to Shift Report form. When examined side by side the two forms: Beside the initials which indicated Client 1's name, were the following items to be checked by facility staff each shift: "Lap tray, Jacket, Backpack, Lunch box, Wheelchair (Parts)." There was no mention of checking the brakes on Client 1's wheelchair to make sure that they were working. During an interview and record review on 7/17/14 at 12 p.m., Administrator G (AD G) pointed out that on the a.m. to p.m. Shift to Shift Report, in columns three and four, where the Day Program drivers were supposed to sign, that neither Day Program a.m. nor p.m. drivers had signed the shift to shift report from July 2014. Closer examination of the facility's Shift to Shift Report form, dated 7/1/14 to 7/17/14, indicated that facility staff had failed to obtain any Day Program Drivers' initials, on their shift to shift report form for the month of July 2014. During an interview and record review on 7/17/14 at 12:20 p.m., Qualified Intellectual Disabilities Professional H (QIDP -H) stated that the facility had asked the wheelchair company out, on 7/8/14, to check out Client 1's wheelchair, and that it was okay. QIDP H offered a copy of the facility's receipt from the wheelchair company as proof of the facility's claims that Client 1's wheelchair was functioning. Closer examination of the receipt, from said wheelchair company, dated 7/08/14, indicated: "Labor - $138.00 for Emergency Brake Repairs." During a subsequent interview on 3/3/15 QIDP H stated, "We are just now getting all the parts to repair Client 1's wheelchair." The facility violated the regulation by failing to prevent harm to Client 1, when Client 1's wheelchair brakes were not locked properly, and Client 1's wheelchair rolled forward over the curb, and toppled over on top of Client 1. Client 1 was strapped into the wheelchair, and fell onto the street surface face first, with the wheel chair on top of Client 1. Client 1 sustained a bleeding laceration to her lip that required sutures and an abrasion to her forehead. The violation of this regulation had a direct relationship to the health, safety and security of this client. |
| 010000001 |
Golden Livingcenter Petaluma |
110011341 |
B |
01-Apr-15 |
RVEL11 |
9610 |
T22 DIV5 CH3 ART3-72315(b) Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to prevent verbal and mental abuse for one of 86 residents (Resident 1), when a staff deliberately sprayed Resident 1 with cleaning solution on his left shoulder and a second time, towards his chest. This failure resulted in Resident 1 becoming frustrated and extremely upset, potentially jeopardizing his health status and well-being. Findings: During a review of Resident 1's clinical record, the Admission Record, dated 5/2/14, indicated he was admitted for aftercare surgery rehabilitation. Resident 1 had other diagnoses that included generalized weakness, anxiety, and diabetes. During an observation, on 5/2/14, at 1:35 p.m., Resident 1 was sitting in a wheelchair, outside in the patio by himself. Resident 1 understood basic English but expressed more ease communicating in Spanish. Resident 1 was awake, stated his age, birthday, how long he had been at the facility and the reason for his admission. Resident 1 was able to recall details of the alleged incident. During an interview in Spanish, on 5/2/14, at 1:35 p.m., Resident 1 stated that while sitting in the dining room with Resident 4 and visitors, Staff E sprayed cleaning solution on his left shoulder. Resident 1 stated that he tried to get Staff E's attention by following the staff in his wheelchair and telling the staff that he was sprayed with the cleaning solution. Resident 1 stated that Staff E got mad and pointed the cleaning solution spray bottle at his chest and sprayed him a second time. During an interview, on 5/2/14, at 1:50 p.m., Staff E stated that Resident 1 told him that he was sprayed and he told the resident, " ... there is no way that I could have sprayed you because you are too far." Staff E stated that he sprayed Resident 1 to show him that it was not possible to spray someone from a distance. Staff E stated that Resident 1 was a trouble maker and an antagonist because he changed the television channel in the dining room and then would leave the room.During an interview, on 5/2/14, at 2:05 p.m., Administrative Staff B stated that Resident 1 had been hospitalized several times in March 2014, one of the hospitalization happened on 3/20/14, when Resident 1 was having chest pain and was diagnosed with anxiety. During an interview, on 5/2/14, at 2:50 p.m., Administrative Staff A stated that Staff E did not handle the situation well by spraying Resident 1 a second time. During an interview, on 5/2/14, at 3:55 p.m., Resident 3 stated that he did not observe the beginning of the incident, but heard Resident 1, saying, "You sprayed me in the eyes," and heard Staff E saying, "I sprayed the table, now let me finish my work." [Review of Resident 3's Minimum Data Set - MDS (a screening assessment tool), dated 4/17/14, indicated under section C0500-Brief Interview for Mental Status (BIMS), that his score was a 15, indicating he had no cognitive impairments.]During an interview, on 5/2/14, at 4 p.m., Resident 2 stated that while sitting in the dining room doing a computer activity class, Staff E was cleaning the dining room tables with a spray bottle. Resident 2 saw Resident 1 go towards the kitchen and was yelling something to Staff E, then Staff E was upset and sprayed Resident 1 about six feet away. Resident 2 stated that Staff E told Resident 1, "If you are acting this way, you should not be here." [Review of Resident 2's MDS, dated 3/7/14, indicated under section C0500-BIMS, that Resident 3's score was 15, indicating she had no cognitive impairment.]During an interview, on 5/6/14, at 11:35 a.m., Staff D stated that there was yelling going back and forth, and he saw Staff E point the cleaning solution at Resident 1 about 20 feet apart and sprayed Resident 1. Staff D stated, "Not the best thing that [Staff E] could have done." During an interview, on 5/7/14, at 1:46 p.m., Staff F stated she saw Resident 1 and Staff E exchanging words. Resident 1 was upset and Staff E was cleaning a table with a spray bottle about three feet from the table. Staff F stated that Resident 1 kept saying, "Don't spray that on my face," and that Staff E responded, "You shouldn't be here." Staff F stated, "[Staff E] didn't handle it and could have handled it differently" "... I think [Resident 1's] feelings got hurt because he was asked to leave." During an interview, on 5/8/14, at 10:25 a.m., Staff G stated that she saw Resident 1 coming out of the dining room very upset, and he approached her and told her in Spanish that Staff E had sprayed him.During an interview, on 5/8/14, at 10:32 a.m., Resident 4 stated that they were sitting in the dining room with Resident 1 and visitors, eating food brought by the visitor, when Resident 1 told Staff E to not spray in his glass of water. Resident 4 stated, Staff E was unprofessional and was screaming at Resident 1, "Get out of my room....You are not supposed to be here." Resident 4 stated, "You can't treat residents like that," and that Staff E was intimidating. [Review of Resident 4's MDS, dated 4/25/14, indicated under section C0500-BIMS, that her score was 15, indicating she had no cognitive impairments.]During an interview, on 5/8/14, at 11:20 a.m., Administrative Staff C stated that Staff E did not handle the incident right, by spraying Resident 1 two times. Administrative Staff C stated that their policy was for housekeeping staff to get the Registered Nurse or the Certified Nurse Assistant, and to politely move the resident, and not to use chemical cleaners around the residents. Administrative Staff C also stated there was no policy and procedure regarding cleaning around patients and that staff knew not to clean when residents were eating. The Housekeeping Check List, brought by Administrative Staff C, indicated that the Main Dining Room cleaning time was 1 p.m. and not 2 p.m. During an interview in Spanish, on 5/8/14, at 2:10 p.m., Resident 1 stated that he felt that Staff E was being defiant when the spray bottle was pointed at his chest the second time and when the staff told him to shut up.During a review of Resident 1's clinical record, on 5/2/14/ at 2:05 p.m., the MDS, dated 3/27/14, indicated under section C0500-Brief Interview for Mental Status (BIMS-a score that determines cognitive level), that Resident 1 had a score of 15, indicating his thinking ability was intact, with no history of delusions, hallucinations, and no exhibited behaviors.Resident 1's Care Plan, dated 3/26/14, indicated he had been diagnosed with anxiety and was receiving Ativan (anxiety medication). The care plan indicated under interventions the following: "Approach resident in a calm non-threatening manner," and to, "encourage resident to express feelings in a calm appropriate manner."During a review of the personnel file for Staff E, on 5/2/14, at 3:15 p.m., there was a 'Notice of Disciplinary Action,' dated 10/24/13, that indicated that Staff E had been hostile, rude, and unprofessional to Administrative Staff C when the flu vaccine was scheduled. The personnel file also had an 'Employee Warning Notice,' dated 11/11/13, that indicated Staff E had posted inappropriate material in the staff lounge. Review of the document titled, "Housekeeping In-Service-Accident Prevention," dated 5/1/14, indicated on item 8, "Keep all bottles out of patients' reach and have all bottles labeled. ... Do not spray any cleaning chemical in the direction of a patient." Review of the document titled, "Housekeeping In-Service-Employee/Resident Relations," dated 5/1/14, indicated the purpose, "To insure that all Housekeeping and Laundry personnel understand that they are working in the "Home" of the resident and should conduct themselves accordingly." Item 3 indicated, "Necessity to respect the residents' individuality and privacy." Item 4 indicated, "Necessity to inform appropriate staff members of various situations involving residents." The facility policy and procedure titled, "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property-Ca," dated 3/1/13, indicated of Page 8 of 9, "Abuse, the willful infraction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.....Verbal Abuse, any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability......Mental Abuse, this includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation." The facility policy for Resident's Rights titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities," dated 5/2011, indicated on page 38, "Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality."Therefore, facility staff deliberately spraying Resident 1 with cleaning solution on his left shoulder and a second time, towards his chest, resulted in Resident 1 becoming frustrated and extremely upset, potentially jeopardizing his health status and well-being. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000034 |
Golden Living Center - London House Sonoma |
110011503 |
B |
16-Jun-15 |
NJHS11 |
3200 |
B830 Nursing Service - General T22 DIV5 CH3 ART3-72311(a)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to follow the care plan to attach a tab alarm to Resident 1's high-back wheelchair, when she was sitting in it during daily activities. A tab alarm makes a loud noise when a resident moves, which alerts staff that the resident is trying to get up out of the wheelchair. This failure resulted in Resident 1 falling out of her wheelchair and fracturing a bone in her face. Findings: Resident 1 was 97-year's old and admitted to the facility on 1/2/15, with diagnoses including dementia, glaucoma, cerebral vascular disease, and debility. Resident 1 had been on Hospice Care since admission. Resident 1 was nonverbal. During an interview on 4/6/15 at 2 p.m., Licensed Staff A stated that she heard a resident calling out from the dining room before dinner was served on 3/20/15. When she went into the dining room, she saw Resident 1 on the floor beside her wheelchair. Licensed Staff A stated that there was no staff in the dining room. The high-back wheelchair was in the upright position for eating. Licensed Staff A stated that there was no alarm on the wheelchair. Licensed Staff A stated that when she asked Unlicensed Staff C why the alarm was not on the wheelchair, Unlicensed Staff C stated that she had forgotten the alarm. Licensed Staff A stated that when she went to Resident 1's room after Resident 1 had been transported to the Emergency Department, Resident 1's tab alarm was noted on her bed. During an interview on 4/6/15 at 1:45 p.m., Unlicensed Staff B stated that when he was passing out snacks on 3/20/15, before dinner, he heard a resident calling from the dining room. When he went to the dining room, Resident 1 was on the floor beside her high-back wheelchair. Unlicensed Staff B stated that there was no staff in the dining room. During an interview on 4/6/15 at 1:20 p.m., Unlicensed Staff C stated that she did not remember if Resident 1's tab alarm was in place on the wheelchair at the time of Resident 1's fall on 3/20/15. During an observation and concurrent interview, on 4/6/15 at 12:20 p.m., Resident 1 was sitting in her high-back wheelchair being fed by Unlicensed Staff D. Resident 1 was able to move her left hand and arm to scratch her head and was able to move her upper body slightly forward from the back of the wheelchair.During medical record review on 4/6/15, a Hospice order, dated 1/8/15, indicated, "Clip alarm in place while up in gerichair." A Hospice ADL (Activity of Daily Living) and Potential for Falls Care Plan, dated 1/7/15, indicated, "Safety measures in place as indicated: Bed Alarm, Chair Alarm." The facility failed to follow its care plan to attach a tab alarm to Resident 1's wheelchair; as a result, when Resident 1 was left alone in the dining room, staff was not alerted when she fell out of her wheelchair and sustained a facial bone fracture.The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000033 |
Golden Living Center- Santa Rosa |
110011588 |
B |
02-Jul-15 |
CVSN11 |
7288 |
B830 T22 DIV5 CH3 ART3-72311(A)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to implement Resident 1's care plan to ensure that Resident 1, who had a history of falls and was also identified by facility documentation as having poor safety awareness and being noncompliant in using her front-wheel walker, was adequately monitored and supervised to prevent a fall. This failure resulted in Resident 1 sustaining a hip fracture and two hospitalizations, exacerbated physical pain, and undergoing surgery to repair the damage caused by the fall.Findings: Record review indicated Resident 1, a 68-year-old female, was admitted on 8/21/12, with diagnoses that included end stage renal disease, anxiety disorder, and rheumatoid arthritis. Resident 1 was transferred to the acute care hospital on 5/31/13, after sustaining a fall in the bathroom. Resident 1 was re-admitted to the facility on 6/10/13, and transferred back to the acute care hospital, due to severe right leg pain, secondary to a right hip fracture, related to the fall on 5/31/13. Review of Resident 1's annual Minimum Data Set (MDS/an assessment tool) dated 2/28/13, indicated that Resident 1 relied on staff supervision with help for transfers and walks. Subsequent MDS assessments, dated 5/13/13 and 5/27/13, indicated Resident 1 relied on limited assistance of one person with walking between locations in her room. The MDS also indicated that Resident 1's cognition was intact. A review of, "Change in condition report-post fall/trauma," dated 5/31/13, indicated history of falls, and the interventions used prior to resident's fall on 5/31/13, included night light, toileting schedule, and an assistive device [walker] within reach." Review of Resident 1's care plan dated 5/31/12, indicated that Resident 1 was at risk for falls related to: Use of medication; poor safety awareness; and that Resident 1 ambulated with a front-wheel walker (FWW) and could be noncompliant in using her FWW in her room. The care plan also indicated that Resident 1 could display various performance levels dependent on fatigue, poor endurance, and dialysis. Interventions included that Resident 1 would have personal items available and in easy reach and to keep her environment well lit and free of clutter. Subsequent review of Resident 1's care plan dated 4/30/13, which was in effect prior to her fall documented, "Pt. requiring max A [assist] to dress & toilet due to weakness and low activity tolerance." A nurse's notes, dated 5/31/13 at 9:24 a.m., documented that Resident 1 was found on the bathroom floor and had a history of falls and generalized weakness. The note indicated that Resident 1 had an abrasion to her right leg and elbow and was complaining of lower back pain, and her buttocks and hip area had purple discoloration. A hospital Case Management Letter, dated 6/3/13, indicated that, during her post-fall Emergency Department visit, Resident 1 received a spinal x-ray which showed an L1 (Lumbar) fracture of indeterminate age, as well as a complete fracture of her T-11 (Thoracic). The letter also indicated that Resident 1 was diagnosed with, "....fall, acute exacerbation of chronic pain with inability to ambulate......" During an interview on 6/11/13 at 1:50 P.M., Resident 1 stated that she got up early in the morning, that it was dark in there [the bathroom], and when she turned to turn the lights on, her legs gave away and she went down, hitting her head, knees and elbow, and ended up on her back. Resident 1 also stated that she was in a lot of pain. When Resident 1 was asked if she had called for assistance to the bathroom, she responded that she had not, and that she had given up on calling for help because, "They don't come for an hour or more or they never come." Resident 1 further stated that, "The girls," that work the hall where she resides, work the other halls as well, and they could not get to everyone or see the call lights, and that was the reason Resident 1 had stopped calling for help at night. Resident 1 also stated that her colostomy bag was full and she was concerned it might burst, and she went to the bathroom to empty her bag. During an interview on 7/3/13, Management Staff B stated that on 6/11/13, when Resident 1 returned to the facility from the acute care hospital she started complaining of severe pain in the right groin area. During the night, the pain increased, and Resident 1 was transferred back to the acute care hospital on 6/12/13, underwent surgery for right hip fracture secondary to the fall, and returned to the facility on 6/21/13. A hospital Operation Report, dated 6/14/13, indicated a Preoperative Diagnosis of displaced right femoral neck (hip) fracture.During an interview on 7/8/13, at 3:40 p.m., Unlicensed Staff K stated that on the night of the incident, Resident 1 told her that the bathroom was dark, and that she turned around to turn the lights on and fell. Unlicensed Staff K indicated that she had never seen any night light in Resident 1's room or the bathroom, and that she saw the FWW behind the door, but was not sure if Resident 1 used it or not and did not ask. Unlicensed Staff K also indicated that Resident 1 also told her that when she called for help nobody ever came so she did not call anymore.During an interview on 7/8/13 at 1:30 p.m., Management Staff B/DON was asked for a copy of Resident 1's post-fall assessments for the two falls prior to the most recent fall on 5/31/13. Management Staff B stated "The falls are care planned and that these were the same as the post-fall assessment. During a subsequent interview on 7/11/13 at 2 p.m., Resident 1 stated that on the day of her fall her front-wheel walker (FWW) was not within reach, and that it was about four feet or more from her bed. Resident 1 further stated that there was no night light in her room, or the bathroom, and that it was dark.In an interview on 7/11/13 at 3:55 p.m., Management Staff B was informed that no night light was observed at Resident 1's bedside or in the bathroom, on the surveyor's first visit to the facility on 6/6/13.During a telephone interview on 7/15/13 at 10:15 a.m., Resident 1's family member was asked when she had provided a night light for Resident 1. She stated, "I don't know anything about a night light. I did not provide any night light, and I don't remember seeing a night light at my mother's bedside before her fall." During a subsequent telephone interview on 7/18/13 at 9:10 a.m., another family member stated, "I did not provide a night light and do not recall seeing one before my mother's recent fall. I believe it was provided by the facility after her fall." Review of facility policy titled, "Falls Management Clinical Guidelines," revised 2013, indicated, "The interdisciplinary team reviews the change of condition report--post fall/trauma and makes additional recommendations within 72 hours of the fall......Licensed nurse completes change of condition--post fall following a resident fall." The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000024 |
Granada Rehab & Wellness Center, LP |
110012256 |
A |
13-Jun-16 |
P6CJ11 |
14176 |
F281 ?483.20(k)(3)(i) Services Provided Meet Professional Standards The services provided or arranged by the facility must meet professional standards of quality. The facility failed to follow nursing professional standards of practice and facility policy when licensed nursing staff withheld the necessary care and services by failing to notify the physician in a timely manner of significant changes of condition on 4/27/16 for Resident 1. Resident 1 required transfer to the emergency room of the local hospital shortly after midnight, on 4/28/16, with agonal breathing (shallow breathing pattern that is often related to cardiac arrest and death), and severe dehydration. Her admission diagnoses included encephalopathy (disease of the brain that alters brain function or structure, may be caused by infectious agent bacteria, virus, or lack of oxygen or blood flow to the brain), and sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs). Resident 1 was intubated (a tube inserted into the windpipe), placed on mechanical ventilation, and admitted to the Intensive Care Unit (ICU). Resident 1's demographic facesheet, dated 4/19/16, indicated she was readmitted to the facility on 4/18/16 following a hospital stay with diagnoses that included: pressure ulcer of the sacral region (bone at the base of the spine), Stage 4 (Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia (band or sheet of connective tissue, primarily collagen, beneath the skin) muscle, tendon, ligament, cartilage or bone in the ulcer. The National Pressure Ulcer Advisory Panel), urinary tract infection, traumatic hemothorax (a collection of blood in the space between the chest wall and the lung, which required 3 chest tubes to drain), acute kidney failure, poorly controlled diabetes and a heart attack following a cardiac arrest. The Stage 4 pressure ulcer was infected with Vancomyocin Resistant Enterococcus (VRE). "Enterococci, a bacteria, can resist and evade several forms of antibiotic therapy, including Vancomycin, the antibiotic of last resort for resistant infections...Enterococcal infections that result in human disease can be fatal, particularly those caused by strains of Vancomycin-resistant enterococci " (http://www.niaid.nih.gov/topics/antimicrobialResistance/Examples/vre/Pages/overview.aspx) Physician admission orders, dated 4/18/16, included Full code status and noted that Resident 1 was capable of making health care decisions and the code status had been discussed with Resident 1.(A full code means a person will allow all interventions needed to get their heart started. This may include chest compressions and defibrillation to shock the heart out of a life-threatening heart rhythm. Placing a breathing tube in the airway to assist with ventilation and medications to treat the heart are all resuscitation interventions. Not all patients require each step. But if a patient is a full code, it means they are willing to allow any of the above measures. Source: Medical Students Guide to Understanding Code Status, October 2014.) A fax, dated 4/27/16, with no time or date stamp indicating it was sent, from the Registered Dietician to the attending physician, noted that Resident 1 lost 8.6 pounds in one week and the current average intake by mouth was 15% of meals and 95 milliliters (ml) of fluid (per meal) over the last 21 meals (7 days). Long-term care residents, for example, eat far from 100% of their meals, whereas almost 80% of the total daily fluid comes from fluid intake associated with meals. Patients consuming less than 50% of their meals are at high risk for dehydration. (http://www.medscape.com/viewarticle/567678_6) Nurses notes, dated 4/27/16 at 7:30 p.m., indicated that at 4:40 p.m., while working with physical therapy, Resident 1's body became rigid and her eyes rolled back into her head and then Resident 1 vomited approximately 2 cups of brownish-yellow fluid. The vomit was suctioned from the mouth and the oxygen was turned up to 3 liters (L) due to a blood oxygen level of 87% (normal is 97 to 100%), this was reported to the Director of Nurses (DON). Nurses notes, dated 4/27/16 at 11:15 p.m. indicated: "R [Resident 1] unable to speak, seemed lethargic and not responding at first. Continued to talk to R [Resident 1], she would open her eyes, but not talk. Eventually she started moving her tongue and mouth as if trying to say something. O2 [oxygen saturation level] at 88 to 89% via NC [nasal cannula] at 3 LPM [liters per minute] at 8:30 p.m...low grade fever of 99.6 [degrees Fahrenheit]. Checked on at 10 p.m., sleeping without shortness of breath, O2 went up to 93% on 3L [liters]. Repositioned every 2 hours as needed. Foley [catheter into the bladder] draining amber color urine." Severe dehydration can produce urine the color of amber. (http://www.mayoclinic.org/diseases-conditions/urine-color/basics/symptoms). Intake and urine output was not recorded for 4/27/16 on the Intake and Output record. Nurses notes, dated 4/27/16 at 11:30 p.m., indicated "upon beginning of the shift," [10:30 p.m. to 6:30 a.m.] a Certified Nursing Assistant (CNA) reported to the nurse that Resident 1 was not responsive. Vital signs noted were: temperature of 101.8 degrees Fahrenheit (normal 97.8 - 99.1 degrees Fahrenheit ), Pulse 118 (normal 60 - 80 ), Respirations 26 (normal 12 - 18), blood pressure of 88/50 and oxygen level 85% on 3 L of oxygen with minimal response to painful stimulus (used to check level of consciousness). The Physician was notified and received orders to transfer to the hospital as an emergency for possible sepsis.The City Ambulance of Eureka Prehospital Care Report, dated 4/28/16, noted arrival at the facility at 00:07 a.m., and noted the primary impression as unconscious and secondary impression as respiratory distress. The vital signs recorded were: blood pressure 80/42, pulse 118, respirations 28 per minute with oxygen saturation of 85% on low oxygen. The ambulance left the facility at 00:16 a.m. with lights and sirens to transport Resident 1 to the emergency room. Often, older people are unable to create a higher temperature with infection so very low temperatures and checking the other vital signs plays an important role in following these people for signs of infection. (http://nursinglink.monster.com/training/articles/944-vital-signs-overview-and-effect-of-aging-changes) Sepsis is a potentially life-threatening complication of an infection. If sepsis progresses to septic shock, blood pressure drops dramatically, this may lead to death. To be diagnosed with sepsis, you must exhibit at least two of the following symptoms, plus a probable or confirmed infection: body temperature above 101 F (38.3 C) or below 96.8 F (36 C); heart rate higher than 90 beats a minute; and/or respiratory rate higher than 20 breaths a minute. Diagnosis will be upgraded to severe sepsis if you also exhibit at least one of the following signs and symptoms, which indicate an organ may be failing: significantly decreased urine output; abrupt change in mental status; decrease in platelet count; difficulty breathing; abnormal heart pumping function; or abdominal pain. (http://www.mayoclinic.org/diseases-conditions/sepsis/home/ovc-20169784)During an interview, on 5/4/16 at 9:30 a.m., Physical Therapy Assistant (PTA) A stated that on 4/27/16 at around 4:30 p.m., Resident 1 had agreed to try to sit on the edge of the bed. When PTA A rolled Resident 1 to one side, Resident 1 stated in a garbled voice, "I don't feel so good," and then became rigid and stiff all over and her eyes rolled up in her head. PTA A stated Resident 1 began to vomit, so PTA A called for help and a CNA and Licensed Nurse (LN) B came into the room and took over.During an interview, on 5/3/16 at 5:10 p.m., Licensed Nurse B (LN B) who was assigned to Resident 1 from 2:30 p.m. to 7 p.m. on 4/27/16 stated a CNA reported that Resident 1 went rigid and her eyes rolled back in her head and then started to vomit. LN B stated she suctioned Resident 1's mouth and checked oxygen levels frequently. LN B stated she was concerned that Resident 1 might have aspiration pneumonia (occurs when food, drink, vomit or saliva is inhaled into the lungs) after the vomiting episode. When asked if the physician had been notified of this change in condition, LN B stated "No, I did not notify the physician, but in hindsight I guess I should have. I kept checking her oxygen levels and I told the DON." During an interview, on 5/4/16 at 5 p.m., DON stated when LN B notified her of the change on 4/27/16, after the rigid posture and vomiting, LN B was instructed to call the physician and report the change in Resident 1's condition. Additionally, DON stated LN B was told not to send a Fax, but to actually call the physician and report the changes.During an interview, on 5/4/16 at 2:50 p.m., LN C, who was assigned to Resident 1 from 7 p.m. to 10:30 p.m. on 4/27/16, stated LN B had reported that Resident 1 had vomited, but did not relay the information about Resident 1's episode of being rigid and with eyes rolled back, prior to the vomiting. Resident 1 was twitching so LN C stated she checked the blood sugar levels which were "okay." LN C stated Resident 1 was lethargic and mumbling and the oxygen level was "low" so the head of the bed was raised and the oxygen was turned up to 3L and the oxygen levels came up to 93% around 9 p.m.. LN C stated Resident 1 had a low grade fever, but it was not retaken. Resident 1's blood pressure and pulse were not taken, and Resident 1 had dark urine in the Foley with about 300 ml of urine output. LN C agreed, the output was not documented in the record. LN C stated she did not report the lethargic episode with the inability to speak, the dark urine, twitching or the low grade temperature to the physician. Normal urine output is 70 to 80 ml per hour [80 ml per hour times 8 hours equals 640 ml] during waking hours and 30 to 40 ml per hour while sleeping. http://www.asn-online.org/education/distancelearning/curricula/geriatrics/Chapter17.pdf During an interview, on 5/4/16 at 6:50 a.m., LN D stated that at the beginning of the night shift on 4/27/16 (10:30 p.m. to 6:30 a.m.) the nursing staff for the evening shift (2:30 p.m. to 10:30 p.m.) were busy, so did not immediately give report to the oncoming shift. LN D stated a CNA, who was checking vital signs at the beginning of the night shift ran to her and reported that Resident 1 was not responsive. LN D stated she immediately evaluated Resident 1 and the vital signs were "not good," so the physician was immediately contacted by telephone and the physician told LN D to send Resident 1 immediately to the hospital for probable sepsis.LN D stated the ambulance arrived quickly and Resident 1 was transferred to the hospital. Soon after the emergency room called and asked what Resident 1's code status was as they wanted to intubate and send Resident 1 to ICU. LN D stated that the evening shift had only reported that Resident 1 had vomited earlier that evening. During an interview, on 5/4/16 at 9:55 a.m., Resident 1's attending physician stated that due to Resident 1's complex clinical condition, which included the Stage 4 pressure ulcer with VRE, poor nutritional status, poor lungs and heart, that Resident 1 was at high risk for severe sepsis and repeated hospitalizations and she was not sure that the hospital would be able to remove the mechanical ventilator. Facility policy, titled "Change of Condition Notification", dated 1/1/12, indicated: "Policy: ...The facility will promptly inform the resident, consult with the resident's Attending physician...when the resident endures a significant change of condition...II. "Significant Change of Condition" related to Attending Physician notification is defined as when the Attending physician must be notified when any sudden and marked adverse change in the resident's condition, which is manifested by signs and symptoms different than the usual, denote a new problem, complication, or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan...III. A Licensed Nurse will notify the resident's Attending Physician...when there is...C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications..." Saunders Manual of Nursing Care: "Communicating with Physicians: 1 d.(1) Make sure the nurse shares with the physician any information about patient needs and response to treatment...When telephoning physicians about change of condition, do the following:...3. Identify the patient and the diagnosis, 4. State the problem and include: vital signs and level of consciousness; appearance of the patient, response to interventions and any other pertinent data..."Therefore, the facility failed to follow nursing professional standards of practice and facility policy when licensed nursing staff withheld the necessary care and services by failing to notify the physician in a timely manner of significant changes of condition on 4/27/16 for Resident 1. Resident 1 required transfer to the emergency room of the local hospital shortly after midnight, on 4/28/16, with agonal breathing (shallow breathing pattern that is often related to cardiac arrest and death), and severe dehydration. Her admission diagnoses included encephalopathy (disease of the brain that alters brain function or structure, may be caused by infectious agent bacteria, virus, or lack of oxygen or blood flow to the brain), and sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs). Resident 1 was intubated (a tube inserted into the windpipe), placed on mechanical ventilation, and admitted to the Intensive Care Unit (ICU), which presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 010000024 |
Granada Rehab & Wellness Center, LP |
110012818 |
B |
13-Jan-17 |
XOJI11 |
3580 |
Health & Safety Code 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. See Tag A 065 (Citation # 11-2123-0012818) Health & Safety Code 1418.91(b) (b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview and record review, the facility failed to report one altercation between two residents (Resident 11) and Random Residents 18, to the department within 24 hours of the occurrence. This could decrease the department's ability to ensure a complete investigation was done and inventions were started to protect the residents involved and other residents so there was no reoccurrence of abusive behaviors. During an interview and record review with the Administrator on 12/8/16 at 12 p.m., the Administrator stated as she reviewed two SOC 341, abuse reporting forms both dated 6/13/16, that both Resident 11 and Random Resident 18 were listed as victims and alleged abusers. Documentation on the forms indicated Random Resident 18 was observed in the doorway of the dining room when Random Resident 18 become upset and made contact with Resident 11. Resident 11 reacted by kicking Random Resident 18 in the knee. The documentation indicated Random Resident 18 had a history of Alzheimer's (Type of mental decline where there were problems with memory and thinking). The forms did not have documentation that the incident was reported to the Department of Public Health Licensing and Certification. The Interdisciplinary Progress Notes dated 6/13/16 indicated the resident's physicians and family were notified and the sheriff's office but did not indicate the Department was notified. During an interview on 12/8/16 at 12 p.m., The Administrator stated she did not report resident abuse cases to the Department of Public health when a resident had dementia (decline in mental ability associated with memory loss) and there was no injury. The Administrator stated she followed the facility abuse reporting policy dated 2015. During an interview on 12/8/16 at 2:10 p.m., the Administrator stated the newer facility abuse policy just came out 11/16 and these incidents were before that time, so she followed the old abuse policy. The Administrator stated she should have been aware of the state regulations for reporting, Review of the Facility Abuse Reporting policy first provided by the Administrator, revised 4/2015 indicated if the suspected abuse is allegedly caused by a resident who has been diagnosed with dementia and a licensed nurse reasonably determines that there was no serious bodily injury, the administrator or his or her designee shall report to the ombudsman or law enforcement agency as soon as practically possible and file a written report with 24 hours. Review of the Abuse Reporting & Investigations facility policy revised 11/2016, indicated under the title V. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia Diagnosed by a Physician -No Serious Bodily Injury. indicated the administrator or designated representative will immediately or as soon as practicable, notify by telephone, the ombudsman or law enforcement and send a written SOC 341 to the ombudsman or law enforcement and CDPH (California Department Of Public Health) Licensing and Certification 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. |
| 010000024 |
Granada Rehab & Wellness Center, LP |
110012819 |
B |
13-Jan-17 |
XOJI11 |
3608 |
Health & Safety Code 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. See Tag A 065 (Citation # 11-2123-0012819) Health & Safety Code 1418.91(b) (b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview and record review, the facility failed to report one altercation between two residents (Resident 11) and Random Residents 18, to the department within 24 hours of the occurrence. This could decrease the department's ability to ensure a complete investigation was done and inventions were started to protect the residents involved and other residents so there was no reoccurrence of abusive behaviors. Based on interview and record review, the facility failed to report one altercation between two residents, (Resident 11) and (Random Residents 19), to the department within 24 hours of the occurrence. This could decrease the department's ability to ensure a complete investigation was done and ensure inventions were started to protect the residents involved and other residents so there was no reoccurrence of abusive behaviors. Review of SOC 341 abuse reporting form dated 8/9/16 indicated on 8/9/16 at approximately 10:15 a.m., Resident 11 was listed as the abuser and Random Resident 19 was the victim. There was documentation, Random Resident 19 wheeled up the hallway and stopped in front of Resident 11's door. Resident 11 stated he slapped Random Resident 19 across the face. Random Resident 19 had a diagnosis of dementia (decline in mental ability associated memory loss). The form did not indicate the Department of Public health was notified. There was no injury according to Interdisciplinary progress notes dated 8/9/16 During an interview on 12/8/16 at 12 p.m., The Administrator stated she did not report resident abuse cases to the Department of Public health where a resident had dementia and there was no injury from the altercation. The Administrator stated she followed the facility abuse reporting policy dated 2015. During an interview on 12/8/16 at 2:10 p.m., the Administrator stated the newer facility abuse policy just came out 11/16 and these incidents were before that time, so she followed the old abuse policy. The administrator stated she should have been aware of the state regulations for reporting, Review of the Facility Abuse Reporting policy first provided by the Administrator and last revised 4/2015, indicated if the suspected abuse is allegedly caused by a resident who has been diagnosed with dementia and a licensed nurse reasonably determines that there is no serious bodily injury, the administrator or his or her designee shall report to the ombudsman or law enforcement agency as soon as practically possible and file a written report with 24 hours. Review of the Abuse Reporting & Investigations facility policy revised 11/2016, indicated under the title V. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia Diagnosed by a Physician -No Serious Bodily Injury. indicated the administrator or designated representative will immediately or as soon as practicable, notify by telephone, the ombudsman or law enforcement and send a written SOC 341 to the ombudsman or law enforcement and CDPH (California Department Of Public Health) Licensing and Certification 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. |
| 120000322 |
Golden Living Center - Bakersfield |
120008976 |
B |
21-Feb-12 |
XGKD11 |
2488 |
Title 22, Section 72311(a)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.Based on interview and record review, the facility failed to follow their care plan for transferring a patient, (A), which resulted in Patient A obtaining a laceration that required sutures, (stitches). Patient A was an 82 year old with a diagnosis of CVA (Cerebral Vascular Accident, also known as a stroke), and hemiplegia (total or partial paralysis of one side of the body). On 12/13/11, Patient A received a laceration three inches long and 1/4 of an inch wide to her left leg while being transferred from her wheel chair to her bed, using a lift device. This required Patient A to be transported to the hospital emergency department where she received sutures.During an interview with CNA (Certified Nursing Assistant) 1 on 12/23/11, at 8:40 AM, she stated that Patient A was a two person assist to transfer. CNA 1 stated it was, "Just me," when she transferred her to the bed. CNA 1 stated, "I used the Marrisa lift (a mechanical device used to transfer patients in and out of bed) by myself." CNA 1 indicated when she took off Patient A's pants, she noticed blood on her leg and notified the nurse.The clinical record was reviewed on 12/23/11 at 9:15 AM. Patient A's care plan for ADL (Activities of Daily Living) dated 12/31/10, indicated under "interventions," "Transfer assistance of two person Mech (mechanical) lift."During an interview with the Administrator on 12/23/11 at 9:45 AM, he reviewed the care plan for Patient A and stated she should have been a two person transfer and it was not done. The DSD (Director of Staff Development) Individual Training Form dated 12/13/11 for CNA 1was reviewed 12/23/11 at 10:15 AM. Under "reason for training," the form indicated, "Employee failed to follow P&P (Policy and Procedure) for mechanical lift usage with a resident. Under "response," it indicated, "Employee stated she transferred her resident from the w/c (wheel chair) with the Marissa lift without any assistance. The Administrator stated the resident was Patient A. Therefore, the facility failed to follow their care plan for transferring a patient, (A), which resulted in Patient A obtaining a laceration that required sutures. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 120000375 |
Golden Living Center - Shafter |
120008991 |
B |
16-Sep-13 |
GLXZ11 |
10200 |
F 226 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.On February 17, 2011 at 9:12 AM, an unannounced visit was made to investigate an entity reported event whereby one resident (Resident A) hit another resident (Resident B).Based on observation, interview, and record review, the facility failed to follow the abuse policy and procedure for two residents when one resident (Resident A) kicked another resident (Resident B). The facility failed to ensure a care plan was developed the day of the incident for Resident A and Resident B to ensure corrective action was implemented and continuous monitoring was initiated immediately following the incident. The facility failed to ensure the physician for Resident A and Resident B was notified immediately following the incident. The facility failed to assess Resident B for any injuries, both physical and emotional. This failure had the potential to result in a reoccurrence and/or an unawareness of the effects of the incident i.e. physical and/or emotional injury.The facility report for the incident between Resident A and Resident B was reviewed on 2/17/2011 at 8:30 AM. The report read in part, "On February 5th at approximately 1:20 PM, (Family Member 1 of Resident B) approached the Executive Director in the hallway to inform her that she was pushing (Resident B) and passed by (Resident A's) room. (Family Member 1) stated that (Resident A) kicked her (family member 1) three times in the leg...On 02-07-11 (family member 1) informed ED (Executive Director) that her sister (Resident B) was in fact kicked on 02-05-11 as well...there was a scuffle and (Resident B) got kicked..." During an observation on 2/17/2011 at 9:15 AM, Resident A was observed in her room, sitting in her wheelchair. A certified nursing assistant (CNA 1) was also in the room.During an interview with CNA 1, she indicated she was the one-one-staff assigned to supervise the resident from 6 AM until 2 PM on this particular day, due to the above stated incident on 2/5/2011. CNA 1 indicated, prior to the incident, she had not cared for Resident A. She did state, there was an incident recently whereby another resident wandered into Resident A's room, in order to stop Resident A from striking at the other resident, she intervened. She also stated, a Velcro strapped stop sign is on the resident's front door to prevent the reoccurrence of other wandering residents.During an interview with the director of nursing (DON), on 2/17/2011 at 9:35 AM, she stated on the day of occurrence (2/5/2011) family member 1 (FM 1) was pushing Resident B past Resident A who was in the hallway, when Resident A kicked FM 1 and Resident B. DON indicated Resident A tends to be territorial. During a subsequent interview DON indicated the one-to-one staff supervision was implemented on 2/12/ 2011, seven days after the incident and five days after the incident was reported to the ED.During an interview with CNA 2, on 2/17/2011 at 10:25 AM, she stated she has cared for Resident A on and off for the past three months. She indicated, Resident A tends to prefer to remain in her room. "Very rare she (Resident A) goes out..." Resident A tends to be very "easily agitated" and "territorial". If other residents even come near her room door, Resident A gets "agitated".During an interview with FM 1, on 2/17/2011 at 11:20 AM, she indicated she has seen Resident A kick out at others. A few days before the day of the incident, she stated, "We (Resident B and FM 1) were walking up/down the hallway...she (Resident A) kicked me on the outside of left knee...a couple of days later we're walking up/down the hallway" and Resident A kicked me three times and kicked Resident B once on her left leg (day of incident).The clinical record for Resident A was reviewed on 2/17/2011 at 10:45 AM. The Minimum Data Set (MDS) assessment dated, November 23, 2010 indicated the resident did display behaviors during this assessment period. The active care plans indicated, Resident A had cognitive impairment with impaired decision making and short term memory loss due to Alzheimer's disease. The care plans were reviewed. There were care plans in place for "trying to hit others", "Has persistent episodes of anger manifested by: angry outbursts", "Resident has episodes of Depression as manifested by: irritable. Depression, sad facial expressions, tearfulness"...A short term care plan, initiated "2/10/2011" read in part, "Resident involved in resident to resident altercation: kicked fellow resident on 02/05/2011. She has period of confusion & forgetfulness r/t (related to) dx. (diagnosis) of Alzheimer's". The approaches included, "Attempt interventions before her behaviors begin Date initiated:2/10/2011...Do not seat resident around others who disturb her Date initiated:2/10/2011...Monitor resident for s/s (signs and symptoms) of distress r/t alleged incident x 72 hrs Date initiated 2/10/2011...1:1 coverage Date initiated 2/10/2011..." The initiation of this short term care plan was five days after the incident occurred and three days after the incident was reported to the administrator.A continued review of Resident A's clinical record was conducted. The first nursing note was done on 2/10/2011 at 9:13 PM, the note indicated it was a late entry and read in part, "resident on post altercation monitoring for incident on 02-05-2011. no further episodes this shift. Resident sepnt (sic) most of shift up in WC (wheelchair) in hallway near room and at nursing station. Resident currently in bed resting comfortably with eyes closed...nsg (nursing) will continue to monitor for safety and needs." There is no indication on the nursing note; the physician was notified of the incident on the date of occurrence.The clinical record for Resident B was reviewed on 2/17/2011 at 9:40 AM. Resident B has a diagnosis which includes Debility. The care plans were reviewed. A short term care plan initiated February 10, 2011 read in part, "resident to resident altercation on 02/05/2011. resident was kicked by another resident in the hallway." Approaches included, "Assess for pain/discomfort Date initiated:2/10/2011...Monitor resident for any s/s/ of distress from alleged incident x 72 hours Date initiated:2/10/2011...Notify MD Date inititated:2/12/2011..." This care plan was initiated five days after the incident and three days after it was reported to the administrator.A continued review of Resident B's clinical record was conducted. The nurse's notes were reviewed. On the day of the incident, 2/5/2011 there was no documentation of the incident. There was no documentation of the incident and monitoring by nursing being done on 2/5, 2/6, 2/7, 2/8, or 2/9/2011. The first noted nursing documentation was on February 10, 2011 at 9:26 PM, late entry and it read in part, "resident continues on post altercation monitoring for allegid (sic) abuse by fellow resident on 02/05/2011. no s/s or complaints of pain or discomfort. No appearant (sic) s/s of distress noted this shift. Resident currently in bed resting comfortably with eyes closed..." There was no documentation by this nurse or any other nurse the physician was made aware of the incident or any documentation a nurse assessed her for any injuries on the day of the incident.During a subsequent interview with DON, on February 17, 2011 at 9:50 AM, she stated after the Interdisciplinary Team (IDT) met, Resident A was placed on one-to-one supervision. A review of the staff assignment sheets for the one-to-one supervision was conducted with DON and the assignments confirm the one-to-one supervision started on February 12, 2011 which is seven days after the incident occurred and five days after the incident. She stated the Social Service Director kept record of the IDT notes.During an interview with the Social Service Director (SSD), on February 17, 2011 at 10 AM a review of the "GRAND ROUNDS / CARE PLAN CONFERENCE" dated February 12, 2011 for Resident A had documented, "Episodes of tearfulness...Resident put on 1:1 monitoring." SSD confirmed at this time, Resident A was started on one-to-one supervision on February 12, 2011 which was seven days after the incident and five days after the incident was reported to the administrator.The facility policy and procedure titled, "POLICIES AND PROCEDURES REGARDING INVESTIGATION AND REPORTING OF ALLEGED VIOLATIONS OF FEDERAL OR STATE LAWS INVOLVING MISTREATMENT, NEGLECT, ABUSE, INJURIES OF UNKNOWN SOURCE AND MISAPPROPRIATION OF RESIDENT'S PROPERTY' dated July 2002 was reviewed. Under the "PROTECTION" subheading it indicated, "Where the circumstances of the alleged violation warrants, the DNS (Director of Nursing Services) or his/her designee shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented...The DNS shall also notify the attending physician regarding the alleged violation and findings and document the contact." Under the "CORRECTIVE ACTION" it indicated in part, "A. The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action...and to eliminate any ongoing dangers to the resident. B. The DNS, or his/her designee, shall initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. The steps taken should be documented." Under the "DOCUMENTATION" subheading it indicated in part, "...B. Documentation in the medical record shall be made where necessary for continuity of care for the resident." Therefore the facility failed to follow its abuse policy and procedure when one resident kicked another resident and there was no care plan developed on the day of the incident to ensure appropriate action was initiated and monitoring was done, there was no physician notification on the day of the incident and there was noted assessment of the resident who was kicked to ensure there was no emotional or physical injuries.The above violation has a direct relationship to the health, safety or security of the resident. |
| 120000322 |
Golden Living Center - Bakersfield |
120010491 |
B |
25-Feb-14 |
3QQT11 |
2818 |
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. On 12/9/13, an unannounced visit was made to the facility to investigate a complaint regarding Resident 1's fractured left arm.Based on interview and record review, the facility failed to report injuries of unknown source within the required time frame for one patient (1). Findings: During an interview with Certified Nursing Assistant (CNA), on 12/9/13, at 4:30 PM, she stated on 12/4/13, at around 9 PM, she noticed a big bruise and swelling to Patient 1's left arm. She also stated, the patient was so confused but screaming louder than usual. She reported the bruise to the Registered Nurse (RN). During an interview with the RN, on 12/9/13, at 4:40 PM, she stated on 12/4/13, the CNA reported to her a bruise to Patient 1's left arm. She noted a big light blue discoloration to the left upper arm, and the whole arm was fluid filled. Patient 1 moaned and yelled out loud when the area was being touched. She did not know what happened because the patient was confused. The physician was made aware and ordered Lasix (water pill) and to elevate the left arm.During an interview with the Director of Nursing (DON), on 12/11/13, at 11:15 AM, he stated Patient 1 was dependent with activities of daily living. The bruise to her left arm was found on 12/4/13, afternoon shift. The next day 12/5/13, the discoloration was increased in size. The staff called the physician and ordered an X- ray. The X- ray result showed there was a fracture, and the physician ordered to send Patient 1 to the hospital. When the DON was asked if the facility reported the incident to the Department within the required time frame. He stated the facility reported the incident to the Department on 12/9/13.The facility policy and procedure revised 3/1/13 indicated under Policy, read in part "It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property ("alleged violations"), are reported immediately to the Executive Director of the center /location or the Aegis District Manager shall report all "alleged" or "suspected" abuse of a resident to the Dept. of Health Services immediately or within 24 hours (CA H&S Code 1418.19a)..."Therefore, the facility failed to notify the Department of an injury of unknown source within 24 hours in accordance with Health and Safety Code Section 1418.91, this violation is a class "B" violation. |
| 120000375 |
Golden Living Center - Shafter |
120011044 |
A |
08-Oct-14 |
06T811 |
9388 |
The facility must ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. On 7/23/14, at 10:45 AM, an unannounced visit was made to the facility to investigate an entity reported incident of a fall with injury. Based on interview and record review, the facility failed to: 1) Adequately supervise one sampled resident (1), who was at high risk for falls, while ambulating 2) Refer one sampled resident (1) for a rehabilitation screening when there was a decline in function. These failures resulted in Resident 1 falling and sustaining a fractured left fifth finger. Resident 1 was a 60 year old female admitted on 11/12/13, with diagnoses of Alzheimer's disease (a chronic, progressive cognitive disorder), senile dementia (general loss of cognitive abilities including impairment in memory), anxiety disorder, history of a closed fracture of the patella (kneecap), cataracts (clouding of the lens inside the eye which leads to a decrease in vision), muscle weakness, and atrial fibrillation (abnormal heartbeat, heart rhythm is irregular). During a review of the clinical record, the care plans were reviewed. The care plan, dated 11/13/13, indicated: "At risk for falls related to: use of medication antianxiety (medication that can relieve symptoms of anxiety), poor safety awareness secondary to Dx (diagnosis): Dementia, Wandering and poor eyesight, h/o (history of) fall..." Under the "Interventions" subheading it read, "...Direct resident as needed due to her poor eyesight. Assist to get to areas she needs to be in for programs, her room, bathroom, hallway..." The care plan dated 1/2/14, indicated, "Resident noted to have poor vision...Interventions...Monitor resident's movement while ambulating..."The Minimum Data Set (MDS, assessment tool) dated 3/4/14, was reviewed. The "Brief Interview for Mental Status (BIMS-a brief screener that aids in detecting cognitive impairment)" score was 3/15 (severe cognitive impairment). The vision was coded a 3 (highly impaired vision-object identification in question, but eyes appear to follow object). The active diagnoses included Alzheimer's disease and anxiety disorder. The 6/4/14, MDS assessment was reviewed. The BIMS score was 1/15 (severe cognitive impairment) and the vision was coded a 3 (highly impaired vision). The document titled "Quarterly Interdisciplinary Resident Review...Section M...Risk for Falls," dated 6/4/14, indicated a total score of 11 (total score of 10 or above deems the resident is at risk for falls). The "Progress Notes" dated 7/14/14, at 9:22 PM, indicated in part, "...Resident (1) was pacing throughout ACU (Alzheimer's Care Unit); Seen resident bump head on corner of the door Room # (number) 8; staff attempted to help resident before resident fell on the floor and landed on left arm...Resident crying as usual behavior; Noted resident to be in distress with severe pain while resident holding onto left hand; swelling and purplish discoloration between pinky and ring finger; and between middle finger and index finger...Sent to ER (Emergency Room) for treatment and evaluation..."The hospital "History and Physical" dated 7/14/14, indicated in part, "History of Present Illness...history of severe dementia...had an accidental fall, hit the corner of the wall and injured the right hip as well as the left forearm...She is not well ambulatory...". Past Medical History included, "Severe Alzheimer dementia". Under the Assessment subheading it read, "Status post fall with right hip bruise...Fracture of the left fifth finger...Severe dementia and blindness..."1. During an interview with the Alzheimer's Unit Director (AUD), on 7/23/14, at 10:55 AM, she stated Resident 1 can only see shadows but is unable to see faces. AUD stated if Resident 1 would get upset, she would walk up and down the hall. When Resident 1 was unsteady on her feet, a staff would have to assist her getting to and from different locations in the ACU. AUD added Resident 1 would walk aimlessly. Some days she needed to be assisted (when walking and going to other areas of the ACU) when she was tired and upset.During an interview with Certified Nursing Assistant 1 (CNA 1), on 7/23/14, at 12:08 PM, she stated Resident 1's vision was impaired and she would bump into the beds. CNA 1 stated Resident 1 was not steady on her feet when she walked and would lean forward.During an interview with CNA 2, on 7/23/14, at 4:10 PM, she stated while Resident 1 was walking (7/14/14), she saw Resident 1 fall. CNA 2 stated Resident 1 would walk straight without noticing something in front of her because she could not see very well; she was at risk of tripping. CNA 2 added Resident 1 would not stay still; she would get up right away when she was asked to sit down or lay down on the bed. CNA 2 stated Resident 1 had been crying more than usual and she was more anxious wanting to go home, on the day of fall. During an interview with CNA 3, on 7/23/14, at 4:20 PM, CNA 3 stated Licensed Vocational Nurse 1 (LVN 1) told her she would watch the floor and she left Resident 1 being supervised by LVN 1. Resident 1 needed to be watched constantly because she wandered into the other residents' rooms, walked up and down the hallway and would not stand still. During a subsequent interview with CNA 3, on 9/25/14, at 5:10 PM, she stated on the day Resident 1 fell (7/14/14), LVN 1 was standing by the hallway outside the living room. CNA 3 stated Resident 1 walked down the hallway, ran into the door frame of Room 8, which "knocked" her off balance causing her fall to the floor. LVN 1 was not close enough to Resident 1 to catch her before she fell. She added, Resident 1 needed to be assisted when going to the bathroom, living room, dining room/kitchen and to other areas of the ACU.During an interview with the LVN 1, on 7/23/14, at 3:51 PM, she stated Resident 1 was in the hallway walking near her room and she was crying. LVN 1 stated she noticed Resident 1 bumped her head at the corner of the door lost her balance causing her to fall to the floor. LVN 1 added Resident 1 would pace back and forth especially in the afternoon and she would cry looking for her family. During an interview with LVN 2, on 8/21/14, at 12:55 PM, she was asked how often Resident 1 was being monitored. LVN 2 stated when Resident 1 was up walking, she needed to be followed all the time. She stated Resident 1 is now on one to one (one caregiver supervising the resident at all times) supervision after the fall on 7/14/14. She added Resident 1 did not have one to one supervision before she fell. During a concurrent interview and review of the clinical record for Resident 1 with the Director of Nursing (DON), on 9/29/14, at 3:50 PM, the document titled, "Quarterly Interdisciplinary Resident Review" dated 6/4/14, was reviewed. The "Section M...Risk for Falls" indicated a total score of 11 (total score of 10 or above deems resident at risk for falls). This was validated with the DON.The facility policy and procedure titled "Falls Management Clinical Guidelines" revised 2013 indicated "...Residents at risk for falls are care planned with individualized interventions..." 2. During a concurrent interview and review of the clinical record for Resident 1 with the AUD, on 7/23/14, at 1 PM, the MDS assessment dated 2/18/14, indicated for moving on and off the toilet Resident 1 was "Steady at all times", for surface-to-surface transfers Resident 1 was "Steady at all times", and for dressing Resident 1 required "Limited assistance (resident is highly involved in activity; staff provide weight bearing support)". The MDS assessment dated 3/4/14, indicated for moving on and off toilet the resident was "Not steady, only able to stabilize with staff assistance", for surface-to-surface transfer the resident was "Not steady, only able to stabilize with staff assistance", and for dressing the resident required "Extensive assistance (resident involved in activity, staff provide weight bearing support)..." This was verified with the AUD.During an interview with the MDS Nurse, on 8/21/14, at 2:05 PM, she confirmed there was a significant change in status assessment done on 3/4/14, due to a decline in function. MDS Nurse (MDSN) stated, residents are referred to rehabilitation services if there is a noted decline in function, to determine if the resident could benefit from rehabilitation services. She was unable to provide documentation that Resident 1 was referred to rehabilitation services when Resident 1 had a decline in function on 3/4/14. No further information was provided. The facility policy and procedure titled "Falls Management Clinical Guidelines" revised 2013, indicated "...The interdisciplinary team evaluates the fall prevention plan of care for residents "at risk" for falls...This evaluation may include a screening by a rehabilitation services representative..." The facility failed to adequately supervise Resident 1 while ambulating and failed to refer Resident 1 for a rehabilitation screen when there was a decline in function, which resulted in Resident 1 falling and sustaining a fractured left fifth finger. Therefore, the above violation presented a substantial probability that serious physical harm to the resident would result and constitutes a Class "A" citation. |
| 120000322 |
Golden Living Center - Bakersfield |
120011240 |
A |
03-Feb-15 |
FIU511 |
22747 |
F441 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.(a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections.(b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.(c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.On 12/16/14, at 1:40 PM, an unannounced visit was made to the facility to investigate an allegation of a Scabies outbreak at the facility. Based on observation, interview, and record review, the facility failed to ensure an effective infection control program was established when the facility failed to:1. Investigate, prevent and control the spread of scabies (according to Center for Disease Control [CDC] human scabies is caused by an infestation of the skin by the human itch mite. The tiny scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Scabies can spread rapidly under crowded conditions where close body contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks) in the facility for four of four sampled residents (1, 2, 3, and 4) and four of four facility staff (Licensed Nurse [LN] 1, Certified Nursing Assistants [CNA] 1, 2, and 3).2. Develop a care plan for four of four sampled residents (1, 2, 3, and 4) who were receiving treatment for scabies.3. Ensure one of one housekeepers (HS) and one of one laundry staff (LS) interviewed were properly trained and knowledgeable about their roles in scabies prevention and control for four sampled residents (1, 2, 3, and 4) being treated for scabies.4. Report the case of suspected scabies to the County of Public Health.These failures had the potential to place all ninety two residents in the facility at risk of acquiring scabies.Findings:According to the document written by the California Department of Public Health Division of Communicable Disease Control, dated 3/2008, it indicated for the "PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA LONG-TERM CARE FACILITIES", under the subheading for the development of a "SCABIES PREVENTION PROGRAM," it read in part, "Long term care facilities should have a scabies prevention program...When scabies is suspected, an immediate search for additional cases should be initiated." Under the subheading for developing a "SCABIES CONTROL PROGRAM," it read in part, "A scabies control program should be developed and approved by the infection control committee. The program should designate a physician such as the medical director who will act as the program coordinator. The physician should be given the authority to notify attending physicians, perform diagnostic procedures such as skin scrapings and to order prophylactic and therapeutic treatments on exposed residents. The infection control practitioner should be responsible for (1) identification of contacts of symptomatic case(S). (2) prevention of transmission, (3) treatment of symptomatic cases, (4) treatment of contacts. (5) post-treatment assessment and (6) assessment of treatment failures."1a. On 12/16/14, at 2:15 PM, accompanied by a certified nursing attendant (CNA 1), a concurrent observation and interview was conducted with Resident 1 in her room. On entering Resident 1's room, it was noted there was no Personal Protective Equipment setup ([PPE]-specialized clothing including gowns, gloves, masks or equipment worn by an employee for protection against infectious materials) outside her door. As CNA 1 pulling the resident's privacy curtain around her, Resident 1 stated she could just show the rash while sitting in her motorized wheelchair. Resident 1 proceeded to expose the rash while sitting in her motorized wheelchair. There was a reddish/brownish raised rash extending from her abdomen, underneath both breast, and to both underarms. Resident 1 stated, the rash started months ago, when there were five residents playing Bingo and making statements they had rashes with severe itching. Resident 1 also stated, a few days after that she started having itchiness and rashes. Resident 1 added that her roommate (Resident 2) now also has the same rash and "Her rash is really bad."1b. Resident 2 had been residing at the facility for over a year. She is also alert and able to answer questions appropriately. Both Resident 1 and 2 have been roommates during the scabies outbreak.On 12/16/14, at 2:25 PM, accompanied by CNA 1, a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed in bed and scratching her neck and face aggressively. Resident 2 stated, "It's very itchy." It was noted she had raised rashes and crusted skin extending from her face, neck, ears to her trunk and to both of her upper and lower extremities. When Resident 2 was asked about the rash she stated, she has had the rash for months and the staff had applied some cream, "I wish they put more (referring to the application of the cream) because I'm scratching my skin off my bones."During a concurrent observation and interview, on 12/16/14, at 2:35 PM, outside of Resident 1 and Resident 2's room, it was observed that CNA 1, CNA 4, and CNA 5 were coming in and out of their room without wearing PPE. CNA 1 was asked if Resident 1 and Resident 2 were placed on contact precautions. CNA 1 stated, "No".During an interview with the Director of Nursing (DON), on 12/16/14, at 2:09 PM, outside of Resident 1 and Resident 2's room, the DON was asked if Resident 1 and Resident 2 were on contact isolation precautions. The DON stated "No" because Resident 1 just had the Elimite cream (a topical agent for the treatment of infestation with scabies) applied on 12/1/14 prophylactically (action taken to prevent disease). The DON also stated Resident 1 had a skin scraping (to examine under a microscope for mites, eggs, or mite fecal matter) performed and the facility was waiting for the results. She was asked what procedures the facility implemented to prevent and control a scabies infestation. The DON could not provide any further information that the facility had taken actions to prevent the spread of scabies.The facility policy and procedures titled "Isolation-Initiating Transmission-Based Precautions", revised 8/2012, indicated, under the subheading for Policy Interpretation and Implementation, "...5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves gowns, masks, etc.) is maintained outside the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door, so that all personnel and staff will be aware of precautions, or be aware that they must see a nurse to obtain additional information about the situation before entering the room. c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room..." During an interview with the DON, on 12/16/14, at 2:40 PM, in regards to Resident 1 and 2's rashes, the DON stated she did not assess Resident 1 or Resident 2's rash, but was aware these two residents were treated with Elimite. She also stated Treatment Nurse (TN) 1, had been updating her in regards to the residents' rashes. The DON was asked about the facility's policy and procedures for Infection Control (IC) to prevent and control a scabies outbreak, the DON stated she did not know. No further information regarding prevention and control of scabies was provided. The DON was asked again what policies and procedures did the facility have in place to prevent the spread of scabies. The DON stated the nurses were calling the physician to obtain orders for a cream. No further information was provided.During an interview with the Infection Control Nurse (ICN), on 12/16/14, at 4 PM, she stated she was aware Resident 1 and Resident 2 had the Elimite treatment; however, when she asked the nurse about the residents' skin condition, the nurse told her there was no confirmed diagnosis of scabies. The ICN also stated she had not read the policy and procedures for IC nor had she been tracking those residents who had suspected scabies or treated with Elimite.During an interview with CNA 2, on 12/16/14, at 4:25 PM, she stated she was one of the CNAs taking care of Resident 2. She was aware Resident 2 had been treated with Elimite. CNA 2 added whenever they had residents treated with Elimite cream, the protocol was to get the resident's linens and clothes and place them in a red bag. Then endorse to the laundry staff that these items were infectious. If the laundry staff were not in the laundry room, staff would return the bag back to the resident's room and place it in the bathroom.The facility policy and procedures titled "Scabies", effective date 12/1/14, indicated under Pre-Treatment Procedure, "1. While the resident is being treated, remove four (4) sets of clothing from the resident's room. Bag the clothing in a bag, and send the bag to the laundry for processing. 2. Place all remaining clothes of the infected resident into a bag. Seal the bag and label "Do not open until___" (date 14 days from storage date). Take to designated storage area. Note: Coordinate these procedures between nursing and environmental services."1c. During a review of the clinical record for Resident 3, a physician's order dated 11/29/14, read: "Elimite Cream 5% (Permethrin) Apply to body topically at bedtime for rash until 11/30/14 at 23:59 [11:59 PM], apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens AND apply to body topically at bedtime for rash until 12/14/14, 23:59 (11:59 PM) apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens."During an interview with LN 2, on 12/16/14, at 4:35 PM, she stated when she applied the Elimite cream on Resident 3, she did not wear any PPE. LN 2 only wore PPE when the physician ordered isolation precautions. LN 2 stated, there was no physician's order for isolation for Resident 3; therefore, she did not wear any PPE. LN 2 also stated the facility did not treat Resident 3's roommate, because Resident 3's roommate did not complain of any rash.According to California Department of Public Health, Management of Scabies Outbreak in California Health Care Facilities, dated 3/2008, under "Controlling the Outbreak," it read: "Control of an outbreak involves a choice between treating only symptomatic cases and their known contacts or treating possible contacts including asymptomatic patients, healthcare workers, volunteers, and visitors (mass prophylaxis)... Treatment of only symptomatic cases and their identified contacts may result in silent, continuous transmission over a sustained period of time. As a result, retreatment of all or some of the cases may be required."1d. During a review of the clinical record for Resident 4, a physician's order dated 12/7/14, indicated, "Elimite Cream 5% (Permethrin) Apply to rash all over body topically one time only to rash on body and leave for 12 hours related to Rash and OTHER NONSPECIFIC SKIN ERUPTION for 1 Day give shower after 12 hours and remove elimite [sic]." Resident 4 was in a room with four other roommates. There was no documentation that Resident 4 was placed on isolation or separated from the other three roommates.During an interview with TN 1, on 12/16/14, at 3:40 PM, TN 1 stated she currently had approximately nine residents under treatments for rash and several other residents had received Elimite Cream. TN 1 was asked in regards to the facility policy and procedure on prevention and control of scabies outbreak. She stated she had not read it. TN 1 was then asked about the process followed when residents develop unexplained rashes, TN 1 replied, "I don't know." She stated she did not wear PPE when treating residents with suspected scabies. She only used PPE for residents who had physician's orders for Isolation precaution.The facility policy and procedures titled "INFECTIOUS -CLINICAL PROTOCOL" revised 10/2013, indicated: "C. Skin/Soft Tissue Infection (SSTI)...(5) Consider scabies in any resident with unexplained generalized rash. It may be helpful to consult a dermatologist (branch of medicine dealing with the hair, nails, skin and its diseases) and/or obtain scrapings for evaluation of mites, eggs, or mite feces."1e. During an interview with LN 1, on 12/17/14, at 10:30 AM, he stated he started seeing residents with skin rashes in 6/2014. He notified the acting DON at the time. He stated the Administrator was also aware of the residents with rashes; however, the facility did not want to acknowledge there was suspected scabies in the facility. LN 1 stated he currently had a rash and was diagnosed and treated for scabies. He reported to the Administrator again.1f. During an interview with CNA 1, on 12/16/14, at 2:28 PM, she stated, after she gave Resident 2 a shower (cannot remember the date) and two days later she developed a rash on her stomach. She treated herself at home. She also stated she informed the nurses and administration about her rash "But they keep saying it's not scabies."1g. During an interview with CNA 2, on 12/16/14, at 4:27 PM, she stated she also had a rash and she treated herself with Kwell (another medication used to treat scabies). She had scabies in the past and she knew she had scabies. CNA 2 stated, about two weeks ago, she told the Administrator about the rash and that it might be scabies. The Administrator told her he would investigate.During an interview with the Administrator, on 12/16/14, at 4:50 PM, he stated CNA 2 did notify him of her skin rash but he did not investigate it.1h. During an interview with CNA 3, on 12/17/14, at 11:37 AM, she stated on 12/4/14 she had to go to a local acute hospital due to her worsening skin rash and itchiness. The hospital told her that she had scabies. CNA 3 stated she notified the ICN that day that she would be absent for a couple of days because she had scabies.During an interview with the ICN, on 12/17/14, at 11:30 AM, the ICN verified that CNA 3 did inform her that she was diagnosed and treated for scabies.According to California Department of Public Health Division of Communicable Disease Control, dated 3/2008, under "PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA LONG-TERM CARE facilities," under the subheading Identification of Contacts of Symptomatic Case(s), read: "As soon as a possible case of scabies is identified, the infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had a direct, physical contact with the case within the previous month. If more than one symptomatic case is identified, a separate contact list for each case may be required."The facility policy and procedures titled "Scabies," effective date 12/1/14, under "General Guidelines," read, "7. Staff members who may have been exposed should report any rashes developing on their bodies to the Infection Preventionist or Director of Nursing Services."2a. During a review of the clinical record for Resident 1, a physician's order dated 12/1/14, indicated, "Elimite Cream 5% topically, apply to skin from neck down in pm, and wash off in am repeat in 1 week 2 weeks." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control the possible spread of the infection. TN 1 verified the findings.2b. During a review of the clinical record for Resident 2, a physician's order dated 10/26/14, indicated "Elimite Cream 5% (Permethrin) Apply to entire body topically one time only related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION until 10/27/14 at 23:59 [11:59 PM]." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control the possible spread of infection. TN 1 verified the findings.2c. During a review of the clinical record for Resident 3, a physician's order dated 11/29/14, indicated: "Elimite Cream 5% (Permethrin) Apply to body topically at bedtime for rash until 11/30/14 at 23:59, apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens AND apply to body topically at bedtime for rash until 12/14/14, 23:59 (11:59 PM) apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control possible spread of infection. TN 1 verified the findings.2d. During a review of the clinical record for Resident 4, a physician's order dated 12/7/14, read: "Elimite Cream 5% (Permethrin) Apply to rash all over body topically one time only to rash on body and leave for 12 hours related to Rash and OTHER NONSPECIFIC SKIN ERUPTION for 1 Day give shower after 12 hours and remove elimite." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control possible spread of infection. TN 1 verified the findings.3a. During an interview with the Housekeeping Supervisor (HS), on 12/17/14, at 10:35 AM, he was asked if nursing staff had informed him to clean the following rooms:Resident 1's room on 12/2/14, after Resident 1 received Elimite treatment, Resident 2's room, on 10/27/14, after Resident 2 received Elimite treatment, Resident 3's room, on 11/30/14, after Resident 3 received Elimite treatment, and Resident 4's room, on 12/8/14, after Resident 4 received Elimite treatment.The HS stated, those rooms were cleaned daily with no special instructions from the nursing department and no special precautions were taken by the housekeeping department. When the HS was asked how the housekeeping department was informed if residents had infectious diseases such as scabies, he stated, "No one tells me."The facility policy and procedures titled, "Scabies", effective date 12/1/14, indicated under Environmental Services: "1. Clean lobbies, lounges, etc., before resident bathing and treatment times so that "treated" residents do not use unclean areas. 2. Clean and disinfect shower rooms after all residents have received their treatment. 3. Vacuum furniture made of fabric in the residents room. Wrap the furniture in plastic and store for two (2) weeks..."The facility policy and procedures titled "HEALTHCARE SERVICES GROUP, INC. JOB TO BE DONE: CONTAMINATED ISOLATION ROOM CLEANING," dated 5/11/05, under "Steps to do Job," it read, "Before entering the room: 1) Scrub hands and arms for 3 minutes with disinfectant soap. 2) Dress on Isolation clothes: 1st- Booties 2nd- Cap 3rd- Mask 4th- Gown 5th- Gloves..."3b. During a concurrent observation and interview with a Laundry Staff (LS), on 12/19/14, at 1:40 PM, the LS was asked if she received inservice training about scabies prevention and control, she replied, "Yes". The LS stated, the CNAs would place the dirty laundry infected with scabies in the soiled laundry room barrels or on the floor. When the LS was asked how she would know if the dirty laundry was infectious or not, the LS stated, "I don't' know."The facility policy and procedures titled "Scabies," effective date 12/1/14, under Laundry Department, read: "1. Wash four (4) changes of clothing for each affected resident and place the clothing in a plastic bag. Label it with the resident's name and store it in the clean laundry area until treatment has ended (8 to 14 hours). 2. Upon completion of treatment, return these 4 changes of clothing to the resident's room. 3. Store the resident's remaining clothing in a storage area for 14 days, without laundering it. 4. Upon completion of 14 day storage, launder and return clothing to the resident's room. 5. Wear gloves and gowns when handling contaminated laundry..."4. During an interview with the ICN regarding scabies reporting to the local health department, on 12/16/14, at 4:10 PM, she stated the facility had not reported the scabies outbreak to the County Department of Public Health.The facility policy and procedures titled "Isolation-Initiating Transmission-Based Precautions", revised 8/2012, under Authority in Emergency Situations, read: "In an emergency, the Infection Preventionist, Administrator and/or Medical Director shall have the administrative authority, accountability and responsibility to...b. Notify the health department of reportable diseases, as appropriate..."According to the document written by the California Department of Public Health Division of Communicable Disease, dated 3/2008, it indicated under Outbreak Definition: "a scabies outbreak can be defined as two or more patients, healthcare workers, volunteers, and/or visitors with at least one confirmed positive skin scrapings within two week period; one confirmed (positive skin scarping) and at least two clinically suspect cases identified in patients, health care workers, volunteers, and/or visitors during a two week period or at least one clinically suspect of scabies identified in patients, healthcare workers, volunteers and/or visitors within a two week period."The facility was aware that one of its healthcare workers (CNA 3) was confirmed and treated with scabies on 12/4/14 and four suspected cases (Resident 1, 2, 3, and 4) within a two-week period. The facility administration did not report the scabies outbreak to the county health department.These violations presented either imminent danger that serious harm would result or a substantial probability that serious physical harm would result. |
| 120000375 |
Golden Living Center - Shafter |
120012066 |
B |
14-Mar-16 |
H82C11 |
3796 |
T22 72520(a)(b)(c) (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and the insurance may or may not cover such costs. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. Based on interview and record review, the facility failed, upon transfer to the acute hospital, to offer a seven day bed hold, offer the first available bed, and readmit one of one sampled resident (1). This resulted in a violation of Resident 1's admission agreement and Regulation. Findings:The clinical record for Resident 1 was reviewed. Resident 1's admission record indicated her pay sources included Medicare and Medicaid. A seven day bed hold was not documented in this record. During an interview with the Administrator, on 2/12/16, at 1:10 PM, she stated yesterday (2/10/16) the resident (Resident 1) was transferred to the acute hospital because of her behavior. The Administrator stated the resident was not offered a seven day bed hold and the facility decided not to readmit the resident back to the facility. During an interview with the acute hospital House Manager (HM), on 2/17/16, at 8:55 AM, she stated the resident was medically stable, but the resident was still at the hospital because the facility was refusing to readmit the resident.The facility provided the booklet titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" dated 5/11, as the admission agreement provided to all admitted residents. This Admission Agreement read "If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medi-Cal [Medicaid] is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If you are not eligible for Medi-Cal and the daily rate is not covered by your insurance, then you are responsible for paying $________ for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations. If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted." |
| 120000322 |
Golden Living Center - Bakersfield |
120012180 |
A |
23-May-16 |
TS5C12 |
11988 |
F309-42CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On February 16, 2016, at 6:02 AM, an unannounced visit was made to the facility for an annual recertification survey. Based on observation, interview, and record review, the facility failed to provide effective pain medication in a timely manner for two random residents (21 and 22). This failure resulted in unrelieved pain for Resident 21 and Resident 22.1. Resident 21 was a 52 year old female with diagnoses of pulmonary fibrosis (the formation of scar tissue in the lungs which causes difficulty breathing), diabetes (a serious medical life-long disease that affects the way the body handles sugar in the blood and has many complications), diabetic related peripheral neuropathy (a condition in which muscle weakness, loss of feeling and impaired reflexes in the hands and feet are common), and a history of Charcot arthropathy (the progressive destruction of weight bearing joints). She was admitted to Golden Living Center Bakersfield on February 15, 2016 from an acute care hospital following an open lung biopsy (surgery). She was alert and oriented and was observed to have a splint on her right wrist and an orthotic device on her left foot and lower leg. During an initial tour observation on 2/16/16, at 7:05 AM, in Hallway A, Resident 21 was observed lying in bed, with a grimacing facial expression. A black splint was observed on her right wrist area and a black orthotic device (boot) was on her left foot and lower leg.During an interview with Resident 21, on 2/16/16, at 7:05 AM, she stated she was "dumped" here [at the facility] the previous night and had not received any medication that relieved her pain. She stated she had just had an open lung biopsy [surgery] and was at this facility for post-operative rehabilitation care. Resident 21 stated she had fallen prior to admission and fractured (broke) her right wrist. She stated the boot to her left foot and leg was related to her diabetes.Resident 21 stated the facility staff had been unable to obtain the pain relief medication ordered by her physician and she had been in pain all night. She stated the facility gave her "some [non-narcotic] pain medication around 9 PM last night" [three hours after she was admitted], but that it did not come close to relieving her pain. She stated the facility informed her they were trying to obtain the narcotic pain medication but were having difficulty getting the order or obtaining it from the pharmacy.During a review of the clinical record for Resident 21, the Pulmonary and Critical Care Consultation Report transcribed 2/10/16, at 3:32 PM, indicated Resident 21 had a past medical history of diabetes with related complications, pulmonary fibrosis (damaged and scarred lung tissue which makes it hard to breathe), history of emphysema (chronic lung disease which causes difficulty in breathing), possible lupus autoimmune related disease, Charcot arthropathy (progressive destruction of weight bearing joint). The Progress Notes dated 2/15/16, at 6:30 PM indicated Resident 21 was admitted to the facility and had no complaints of pain at that time. The Progress Notes dated 2/16/16, at 8:57 AM, "General Note", indicated the resident stated "she was in ...pain on admission."During a review of the clinical record for Resident 21, the Order Summary Report dated 2/15/16, at 10:25 PM, indicated the following pain medication orders: Norco (narcotic pain medication) 5-325 milligrams (mg-a unit of measurement) one tablet every four hours as needed for moderate pain; Norco 5-325 mg two tablets every four hours as needed for severe pain; Ibuprofen (Non-Narcotic anti-inflammatory) 800 mg one tablets every eight hour as needed for moderate pain.During a review of the clinical record for Resident 21, the Medication Administration Record (MAR) dated 2/15/16, at 9:24 PM, indicated the resident had a pain level of six out of ten. One tablet of Ibuprofen 800 mg was documented as given at 9:24 PM, for moderate pain, and was noted as ineffective for pain relief. No other actions were taken to relieve the resident's pain at that time. On 2/16/16, at 8:12 AM, she received Ibuprofen 800 mg for a pain level of five out of ten, which was indicated as effective on the MAR. She did not receive the prescribed narcotic pain medication for severe pain (six out of ten level) until 2/16/16, at 4 PM, 10 hours after her admission to the facility.During an interview with Licensed Vocational Nurse (LVN) 2, on 2/18/16, at 3:30 PM, she stated when a resident is admitted from a hospital and in pain, the facility will request the transferring hospital to give pain medication prior to coming and would need to obtain a prescription (physician order) from the doctor. LVN 2 stated the facility must fax a prescription for a narcotic pain reliever to the pharmacy, who must contact the ordering physician to confirm the order before the pharmacist can provide the medication for the resident. LVN 2 did not indicate whether Resident 21 had received medication from the hospital prior to her transfer to this facility.During an interview with LVN 3, on 2/18/16, at 3:48 PM, he stated when a resident was admitted in pain the facility would fax the narcotic pain medication prescription to the pharmacy. If there was no prescription the facility would call the pharmacy who must contact the physician. LVN 3 stated at night there can often be an issue when the facility or pharmacy was unable to contact the physician to confirm the order. LVN 3 stated he was on duty when Resident 21 was admitted and the resident's Norco had not been received by the time his shift was over. LVN 3 stated "I do know they got a hold of the doctor eventually and I know her medications came in the next day." He stated he remembered giving the resident an ibuprofen as a standing order for pain, as they had not received the approval from the pharmacy to provide the Norco. He did not indicate any other actions were taken to relieve the resident's pain when the ibuprofen was ineffective. Resident 21 did not receive the prescribed Norco 5-325 mg two tablets as indicated for severe pain until the late afternoon following her admission day (2/16/16 at 4 PM).2. Resident 22 was an 85 year old female with diagnoses of chronic kidney disease, osteoarthritis (a type of arthritis with progressive deterioration of the joints), and anxiety disorder. She was admitted to Golden Living Center Bakersfield on 8/27/15. She was alert and oriented and received narcotic pain medication for generalized pain related to her arthritis. During the Quality of Life Group Interview, on 2/17/16, at 2 PM, Resident 22 stated that she had been in pain for two days about 1.5 weeks ago because the facility did not have her regular pain medication (Norco - a narcotic pain medication) available.During an interview with Resident 22, on 2/18/16, at 10:05 AM, she stated about 1.5 weeks ago, she requested her regular pain medication, Norco. The resident stated she was told the facility did not have the medication and they had been faxing requests to the doctor with no response. Resident 22 stated she waited two days until her regular pain medication was available and her pain resolved. She stated she was unable to sleep due to pain until she received her regular pain medication (Norco).During an interview with Registered Nurse (RN) 1, on 2/18/16, at 3:30 PM, RN 1 stated the facility's process to obtain a narcotic pain medication for a resident included the following: "...if we don't have the order the Pharmacy has to call the doctor to OK. It can take a long time to get...a day or a few hours...mostly weekends or holidays are hard. We can call the facility doctor for an order if the other doctor does not call back...I have done that (called the facility doctor). There is no policy on how long to wait...it depends on how much pain the person is in. We can give them Tylenol if they are not allergic."During an interview with LVN 1 and a clinical record review for Resident 22, on 2/19/16, at 9:45 AM, the Medication Administration Record (MAR), dated 2/2016, indicated Norco 10-325 milligrams (mg), one tablet, had been given to Resident 22 twice a day for a pain level of six out of 10 on 2/3/16, 2/4/16, 2/5/16, 2/6/16, 2/8,16, 2/9/16, 2/10/16, and 2/11/16. The MAR indicated the medication was effective in the relief of Resident 22's pain on those dates. Tylenol 325 mg, two tablets for mild pain with a pain scale of 1-3, was given to Resident 22 on 2/12/16, at 8:16 PM, for a pain level of six out of ten and again on 2/13/16, at 7:49 AM for a pain level of 10 out of 10 (severe pain) and was documented as ineffective on 2/13/16. No other action was indicated to relieve Resident 22's pain on 2/12/16 and 2/13/16. On 2/13/16, at 10:42 AM, Norco 10-325 mg, one tablet was given to Resident 22 for her pain level assessed at a nine out of ten pain level, as a one-time dose taken from the facility's E-kit (a facility's medication kit that contains medications to be used on an emergency or urgent basis). The MAR indicated the physician's authorization for Resident 22's Norco was not received until 2/13/16 at 1005 (10:05 AM). Resident 22 had not received Norco for her effective pain relief for a 42 hour period. LVN 1 stated there had been delays in authorizations to refill medications at times... especially on the weekends and holidays (2/13/16 was a Saturday).During a review of the clinical record for Resident 22, the Progress Notes, dated 2/12/16, at 11:46 PM indicated Resident 22's as needed "medication...Norco for pain...still awaiting for valid from MD..." The progress note dated 2/13/16, at 2 PM, indicated "NOC [night] shift charge nurse informed nurse that Norco has not come in from pharmacy. At approx. 7:45 AM resident [22] complaining of pain 10/10 [worst pain imaginable/very severe or horrible] given Tylenol PRN [as needed] via md [physician] order with little effectiveness. Writer call pharmacy and was informed waiting for written prescription."During an interview with the DNS, on 2/19/16 at 9:45 AM, the DNS stated one of the facility's barriers to obtain narcotic pain medication was the time of day an order was received. After hours orders could be more difficult to obtain. She stated the facility preferred to receive a prescription from the transferring hospital for a new resident. The DNS stated it was easier to obtain (the narcotic) if the prescription came from an acute care hospital. She stated the facility had to fax medical orders to the pharmacy by 8 PM, and follow-up with telephone calls. If the pharmacy indicated they did not have the prescription, the facility would have to refax the prescription. The DNS stated the facility does not document when the staff called the Pharmacy "...it's just verbal." She stated "We call the facility doctor between two to four hours [of not receiving the medication]...there is no policy...it is education with my nurses...I am very sorry...it is additional training for my nurses."The facility policy and procedure titled "Pain Management Guideline", undated, indicated under "Guideline: Functions of appropriate pain management include...Intervening to treat pain before the pain becomes severe..." The pain rating scale is indicated as "Numeric Rating Scale: The patient/resident identifies pain on a 0-10 scale, 0=no pain and 10=worst pain imaginable (very severe or horrible)."Therefore, the facility failed to provide Resident 21 and Resident 22 effective pain medication in a timely manner, which caused unrelieved pain for both residents. 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. |
| 120000322 |
Golden Living Center - Bakersfield |
120012222 |
B |
06-May-16 |
UM9G11 |
3976 |
T22 72520(a)(b)(c) (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and the insurance may or may not cover such costs. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. Based on interview and record review, the facility failed, upon transfer to the acute hospital, to offer a seven day bed hold, offer the first available bed, and readmit one of one sampled patient (1). This resulted in a violation of Patient 1's admission agreement and Regulation. The clinical record for Patient 1 was reviewed. The nurses notes dated 4/2/16, indicated Patient 1 was admitted to the acute hospital. A seven day bed hold was not documented in this record. During an interview with Admission Director (AD) 1, on 4/14/16, at 1:47 PM, she stated Patient 1 was admitted on 4/1/16, and fell on 4/2/16. Patient 1 was transferred back to the acute hospital due to an injury. When the acute hospital called to transfer the patient back to the facility, the Director of Nursing (DON) told her not to readmit this patient due to the patient's behavior. AD stated it was also the IDT (Interdisciplinary Team- group of people organized to do a task together) decision not to readmit the patient back to the facility. During an interview with the DON, on 4/14/16, at 2:22 PM, she verified the facility did not offer a seven day bed hold and the facility decided not to readmit the patient back to the facility due to his behaviors. The admission agreement dated 4/1/16, and signed by Resident 1's (Patient's) representative, read "If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medi-Cal [Medicaid] is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If you are not eligible for Medi-Cal and the daily rate is not covered by your insurance, then you are responsible for paying $267 for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations. If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted. " The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 1. |
| 120000375 |
Golden Living Center - Shafter |
120012379 |
A |
18-Jul-16 |
T5HJ11 |
4690 |
F323-The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to provide two staff persons to physically assist one of one sampled resident (1) during toilet use and transfer. This failure resulted in Resident 1 falling and sustaining a fracture (broken bone) to his left hip. An unannounced visit was made to the facility on 6/2/16 at 1:40 PM, to investigate a resident's fall resulting in a hip fracture. Resident 1 was an 89 year old male with the diagnoses of cerebrovascular disease (a group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), generalized muscle weakness, difficulty walking, osteoarthritis (degeneration of joint cartilage and the underlying bone. It causes pain and stiffness, especially in the hip, knee, and thumb joints), and major depressive disorder (a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities). During a review of the clinical record for Resident 1, the nurses progress notes dated 5/26/16, at 6:25 AM, indicated "This nurse [Licensed Vocational Nurse 1-LVN 1] went into rest room. Noticed resident [Resident 1] leaning with his back against the bathroom door and bil [bilateral-both legs] legs straight out on the floor with the cna [certified nursing assistant].... C/O [complained of] pain/discomfort to left hip and left shoulder... Notified (physician), received orders to send to er [emergency room] for further eval [evaluation] and possible treat [treatment]." The Minimum Data Set (MDS-a resident assessment tool) for Resident 1 dated 4/1/16, indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with two persons physical assist with transfers and toilet use. This MDS for Resident 1 indicated Resident 1's balance during moving on and off toilet was not steady and Resident 1 was only able to stabilize with staff assistance. During an interview with LVN 1, on 6/2/16, at 2:45 PM, she stated she heard someone calling her name from Resident 1's room. LVN 1 stated when she opened the bathroom door, she saw Resident 1 sitting on the floor and one CNA (CNA 1) was with him. During a concurrent interview with Registered Nurse (RN) 1 and review of the clinical record for Resident 1, on 6/2/16, at 2:55 PM, the care plan, date initiated 11/25/14, indicated Resident 1 was at risk for falls. This care plan indicated Resident 1 had mobility limitations in both his arms and left leg. The intervention, revised on 4/14/16, indicated "Provide 2 person assist with bed mobility, transfers and toilet use." RN 1 verified Resident 1 should have been assisted by two people while he was in the bathroom. The risk for falls assessment dated 4/1/16, indicated Resident 1's total score was 11. A score of 10 or above indicated Resident 1 was at risk for falls. During a concurrent observation and interview with Resident 1 in his room on 6/2/16, at 3 PM, Resident 1's left leg had three surgical sites covered with bandages. Resident 1 stated his leg was painful. During an interview with CNA 1, on 6/7/16, at 9:08 AM, she stated she was assisting Resident 1 from the toilet to the wheelchair when his left side gave out. CNA 1 stated she was holding on to him and he hit the wall before falling to the floor. CNA 1 stated she could not lift Resident 1 off the floor so she called for help. CNA 1 verified Resident 1 was assisted by one person instead of two people on 5/26/16. During a review of the clinical record for Resident 1, the hospital "History and Physical" dated 5/26/16, indicated "X-ray of the left hip shows that he [Resident 1] has fracture. (Physician's name) was consulted and the patient [Resident 1] will have surgical intervention (operation) soon." The hospital physician progress notes dated 5/27/16, indicated Resident 1 had surgery done on his left hip due to fracture. The facility policy and procedure titled "Falls Management Guideline" dated 10/21/15, indicated "Residents at risk for falls are care planned with individualized interventions." These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000322 |
Golden Living Center - Bakersfield |
120013271 |
A |
27-Jun-17 |
474M11 |
9521 |
F279
Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at ?483.10(c)(2) and ?483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
(ii) Any services that would otherwise be required under ?483.24, ?483.25 or ?483.40 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative (s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
An unannounced visit was made to the facility on 4/24/17, at 1:24 PM, to investigate the incident where Resident 1 received fractures to both legs while being transferred from her wheel chair to her bed.
The facility failed to develop and implement a comprehensive care plan to reflect the care needs and level of assistance for Activities of Daily Living (ADL) for Resident 1 when Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 alone instead of with two or more staff members. As a result, Resident 1 sustained fractures (broken bones) to both lower legs when her legs became tangled together during a transfer from wheelchair to bed and CNA 1 attempted to untangle her legs.
A review of the admission record indicated Resident 1 was admitted on 5/23/14, with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), cerebral palsy (a condition marked by impaired muscle coordination and other disabilities, typically caused by damage to the brain before or at birth), abnormal posture, myalgia (pain in a muscle or group of muscles), and pain.
During a review of the clinical record for Resident 1, the "Progress Notes" for Resident 1 dated 4/12/17, at 4:08 PM, indicated "Resident (Resident 1) complaining of extreme severe pain on BLE (both lower extremities) . . . Resident informed the nurse that during transfer last night (4/11/17) she stated her legs got tangled and when staff (Certified Nursing Assistant 1-CNA 1) put her to bed she heard both legs pop." The "Progress Notes" dated 4/13/17, at 5:25 AM, indicated Resident 1 was admitted to the hospital with fractures to both of her legs.
The hospital progress note for Resident 1 dated 4/13/17, indicated both Resident 1's left and right legs had proximal (near) tibia (the inner and larger of the two bones of the lower leg) fractures and a non-displaced proximal fibular (the outer and narrower bone of the lower leg) fractures (bone fractures occurring at the shinbone area that included both bones of the lower leg called the tibia and fibula which affect the knee joint, stability, and motion). Another Progress Notes dated 4/14/17, indicated under RADIOGRAPHS "She (Resident 1) has minimally displaced bilateral tibial plateau fractures with significant osteopenia (a condition that occurs when the body does not make new bones as quickly as it reabsorbs the bone) of the bone."
The Minimum Data Set (MDS-a comprehensive assessment tool) dated 2/17/17, indicated under "Functional Status," Resident 1 needed two or more person's physical assistance with transfers (transfers such as from wheelchair to bed) because Resident 1 had contractures to both of her legs which put her at risk for injury. The "CNA-ADL TRACKING FORM" for Resident 1 from 4/1/17 to 4/11/17, indicated Resident 1 was totally dependent on staff and required two or more persons to physically assist her with transfers. The "CNA-ADL TRACKING FORM" is a form used to track a resident's ADLs. ADL means "Activities of Daily Living." It is any daily activity performed for self-care such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure. The ability or inability to perform ADLs can be used as a very practical measure of ability/disability in many disorders. The tracker is a record of ADLs and other services performed for the resident by the staff.
The care plan for "FUNCTIONAL MOBILITY/ADL'S" for Resident 1 revised 12/12/15, indicated Resident 1 had impaired physical mobility, had a limitation in independent purposeful physical movement of her legs, and required extensive assistance to total dependence with ADL's. However, the care plan did not reflect such assessment or the level of assistance required to transfer Resident 1.
During an interview with the Director of Nursing (DON), on 4/24/17, at 1:26 PM, she stated Resident 1 was alert and oriented, had a diagnosis of cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), and had contractures (a condition of shortening or hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to both lower legs. The DON stated CNA 1 was transferring Resident 1 from the wheelchair to the bed by herself. When Resident 1's legs became tangled together because of her contractures and CNA 1 untangled Resident 1's legs. The DON stated Resident 1 complained of pain and the facility transferred the resident to a local acute hospital for further evaluation. The DON stated the facility was then informed Resident 1 sustained fractures to both her legs.
During a concurrent observation and interview with Resident 1, on 4/24/17, at 1:50 PM, with Licensed Nurse 1 (LN 1), Resident 1 was lying in bed and was noted with braces (braces are medical equipment used to support the leg, hip, knee, ankle or foot and can be used for a range of needs from stability to immobilization) to both her lower legs. Resident 1 stated she sustained broken bones to both of her legs and she was having a lot of pain.
During an interview with CNA 2, on 4/24/17, at 2:58 PM, he stated that before the incident (with CNA 1 and Resident 1 on 4/11/17), the CNAs were transferring Resident 1 with two persons physical assist and using a Hoyer lift (mechanical device used to transfer residents).
During an interview with the MDS Nurse (MDSN) and review of Resident 1's clinical record, on 4/24/17, at 3 PM, the MDSN was informed when the incident happened; CNA 1 transferred Resident 1 from the wheelchair to the bed by herself. However, the MDS and the CNA-ADL tracking form indicated Resident 1 needed two or more person's physical assist with transfers. The MDSN was also informed the care plan for "Functional mobility/ADL's" did not indicate the level of assistance required for Resident 1's transfers, to guide the staff caring for Resident 1 and avoid confusion over Resident 1's level of assistance with transfers. The MDSN reviewed the clinical record and verified the findings. The MDSN was also asked what was the facility's process regarding care planning Resident 1's ADL's and how would the nurses communicate Resident 1's level of assistance with transfers to the CNAs. The MDSN did not respond.
During an interview with CNA 1, on 4/27/17, at 4 PM, CNA 1 stated she transferred Resident 1 from the wheelchair to the bed by herself. CNA 1 stated she sat Resident 1 on the side of the bed and Resident 1's legs became tangled together. CNA 1 stated she placed Resident 1 in a lying position and untangled the resident's legs.
During an interview with CNA 1, on 5/16/17, at 12:52 PM, she stated before the incident happened, she had been transferring Resident 1 by herself. CNA 1 was asked if she was aware of Resident 1's care plan for transfer. CNA 1 stated "It's my fault, I didn't read."
The facility undated policy and procedures titled "RESIDENT ASSESSMENT AND CARE PLANNING," under "Purpose," indicated "To identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet the resident's individual needs and to assist the resident in reaching the highest level of independence possible." Under "Policy," it read "The assessment information will be used to develop a comprehensive resident care plan to allow the resident to reach his or her highest practicable level of physical, mental and psychological functioning."
This failure to safely transfer Resident 1 presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 230000024 |
Golden Living Center - Redding |
230008710 |
B |
28-Mar-12 |
93NO11 |
3934 |
A 0197 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to ensure that Patient 1 was treated with dignity and respect, and free from verbal abuse, when a visitor of Patient 3 yelled discriminatory words at Patient 1. This failure caused Patient 1 emotional distress and feelings of fear. On 4/7/11, a review of Patient 1's record showed she was admitted on 2/24/10 with diagnoses of anxiety and increased weakness from a previous hip fracture. A review of the Minimum Data Set (MDS), an assessment tool, dated 2/21/11, showed Patient 1 was able to remember things with minor cuing (small hints) she was occasionally incontinent, and had increased needs with transferring to and from the toilet, washing and dressing. It was also noted that Patient 1 was capable of making her needs known.During an interview with Registered Nurse (RN) B on 4/7/11 at 2:30 pm, she stated on 4/4/11 at 6:45 pm, she was standing at the medication cart in the hallway next to Room 8. Pt 1 was sitting in her wheelchair next to RN B. She stated on 4/4/11 at 6:45 pm, a visitor of Patient 3 walked up to Patient 1 and yelled in her face "There is S*** all over the toilet seat and you are not supposed to use that bathroom." RN B stated Patient 1 just sat there with a frightened expression on her face and did not say a word. Patient 1 then wheeled herself into her room and was sitting quietly next to her bed, when Patient 3's visitor followed Patient 1 into the room and continued to verbally abuse her stating she should not use that bathroom. RN B stated she followed Patient 3's visitor into the room and saw Patient 1 was sitting there just staring ahead. During an interview with Licensed Nurse (LN) C on 4/7/11 at 2:10 pm, she stated that Patients 1 and 3 have been roommates for two and one half months in Room 8, and they share a bathroom. She stated Patient 3's visitor comes to have dinner with her almost daily and has angry outbursts about the use of Patient 1 and 3's shared bathroom. She complained that Patient 1 gets stool all over the toilet seat and does not feel Patient 3 and Patient 1 should use the same bathroom. During an interview with LN D on 4/7/11 at 1:45 pm, she stated patient 1 was refusing an interview with the surveyor, stating to her that she was afraid she would be taken away because of what was said by Patient 3's visitor.During an interview with LN D, on 4/7/11 at 2:40 pm, she stated the visitor of Patient 3 has had previous episodes of anger at the staff over the use of the bathroom by Patient 1. When asked what was done about the outbursts from Patient 3's visitor, she stated, aside from trying to explain the situation that no other rooms were available, nothing else was done. A review of IDT notes and facility investigation forms showed previous outbursts from Patient 3's visitor on 3/29/11, 3/30/11.On 4/7/11 at 2:45 pm, a concurrent record review and interview was conducted with LN B. The facility's policy titled, "Abuse and Investigation Policy," dated 7/2002 read, "It is the policy of the company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and to ensure that all alleged violations of Federal or State laws be reported. Also the Director of Nursing Services or his/her designee shall remove a resident suspected of being the subject of an alleged violation to an environment where the residents' safety can be protected." LN B stated that the policy had not been followed, and that Patient 1 had not been protected from verbal abuse. Therefore, the facility failed to ensure that Patient 1 was treated with dignity and respect, and free from verbal abuse, when a visitor of Patient 3 yelled discriminatory words at Patient 1. This failure caused Patient 1 emotional distress and feelings of fear. |
| 230000024 |
Golden Living Center - Redding |
230008963 |
B |
17-May-12 |
NBTM11 |
5461 |
A 882 T22 DIV5 CH3 ART5-72527(a)(11) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to ensure that Patient 1 was treated with respect and dignity when Patient 1 requested tomato slices from the kitchen and Kitchen Staff (KS) L told Patient 1, in a loud and disrespectful manner, that he would not give him the tomatoes and to go take a shower.This action resulted in Patient 1 feeling hurt, staying in his room the rest of the evening, and fearful that he would no longer be able to make requests from the kitchen staff. Patient 1 was admitted to the facility on 6/23/08 with diagnoses that included pain, diabetes, and a pervasive developmental disorder (resulting in social difficulties, maladaptive patterns of behavior and poor insight). Patient 1's Minimum Data Set (an assessment tool), dated 9/28/11, showed that Patient 1 was not cognitively impaired and was able to make his needs known. Patient 1 was able to independently move about the facility using his wheel chair. Patient 1 was not his own responsible party, due to his developmental disability. On 12/21/11 at 8:40 am, Patient 1 stated that he liked to collect the tomato slices to put on toast, that he also saved them in his room, so whenever he felt like a snack he could make a sandwich. Patient 1 stated that it's hard for him to find someone to go to the kitchen for his requests and that he can do it faster himself. He stated that he is always going to the kitchen door and asking for things to be changed.Patient 1 stated that KS L told him that he would not give him the tomatoes that he requested and instead told him to go take a shower. Patient 1 stated that KS L often argues with him.On 12/21/11 at 10 am, Dietary Services Supervisor (DSS) was interviewed and stated that Patient 1 is at the kitchen door before the cooks get to the facility daily and that "all day long" he comes to the kitchen door for requests.On 12/21/11 at 2:50 pm, Facility Cook (FC) A was interviewed and stated she witnessed some of the interactions between KS L and Patient 1 on the evening of 12/18/11. She stated that KS L was in a "really tense mood" that evening before the interaction with Patient 1, and that all three kitchen staff, including KS L, were returning from a break to see that Patient 1 was waiting at the kitchen door with a nurse.FC A stated that when Patient 1 made his request for sliced tomatoes KS L stated, "You don't need to ask me because I won't get them, why don't you take a shower then come back." She stated that KS L "doesn't care for (Patient 1) and usually backs away and ignores him."FC A also stated that she had tried to encourage KS L to go into the kitchen to avoid the situation, but that he would not go, so she left the situation in the hands of the nurse that was also present. FC A stated that everyone in the facility is aware of what Patient 1 was doing with his food.On 1/3/12 at 12 pm, KS L was interviewed and stated that on 12/18/11, after dinner, upon return from his break, he told Patient 1, "Look you need to leave me alone and go take a shower." On 1/3/12 at 11:35 am, Licensed Vocational Nurse (LVN) M was interviewed and stated that on 12/18/11, just after dinner, she was present when KS L said, in a "sarcastic angry tone," "I give you everything you want, you stink, go take a shower." LVN M stated that Patient 1 said he was afraid that he would not be able to ask the kitchen staff for food anymore and that he also stayed in his room the rest of that evening. On 1/3/12 a review of KS L's employee file disclosed that he had a previous incident in the facility with a staff where he had violated the facility's code of conduct by making threatening gestures towards another staff member.The employee code of conduct that KS L signed on 4/20/10 read, "Conduct at work must be professional at all times. There must be ... no other conduct that creates an unprofessional, intimidating and/or hostile environment or the impression of such an environment and all residents must be treated with respect and dignity at all times."A facility investigative report showed that on 12/18/11, KS L violated the facility's code of conduct when he told Patient 1, in a loud and disrespectful manner, that he would not give him cut tomatoes and to go take a shower. KS L was suspended and then discharged from employment. Therefore, the facility failed to ensure that Patient 1 was treated with respect and dignity when Patient 1 requested tomato slices from the kitchen and KS L told Patient 1, in a loud and disrespectful manner, that he would not give him the tomatoes and to go take a shower. This action resulted in Patient 1 feeling hurt, staying in his room the rest of the evening, and fearful that he would no longer be able to make requests from the kitchen staff. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000024 |
Golden Living Center - Redding |
230009034 |
B |
24-Feb-12 |
IOV311 |
5910 |
A163 T22 DIV CH3 ART3-72311(a)(1)(A) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. The facility failed to ensure that nursing services identified Patient 1's needs on an individualized care plan, when they were aware that Patient 1's condition had deteriorated based on a required assessment, the Minimum Data Set (MDS). The MDS, which was due on 8/18/11, was not performed until 9/21/11, one month late, during which time, Patient 1 had not received the level of care that she needed. As a result, Patient 1 had two falls with injuries that could have been prevented. On 9/7/11, Patient 1 fell and hit her elbow and on 9/12/11, just five days later, she fell again and hit her head.Patient 1 was a 91 year old that was admitted to the facility on 11/8/10 with diagnoses that included stroke, fatigue, and dementia. The most current MDS, dated 9/21/11, indicated that she had memory problems and difficulty with decision making. The "Admission Record" reflected that Patient 1's daughter was her responsible party. On 9/14/11, a review of Patient 1's "Nursing Progress Notes" was conducted. On 9/7/11 at 6:26 am, a nurse documented that Patient 1, "was found lying on the floor in front of her bed" and that Patient 1 had stated, "I bumped my elbow." The nurse added that Patient 1 had memory problems and does not remember to use her call light. On 9/12/11 at 10:07 pm, a nurse documented that Patient 1 was coming out of her bathroom with her walker and fell and hit her head which caused, "a small lump to the back of head." On 9/15/11 at 1:03 am, a weekly nursing progress note documented that, "mental ability is declining...she does not remember...she is unable to use the call light...needs assist of one for personal care..." On 9/29/11, Patient 1's MDS, dated 5/19/11, was reviewed and compared with her most current MDS, dated 9/21/11. The following declines were identified between the May and September 2011, assessments: 1. In May, Patient 1 was walking, moving, eating, and managing her own personal hygiene, with supervision. In September, she needed limited assistance and one person to physically help her manage those activities of daily living. 2. In May, Patient 1 was able to use the toilet with limited assistance. In September, she required extensive assistance and one person to physically help her. 3. In May, Patient 1 was fully continent of her bowels and bladder. In September, she had deteriorated to being only "occasionally" continent of her bowels and bladder. 4. In May, Patient 1 was dressing herself with supervision. In September, she required extensive assistance and one person to physically help her get dressed. 5. In May, Patient 1 could bathe herself. In September, she was totally dependent on staff to bathe her. 6. In May, Patient 1 was "steady at all times" when walking and turning around. In September, she was not steady and "only able to stabilize with human assistance."On 9/14/11, a review of Patient 1's care plans was conducted. Patient 1's care plan titled, "physical functioning", which included dressing and eating, had not been revised since 3/13/11, and reflected Patient 1 at a more independent level of functioning, not at her current deteriorated level, based on her 9/21/11 MDS assessment. The "physical functioning" care plan directed staff to provide Patient 1 with, "monitoring of dressing", and to, "minimally cue" her during eating. Patient 1's care plan that addressed "at risk for falls", had not been revised since 9/12/11, and did not identify that, based on assessment, Patient 1's level of care and need for staff assistance had increased. The "at risk for falls" care plan directed that Patient 1, "Needs reminded" to use her walker, and "Remind Res to ask for assist..." however, according to Patient 1's MDS which was completed on 9/21/11, she had severe memory loss, therefore, "reminders" would not be effective. On 9/29/11 at 11:55 am, an interview with Administrative Nurse (AN) Z was conducted. AN Z stated that Patient 1's MDS assessment was due on 8/18/11, and confirmed that he had completed the assessment on 9/21/11, one month late. AN Z stated that Patient 1's care plans should have been updated on 8/18/11, when the MDS assessment was due, but he completed the assessment a month late. AN Z confirmed that even after he had completed Patient 1's MDS assessment on 9/21/11, he still did not update her care plans to reflect that she had deteriorated. AN Z stated that between the time that the MDS assessment was due, and the time that it was actually done, Patient 1's falls could have been prevented. On 9/29/11 at 1:10 pm, Certified Nursing Assistant (CNA) V was interviewed. CNA V stated that she had noticed that Patient 1 had declined over the past month because she could no longer find her room and was unsteady when walking, "she needs someone to walk with her." CNA V added that, "Reminders won't work with her, she can't remember." On 9/29/11 at 2 pm, Administrative Nurse W confirmed during an interview that Patient 1's care plans had not been updated and stated that the falls on 9/7 and 9/12/11, "could have been prevented."Therefore, the facility failed to ensure that Patient 1 had an accurate and individualized patient care plan that identified her specific care needs, based on the assessment of her needs, which led to falls with injuries. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000761 |
Granny's House - Magnolia Road |
230009038 |
B |
19-Apr-12 |
YJ3Z11 |
7227 |
W&I 4502(d) W&I 4502(d) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (d) A right to prompt medical care and treatment. Based on interview and record review, the facility failed to ensure that Client 1 received prompt medical treatment when they did not report Client 1's three falls in two days to the facility's registered nurse (RN) A. This had the potential to contribute to further falls and injuries by Client 1. Client 1 suffered with pain and had to wait for medical care and treatment for a fractured right ankle that occurred after one of her three falls.On 1/25/12, Client 1's record was reviewed. She was a 70 year old female who was admitted to the facility on 3/28/02 with diagnoses including mild mental retardation and right side paralysis. She was described as requiring extensive assist with her daily care and required one person assist while ambulating and transferring. The accident and injury reports were reviewed with the following time line from 1/13/12 to 1/15/12 of Client 1's three falls and her right leg injury. The documentation revealed that she did not receive nursing or a physician evaluation until 1/15/12 when her leg was swollen and painful on movement. All three falls had been reported to the Administrative Staff (Admin) C and the Director (Dir) G, who are not nurses but will decide if the RN should be called and that she will decide if additional treatment will be required. On 1/25/12 at 8:15 am, DCS B was interviewed. She had witnessed the fall on 1/13/12, at 6 am, and stated she had been trained and instructed to call the Admin C or the Dir G first and they would instruct the DCS to call the RN, if required. DCS B stated that on 1/13/12 at 7:45 am, Admin C told DCS B to monitor the client and to call RN A if there were any signs of discomfort or injury. There was no evidence that RN A had been notified. On 1/13/12 at 6 am, Client 1 was reported to have fallen while Direct Care Staff (DCS) D was transferring her from her wheelchair to the bathroom. She landed on the floor with a complaint that her toe hurt. There was no further documentation concerning which toe was hurt or that the fall had been investigated.On 1/13/12 at 8:30 pm, Client 1 fell to the floor while DCS D was assisting her to bed from the wheelchair. The accident/incident report, dated 1/13/12, revealed there was no response to the message left for Admin C notifying of the Client 1's fall. There was no documented evidence that RN A had been notified or that Client 1's fall had been assessed by RN A. On 1/14/12, an accident/incident report documented at 12:30 pm, Client 1 was being transferred from her wheelchair to her recliner in the living room when DCS E reported that Client 1's leg went out and she landed on the floor. The Dir G was a witness to the fall and did not notify RN A. There was no further documentation that RN A had been notified of Client 1's fall. On 1/25/12 at 8:30 am, DCS F was interviewed. She stated she had worked the night shift on 1/14/12 and did not notice Client 1's right leg until she was going to get her ready for the day on 1/15/12 at 6:30 am. She stated Client 1's right leg was purple, swollen, warm to touch, and Client 1 complained of pain with movement.On 1/15/12 at 7 am, DCS F took a photograph of Client 1's right leg with her phone and sent the photograph to RN A at 7:10 am, who told DCS F to call 911.DCS F delayed calling 911 until 8 am, because she had to finish passing the other five client's medications before they left for their day program and she stated, she was the only staff left at the facility to monitor and prepare the five clients for their day program. She also stated she wanted to accompany Client 1 to the hospital.On 1/25/12 at 6:30 pm, RN A was interviewed. She confirmed that no one from the facility had called her concerning Client 1's three falls on 1/13/12 at 6 am, 1/13/12 at 8:30 pm, 1/14/12 at 12:30 pm, until the morning of 1/15/12 at 7:10 am, after the large bruise was noticed. She stated she knew by just looking at the photograph that Client 1 either had a fractured leg or an infection. She also stated that Client 1 should have been assessed after each fall to determine if she required earlier treatment and to determine the causes to prevent further falls. She stated she documented on each of the three accident/incident reports on 1/18/12 that she was not notified of any of the falls until 1/15/12 at 7:10 am. On 1/15/12 at 8 am, Client 1 was transported to the emergency room by ambulance. She was assessed, treated, and medicated for pain, and sent back to the facility that afternoon with orders for pain medications and care of her splinted fractured right ankle. On 1/17/12 at 7:10 pm, Client 1 was transported back to the emergency room for increased swelling, bruising, complaint of pain, and her right leg was warm to touch. She was admitted to the hospital for infection and required antibiotics and further testing to rule out a blood clot to her right leg. On 1/25/12, at 11:45 am, Admin C stated the facility did not have a policy on falls only accident/injury and emergency medical procedures which did not mention falls. Admin C stated Client 1 had a care plan for her history of falls, which this surveyor stated there was no evidence of that care plan in Client 1's record. Admin C acknowledged that Client 1 did not have a care plan for falls.On 1/25/12 at 11:45 am, Admin C confirmed she was notified of Client 1's three falls, and did not notify the RN for her medical advice concerning the falls or documented injuries that her toe hurt after the first fall, or that her leg was unable to support her while being transferred on the third fall. Admin C agreed that the RN should have been notified and evaluated Client 1's injuries from the three falls. The policy, titled, "Accident/Injury," undated, indicated that all cases of injury to resident or staff were to be reported to the nurse consultant (RN A), Admin C (QMRP), or to Director G. The individual contacted would review the incident and the RN would evaluate the need for securing treatment.Therefore, the facility failed to ensure that Client 1 received prompt medical evaluation and treatment when they failed to notify the RN concerning three falls in two days, pain to her toe, and her leg collapsing while attempting to transfer. This resulted in treatment at the emergency room on 1/15/12 and returned home the same day with a fractured right ankle and pain. On 1/17/12 Client 1 was admitted to the hospital with subsequent infection and a possible blood clot of the right leg. This had a direct relationship to the health, safety, or security of clients. |
| 230000578 |
Granny's House - Plumas Avenue |
230009246 |
B |
16-Aug-12 |
671U11 |
6733 |
T22 DIV5 CH8.5 ART3-76865(l) Developmental Program Services-Health, Hygie (l) When indicated, each client's individual service plan shall include measures to prevent the development of decubitus ulcers, contractures and deformities. If contractures and deformities are present, the client's individual service plan shall specify treatment measures. These measures shall be implemented as written. Preventive and treatment measures shall include, but not be limited to:T22 DIV5 CH8.5 ART-3-46865(l)(3) Developmental Program Services-Health, Hygie (3) Preventive Skin Care T22 DIV5 CH8.5 ART3-76865(l)(5) Developmental Program Services-Heath, Hygie (5) Pressure relieving devices. T22 DIV5 CH8.5 ART3-76875(b) Health Support Services-Nursing Services (b) The attending physician shall be notified immediately of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a client. The facility failed to develop an individual service plan for Client 1 that addressed the prevention of pressure ulcers. As a result, Client 1 developed a pressure ulcer on his coccyx that was not identified until it was as a Stage III. The facility failed to notify the physician when the pressure ulcer was discovered, and failed to develop a service plan addressing specific treatment measures for the acquired pressure ulcer. These failures necessitated the transfer of Client 1 from the familiarity of his home at the facility to a long term skilled nursing facility for the treatment of his Stage III pressure ulcer. * Decubiti/Pressure sore/ulcer (a break in the skin from pressure).* Coccyx (tail bone).* Stage III (full-thickness skin loss involving damage of the subcutaneous tissue).On 4/19/12, the facility policy, titled "Decubiti ....", not dated, indicated that "the resident's individual service plan (ISP) will include measures to prevent decubitus ulcers..., implement treatment measures, that include frequent position changes, skin care, good body alignment, joint movement, pressure relieving devices, and activation and mobilization programs." The procedure for this policy, read, "staff will implement treatment measures as determined by the Nurse Consultant... in accordance with the ISP." The facility policy, titled, "Health care plan (Nurse information)," not dated, indicated that the registered nurse consultant (RNC) B was responsible for writing, updating, implementing, and supervising the health care plan, (HCP) on each resident's admission and to maintain the HCP during the resident's stay in the facility. On 4/19/12, Client 1's medical record was reviewed. He was admitted to the facility on 5/10/07 with mental retardation, heart problems, dementia, and chronic constipation. He required assistance with a walker, and supervision while in a wheelchair with a self-release seat belt. There was no evidence of an ISP for the prevention or treatment of pressure ulcers.On 4/19/12 at 7 am, Client 1's bed and wheelchair were observed to be without any pressure relieving mattresses or pads. Client 1's hospital records revealed that his skin was pink but intact on his discharge from the hospital on 2/6/12 and readmission to the facility, after the placement of a pacemaker (to regulate the heart rate when irregular).On 3/16/12 at 7:55 am, Administrative Staff (Admin) A stated, when Client 1 returned from the acute care hospital on 2/6/12, his admit orders specified that he must stay flat in bed and have no showers for 10 days. When questioned if pressure relieving devices were applied to his bed or wheelchair and if a turning side to side schedule had been implemented, she stated that no preventive care had been started. When asked who assessed the clients on their return from the hospital, she stated, the RNC B was responsible, but had not assessed Client 1. Client 1's 2/6/12 discharge orders and pacemaker instructions from the hospital were for no showers for 10 days to the incision and to not lift his arms above his shoulders for six weeks. There was no evidence that Client 1 was to remain flat or in bed. An Accident/Incident (A/I) report for Client 1, dated 3/8/12, revealed that he had bruising and an open area on his coccyx. This was the first documentation of this pressure sore. The record revealed that the House Manager (HM) C had notified Administrator staff (Admin) D and the RNC B on 3/8/12. There was no evidence of the RNC B documentation that Client 1's physician had been notified for treatment for the open area on his coccyx.On 4/11/12 at 10:10 am, the house manager (HM) C was interviewed. She acknowledged that she had written the A/I report, dated 3/8/12, on Client 1's open area and bruise to his coccyx, that had been reported to her by Client 1's day program. She stated she viewed the area, and documented the measurements; "a quarter size bruise above the right buttocks, and nickel size bruise to the crack of rear. One inch long sore in the top of the crack" (coccyx). HM C stated she had left phone messages for the RNC B and Admin D on 3/8/12 regarding the open area.On 4/12/12 at 4 pm, RNC B denied receiving a message concerning Client 1's pressure sore. Upon presentation to the acute care hospital on 3/16/12, for complaint of chest pain, photographs of Client 1's coccyx pressure sore were taken and the wound was assessed as a Stage III pressure ulcer. The area measured 1 cm x 4 cm x 1 cm (width x length x depth in centimeters (cm)). The center had a 3.5 cm necrotic (black dead tissue) area. There were no evidence that Client 1's skin, had been assessed by RNC B for his readmission's after his hospitalizations; on 1/24 to 2/6/12 for a seizure that required a pacemaker for an irregular heart beat; on 2/8 to 2/10/12 for observation after a fall out of bed hitting his head; on 3/16 to 3/17/12 for complaint of chest pain. On 4/19/12 at 1:30 pm, HM C was interviewed. She stated that on 3/22/12, she had accompanied Client 1 to the hospital for treatment for his abscess, and pressure ulcer to his coccyx and the physician's order to send him to the hospital for constipation related to no positive results by the facility with Client 1's bowel regime. On 4/16/12, Client 1 was admitted from the hospital to a long term nursing facility for the treatment of his Stage III pressure ulcer.There was no evidence of a service plan for Client 1 for prevention, treatment, or assessments for Client 1's pressure sore risk and his stage III pressure sore. This resulted in a the development and worsening of his pressure sore, a delay in healing, a decreased level of well being, and an extended stay in a facility that Client 1 was not familiar with. This violation had a direct relationship to the health, safety or security of patients. |
| 230000024 |
Golden Living Center - Redding |
230009272 |
B |
20-Feb-14 |
UEHJ11 |
5417 |
T22 DIV5 CH3 ART3-72311(a)(1)(B) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. The facility failed to develop individualized plans of care to address fall risk and bladder incontinence for Patient 2 after she was readmitted to the facility with a known history of falls and increased urinary incontinence. This failure resulted in Patient 2 not having nursing interventions in place to reduce her risk of injury when she got up from her bed to go to the bathroom, unassisted, and fell on 11/9/11, sustaining a large bruise on her abdomen, bruises on her left hand and lower left arm, and a broken left wrist.Patient 2 was admitted to the facility on 9/2/11, with diagnoses that included stroke, urinary incontinence, and chronic back pain. She discharged home on 9/6/11, but was readmitted to the facility on 10/24/11, after her daily functioning had declined at home and she required a higher level of care.Patient 2's record was reviewed, on 11/29/11. A Minimum Data Set (MDS, an assessment tool) was completed by facility staff, on 10/30/11. The MDS indicated Patient 2 was independent with her decisions, did not have memory problems, required staff assist for transfer and toilet needs, her balance during transitions from surface to surface was not steady, and she could only stabilize to stand up with staff assist. Patient 2 was assessed to have range of motion impairments to both the upper and lower extremities of the right and left sides of her body. She was also assessed as frequently incontinent and with a history of falls. On 11/29/11 at 3:45 pm, the MDS Nurse stated she had assessed Patient 2 as a fall risk but had not completed an individualized care plan, prior to her injury on 11/9/11. On 11/29/11 at 1:50 pm, Patient 2 stated at the time of her fall, early in the morning on 11/9/11, she was walking with a walker and she had slipped on liquid that was on the bedroom floor on her way to the bathroom. Patient 2 stated after she had fallen, she knew she broke her arm. Patient 2 stated she was not instructed to use the call bell when she got up, until after her fall and fracture on 11/9/11.A fall risk assessment form, dated 10/24/11, read, Patient 2 was at risk for falls related to a history of falls, incontinence, balance problems, weakness problems, use of assistive devices, current medications and existing admission diagnoses. On 12/1/11 at 9:20 am, Registered Nurse (RN) A stated she had completed the portion of Patient 2's admission assessment that included a fall risk assessment. No evidence of documentation was found that indicated an incontinence or fall care plan was initiated on this date. A nurse's progress note, dated 10/26/11 and timed 1:13 am, read, Patient 2 had been incontinent of bladder since her return to the facility and she required staff assistance to get out of bed and to the toilet, but could not wait for a very long period of time before becoming incontinent. No evidence of documentation was found that indicated an incontinence or fall care plan was initiated on this date. A nurse's progress note, dated 10/27/11 and timed 12:22 am, indicated Patient 2 tried to get to the bathroom by herself using the walker, lost her balance, and sat on the floor hitting her hip on the way down. No evidence of documenting was found that indicated an incontinence or fall care plan was initiated on this date. A nurse's progress note, dated 11/9/11 and timed 7:21 am, indicated Patient 2 was found on the floor by the side of her bed and that a large puddle of urine was on the floor. The note indicated Patient 2 had a large bruise on the left side of her abdomen, on her left hand, and on her lower left arm. The note indicated Patient 2, "feels she broke her wrist." An x-ray report, dated 11/9/11, confirmed Patient 2's left wrist was broken and Patient 2 subsequently required surgical repair of her broken left wrist in an acute care hospital. On 12/1/11 at 9:20 am, RN A stated she was on duty caring for Patient 2 the night she fell and fractured her wrist. She stated the fall took place around 4 am and after providing first aid, she had notified the doctor and the portable x-ray company. RN A stated she did not complete an individualized fall risk care plan or an incontinence care plan for Patient 2, prior to her fall on 11/9/11.On 12/1/11 at 11 am, the Director of Nursing acknowledged she was unable to find individualized care plans developed for Patient 2's increased incontinence or increased fall risk, prior to 11/9/11.Therefore, the facility failed to develop individualized plans of care to address fall risk and bladder incontinence for Patient 2 who had a history of falls and increased urinary incontinence. This failure resulted in Patient 2 not having nursing interventions in place to reduce her risk of injury when she attempted to get up from her bed to go to the bathroom, unassisted, and fell on 11/9/11, sustaining a fracture to her left wrist.The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000024 |
Golden Living Center - Redding |
230009329 |
B |
20-Feb-14 |
UEHJ11 |
4790 |
T22 DIV5 CH3 ART3-72311(a)(3)(B) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The facility failed to notify the physician when Patient 2 was exhibiting signs and symptoms of a possible urinary tract infection (UTI) and obtain treatment for the UTI. Subsequently, Patient 2 was hospitalized where she was diagnosed with a UTI (that had not been identified or treated at the facility) and sepsis(a bacterial blood infection).Patient 2 was originally admitted to the facility on 9/2/11 with diagnoses that included stroke, diabetes, urinary incontinence, and chronic back pain. She was discharged home on 9/6/11, but was readmitted to the facility on 10/24/11, after her daily functioning had declined at home and she required a higher level of care.Patient 2's record was reviewed. A Minimum Data Set (MDS, an assessment tool) was completed on 10/30/11, and indicated that Patient 2 had a significant change in condition. The MDS indicated Patient 2 was unable to complete the Brief Interview for Mental Status (BIMS), she required staff assistance for transfers and toilet needs, and she was frequently incontinent of urine. A Care Area Assessment (CAA), completed 11/13/11, read, "Resident readmitted after an unsuccessful discharge home. Readmission was due to inability to perform her adl's (activities of daily living)" and Patient 2 was "at risk" for urinary tract infections because of her "functional decline." Patient 2 was identified by the facility to be at risk for UTI's related to a history of having had many UTIs. Signs and symptoms of a UTI in the elderly can include increased urinary incontinence, changes in mental status, and a decline in daily functioning. These signs and symptoms were present and contributed to Patient 2's readmission, on 10/24/11. Poor fluid intake will also contribute to the development or worsening of a UTI. A nurse's progress note, dated 10/26/11 and timed 1:13 am, a nurse (RN A) documented that Patient 2 had been incontinent of urine since her return to the facility, on 10/24/11.On 12/1/11 at 9:20 am, RN A stated she had written the above nurse's note indicating Patient 2's urinary incontinence was worse and said the physician was not notified of Patient 2's increased frequency of incontinence and a urine analysis had not been obtained.On 11/10/11 at 9:31 pm, Patient 2 had a change in condition, experiencing fever, elevated heart rate, lethargy, and was difficult to arouse. Her symptoms persisted on 11/11/11, and her condition worsened by 11/11/11 at 08:26 am. On 11/11/11 at approximately 9:00 pm, Patient 2 requested to go to the hospital. At 9:30 pm, the physician was notified and Patient 2 was transferred to a local hospital where she was found to have a UTI and sepsis. On 4/12/12 at 4 pm, Licensed Vocational Nurse (LVN) B stated the facility does not monitor the intake of fluids unless the patient has a feeding tube or a urinary catheter. She stated there was no process in place to ensure that Patient 2 was provided sufficient fluids.During a concurrent record review and interview on 4/30/12 at 9 am, LVN C stated from the time of Patient 2's fall and fracture, on 11/9/11, to her transfer to the hospital on 11/11/11, Patient 2's oral intake had decreased and there was no measurement of her fluid intake or a facility process in place to ensure sufficient fluid intake. LVN C stated that the physician was not informed of Patient 2's increased incontinence since her readmission to the facility on 10/24/11, no urinalysis had been obtained, and no fluid intake monitoring done. At the time of her transfer to the hospital, a urinalysis was ordered by Patient 2's physician, who continued with her care at the acute care hospital. The first urine sample was obtained on 11/11/11 at 11:05 pm, at the acute care hospital, and was positive for a UTI. The hospital emergency and admission records, dated 11/11/11, documented that Patient 2 had blood cultures taken, on 11/12/11 at 12:43 am. The results indicated Patient 2 had sepsis infection in the blood stream) with the same bacteria that was in her urine.Therefore, the facility failed to notify the physician when Patient 2 was exhibiting signs and symptoms of a possible urinary tract infection (UTI), and obtain treatment for the UTI. Subsequently, Patient 2 was hospitalized where she was diagnosed with a UTI (that had not been identified or treated at the facility) and sepsis(a bacterial blood infection) with the same bacteria that was in her urine.The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000024 |
Golden Living Center - Redding |
230009382 |
B |
05-Jul-12 |
B88711 |
4556 |
F 241 483.15(a) Dignity and Respect of Individuality The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Based on observation, interview, and record review, the facility failed to ensure that Residents 1 and 2 were treated with dignity and respect by Occupational Therapy staff (OT A) when OT A was confrontational, in the presence of Resident 2, toward Resident 1 for attending church instead of therapy. As a result, Resident 1 felt that she would be thrown out on the streets if she did not participate in therapy and was horrified and frustrated, Resident 2 felt horrified and verbally assaulted, and both residents' rights to be treated with dignity and respect were violated. Findings: On 4/3/12 at 12:00 pm, an onsite investigation was initiated for an entity reported incident that occurred on 3/21/12 at 2:15 pm, alleging that OT A verbally abused Resident 1.Facility documentation indicated that two residents (Residents 1 and 2) stated that on 3/21/12 at 2:15 pm, OT A entered their room and questioned Resident 1 as to why she missed her scheduled therapy appointment, the day before. Resident 1 responded to OT A that she attended church, indicating that to her, church was more important than therapy. OT A responded, "No, therapy is more important. Therapy is what is paying your bill to stay here." Resident 1 expressed that she was "horrified" at what OT A said and felt that she "would be thrown out on the streets" if she did not participate. As a result of witnessing the above described confrontational incident, Resident 2 reported that she was also approached by OT A in a threatening manner with the "door closed, curtain pulled and was verbally assaulting her," and as a result she was "horrified." Record review revealed that Resident 1 was admitted on 2/10/12 with diagnoses that included respiratory failure and congestive heart failure. Resident 1 was alert and able to make her own decisions. On 4/3/12 at 1:50 pm, in a concurrent observation and interview, Resident 1 stated that OT A yelled at her saying that it was because of therapy that she had a roof over her head, and then left the room. The next day, Resident 1 said that she told OT A that she wanted a different therapist to work with her.On 4/3/12 at 1:55 pm, during a concurrent observation and interview, Resident 2 stated that on church day (Tuesday) at the facility, OT A entered her room, her roommate (Resident 1) was also present and OT A asked Resident 1 where she had been and the resident said she had been at church. OT A told Resident 1 that therapy, not church, kept a roof over her head. Resident 2 said that the she felt very upset by the incident and reported it at a resident council meeting the next day.Review of Resident 1's care plans revealed a care plan, initiated on 3/22/12, addressing: "Staff to resident altercation secondary to staff confronting resident re: her participation in therapy and the possibility that she would have to leave facility if she did not do her rehab. Resident stated that she felt threatened and horrified by the statement and the manner in which it was said." The care approaches included the staff member's suspension, effective 3/22/12. Review of a Social Services note, dated 3/22/12, revealed, "During resident counsel meeting, this resident along with several others expressed their concerns re: an OT's approach, manner, and attitude..." The note went on to describe a confrontational discussion by OT A toward Resident 1. The note indicated that Resident 1 felt "frustrated" by the incident. On 4/3/12 at 2:20 pm, the Activities Director (AD) stated that during a resident council meeting, Resident 1 brought the incident with OT A to her attention. The AD said that she spoke with the rehabilitation supervisor and informed the administrator of Resident 1's concern. Review of an in service, dated 2/21/12, indicated that OT A had previously been in serviced, as part of a plan of correction for a previous incident with another resident that occurred on 2/16/12, on the importance of caring for residents with dignity and respect. The document indicated that professional and supportive communication was reinforced with OT A. On 4/3/12 at 3:00 pm, the administrator confirmed that he was notified of Residents 1 and 2's concerns regarding OT A, and stated that OT A was terminated on 3/26/12, as a result of the facility's investigation of the 3/21/12 incident. |
| 230000024 |
Golden Living Center - Redding |
230009706 |
A |
16-Jan-14 |
I4SO11 |
12283 |
F329483.25(I) Drug Regimen is Free from Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The facility failed to ensure Resident 1 was free of unnecessary drugs, when he received excessive doses of Ativan (lorazepam: a benzodiazepine medication used as an antianxiety agent, sedative-hypnotic, and anticonvulsant), was not adequately monitored for the excessive dose amount, and did not receive adequate supervision when his one on one (1:1) staff person (assigned to provide care only to the one resident, Resident 1, with never leaving sight of the resident) was reassigned. Resident 1 then suffered a subsequent fall which resulted with a fracture to his left (L) humerus (upper arm bone).Resident 1 was 78 years old, admitted to the facility on 1/13/12 with diagnoses that included dementia with behavioral disturbances and other persistent mental disorders.During a record review on 10/3/12, Resident 1's "At Risk for Falls" care plan, dated 1/14/12, indicated he had an extensive fall history, impaired balance, poor safety awareness, and used medications that increased his fall risk.Resident 1's physician's monthly order sheet for October 2012 showed 0.5 milligrams (mg) of Ativan was ordered every 6 hours, with an additional 0.5 mg Ativan ordered PRN (as needed) every 12 hours. Resident 1's orders included 0.5 mg of Risperdal (antipsychotic medication- reduces/calms the distortion and disorganization of a person's mental capacity) every night at bed time.Resident 1's record included nurse Progress Notes, dated 9/16/12 at 9:46 pm, that read,"...DON (Director of Nursing) was called regarding residents behavior and (licensed nurse) was permitted to call in a 1 on 1 sitter (1:1 monitoring - a Certified Nurse Assistant to be assigned to provide care only to Resident 1 and never leaving sight of Resident 1) to be with resident at all times to ensure his and other residents safety..."Resident 1's nurse Progress Notes, dated 9/17/12 at 3:19 pm, read, "Resident has more behaviors on the night shift then other times of the day, when there is less staff to redirect him."Resident 1's nurse Progress Notes, dated 9/18/12 at 10:39 pm, indicated the following:1. Resident 1 had a verbal confrontation with a resident and hit him with a cloth napkin at 6 pm;2. At 6:15 pm, Resident 1 lunged at another resident and threatened her;3. Resident 1 then attempted to slap a third resident in the face and ended up slapping her arm;4. The nurse contacted Resident 1's physician for a "one time" order of 1 mg of Ativan "to calm his aggression;"5. 1:1 care monitoring had to be provided to ensure everyone's safety; and6. Resident 1 "was able to be calmed ... (Resident 1) slept for 1 and 1/2 hours, but was then up and wandering the facility. 1 on 1 care had to be provided to ensure the safety of everyone will continue to monitor."A review of Resident 1's Medication Administration Records (MARs) for September 2012 showed documentation that he received the following doses of Ativan on 9/18/12:0.5 mg Ativan at midnight between 9/17 and 9/18/12;0.5 mg Ativan at 8 am;0.5 mg Ativan at 12 noon;0.5 mg Ativan at 6 pm;0.5 mg Ativan PRN dose at 3:15 pm; and1.0 mg Ativan "one time" dose at 7:45pm, for a total of 3.5 mg Ativan in less than 20 hours.In addition, on 9/18/12, Resident 1 received his bedtime dosage of 0.5 mg of Risperdal (a sedating medication given to assist with sleep and assist in reducing overall emotional/aggressive behaviors).The manufacturer of Ativan states in the medication's package insert, that lorazepam (Ativan) "is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms. ... The effectiveness of lorazepam in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies. The physician should periodically reassess the usefulness of the drug for the individual patient." The manufacturer does not state that lorazepam is useful in treating agitation associated with dementia. In the CMS Interpretive Guidelines for 42 CFR 483.25(l), the American Geriatrics Society (www.americangeriatrics.org ); American Medical Directors (www.amda.com ); American Society of Consultant Pharmacists (www.ASCP.com ) and other established professional groups are listed as sources of information related to precautions for medication uses in elderly patients. They have published a set of clinical practice guidelines for precautions related to "Potentially Inappropriate Medications in Older Adults," which is also referred to as the "Beer's Criteria List." This document (available at: ) states that benzodiazepine medications (the family of medications that include Ativan) should only rarely be used in older adults because "(Older adults) have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. ... Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium."Lexicomp Online provides an extensive pharmaceutical reference database: At "Geriatric Lexi-Drugs": (http://online.lexi.com/lco/action/doc/retrieve/docid/gdh_f/132583)Information about lorazepam (Ativan) includes: Under "Warnings/Precautions" - "In older adults, benzodiazepines increase the risk of impaired cognition, delirium, falls, fractures, and motor vehicle accidents. Due to increased sensitivity in this age group, avoid use for treatment of insomnia, agitation, or delirium. (Beers Criteria)." Under "Special Geriatric (Elderly) Considerations" - "This medication is considered to be potentially inappropriate in this (elderly) patient population (Beers Criteria: Quality of evidence - high; Strength of recommendation - strong)."Resident 1's Progress Note, dated 9/19/12 at 12:53 am, stated the following: "Situation: resident (Resident 1) got up out of bed at 23:00 (11 pm) and had an unwitnessed fall in his doorway" "Background: resident had been agitated all shift - had several confrontations and was given scheduled and PRN (as needed) 0.5 mg Ativan and 1 mg 1 time dose of Ativan per MD" "Assessment: resident had pain to left shoulder and left hip - red mark behind left ear and left shoulder - VS (vital signs) were unavailable to (SIC) due to resident refusing" "Response: MD was called - no response - called DON (Director of Nursing) - got approval to send (Resident 1) to acute (general acute care hospital)."The following Progress Note, dated 9/19/12 at 4:33 am, stated the following: "Pt (patient) returned from (acute hospital) ER at 0400 (4 am)... pt (patient) has a fractured Left humerus (arm bone) from fall earlier. Pt came back with order for pain meds but was medicated with norco (a combination of the narcotic hydrocodone and acetaminophen [Tylenol] used for pain relief) at hospital before returning..."There was no documented evidence that a CNA (Certified Nursing Aid) or other staff member was assigned, to care only for Resident 1 and to keep visual contact of Resident 1 at all times for his safety, when he sustained the fall, on 9/18/12 at 11 pm.The facility's "Verification of Investigation" report (a typed summary, in the resident's record provided by the facility to the surveyor; reports the facility's investigation into details leading up to and including Resident 1's fall and post fall care), dated 9/19/12 with times listed 6:01 thru 6:17 pm, stated, " ...Contributing Factors ..." - (Resident 1) has a diagnosis of dementia with behaviors ..." "Immediate Resident Protection Initiated: ... (Resident 1) was put on 1 on 1 staff assignment with a CNA. MD (Physician) was notified of the situation and gave an order for a one tie (SIC: time) dose of Ativan 1 mg PO (by mouth) to be given ... At 7:45pm the Ativan was given per the MD order and the 1 on 1 assignment continued. ..." It also stated, "Around 11:00 pm resident was found on the floor in the doorway of his room 10 feet away from where (Licensed Nurse) was at nurses station." The reports do not comment about how the fall at 11 pm could have been "unwitnessed" with a CNA assigned to be with him (1:1) at all times.A review of Resident 1's Physical Therapy "Progress Notes," dated 9/21/12 at 2 pm, read, "Physical Therapy Screen reveals that fall was not due to prominent balance deficits, but rather due to compromised balance from medication (Ativan) given to resident for agitation..."On 10/3/12 at 3:30 pm, the facility's Pharmacist (RPh) was interviewed about Resident 1's Ativan dosing on 9/18/12. RPh stated, daily "doses between 2.0 and 2.5 mg could contribute to falls and over-sedation," and confirmed that "Ativan doses greater than 2.0 mg do contribute to a lack of coordination."On 10/3/12 at 3:48 pm, the DON stated that due to staffing, the sitter was pulled at the beginning of night shift (10 pm to 6 am - The CNA who had been assigned to provide safety to Resident 1 had been taken away from Resident 1's (1:1) observation and care, and reassigned elsewhere in the facility, because there was not sufficient staff in the facility to meet all of the care needs of the residents). The 1:1 CNA had been removed even though the nurse's notes (mentioned earlier from 9/18/12 at 10:39 pm) indicated Resident 1 had slept for 1 & 1/2 hours after the medication was given and then was up again wandering the facility with the 1:1 CNA accompanying him.On 1/8/13 at 4:45 pm, the facility's Medical Director, who is Resident 1's attending medical doctor (MD) was interviewed about the one time dose of 1 mg of Ativan, on 9/18/12. He stated that facility staff had informed him that Resident 1 was agitated and aggressive towards staff and was difficult to control. MD stated "Ativan does affect balance and could have contributed to (Resident 1's) fall."Therefore, the facility failed to ensure Resident 1 did not receive excessive doses of Ativan, a medication that is recognized by the AMDA and Lexicomp:1. to be potentially inappropriate in the geriatric population;2. to be ineffective and should not be used for the treatment of insomnia, agitation or delirium;3. to make worse the risk factors and symptoms Resident 1 already had: impaired cognition, risk of falls and fractures;4. was given in excess of the recommended maximum dose to be given to an adult of any age; and5. For which the facility's Pharmacist and Medical Director had knowledge that the dose of Ativan given was excessive and could contribute to excess sedation, lack of motor coordination (stability on one's feet) and falls.On 9/16/12, the facility established Resident 1 needed special observation and a plan was put in place to have a staff CNA assigned for 1:1 observation and care of Resident 1 to provide for his safety. Resident 1 most often displayed his need for supervision on the night shifts, and on the night shift of 9/18/12, a day when Resident 1 had received more than his usual amount of sedating medications, and far above the recommended doses, his 1:1 care provider was reassigned, leaving him vulnerable and unobserved. Subsequently Resident 1 did fall while not being observed, and as a result fractured his left humerus (upper arm bone).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. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230010990 |
B |
17-Nov-14 |
W6F511 |
5308 |
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. The facility failed to report to the Department of Public Health within 24 hours of an abuse allegation that occurred between two residents. This failed action had the potential to negatively impact the residents' physical and emotional well being (Residents 1 and 2). A facility policy titled, "Abuse Prevention" revised 1/12, disclosed that the Administrator (Admin) had the primary responsibility for the coordination and implementation of the facility's abuse prevention policy and procedures. Another facility policy titled, "Reporting Abuse to Administrator" revised 1/12, disclosed that the Admin would report alleged incidents of abuse to the Department of Public Health within 24 hours. On 7/11/14 at 6:33 pm, the facility sent a fax notification to the Department confirming that a suspected abuse incident had occurred on 5/13/14, two months prior. The notification indicated that documentation was found during a medical record audit that Resident 1 was afraid of her roommate (Resident 2) and did not want to go into her room. Resident 1, an 86 year old female, was admitted to the facility on 3/14/14 with diagnoses that included dementia.Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/23/14, assessed her brief interview for mental status (BIM score, an evaluation of attention, orientation and recall) as 12 indicating that she was moderately impaired.She was assessed to have not had any hallucinations or illusions. Her medical record indicated that she was capable to make her own health care decisions. On 7/25/14 at 12 pm, Resident 1 was interviewed. She was alert and oriented to self, date, and the President of the United States. She stated that she recalled the incident during the month of 5/14, and had told the nurse that she was afraid of her roommate (Resident 2). She stated that Resident 2 came swinging at her twice. She stated her roommate had never hit her in the face because she had grabbed her hands both times. Resident 2, an 84 year old female, was admitted to the facility on 9/29/13, with diagnoses that included dementia with behaviors. Resident 2's MDS, dated 6/3/14, described her as rarely understood and that she was unable to complete her brief interview of mental status. The MDS disclosed that she required supervision with ambulation and hygiene.A nurse's note in Resident 1's medical record dated 5/13/14 at 10:20 pm, disclosed that she was observed sitting outside of her room and stated that she was afraid of her roommate. Documentation indicated that earlier that same day, reports were made to this nurse that her roommate (Resident 2) was going through her nightstand and when Resident 1 asked Resident 2 what she was doing, Resident 2 shook her fists at Resident 1's face. The licensed nurse (LN) then documented that Resident 1 had informed her that Resident 2 had hit her in the face, pointing to the right side of her face.A nursing note in Resident 2's medical record dated 5/13/14 at 11:30 pm, disclosed that this patient was going through her roommates personal belongings and that roommate (Resident 1) reported that Resident 2 had scratched and hit her in the face. Documentation indicated that this nurse reported the alleged incident to the Administrator.On 9/4/14 at 5 pm, Licensed Nurse (LN) A was interviewed. She stated she recalled the incident between Resident 1 and 2. LN A stated that she observed Resident 1 sitting outside of her room in a chair. She stated a certified nursing assistant reported to her that Resident 1 was afraid to sleep in her room. LN A stated that she then went to talk to Resident 1 and she confirmed that she was afraid of her roommate and also informed her that earlier she had found Resident 2 going through her personal items and when she said something to her, Resident 2 told her to "go to hell". LN A stated that later a certified nursing assistant reported that Resident 1 had told her that Resident 2 had scratched her face but when she went to assess her she found no scratches or marks on her face. LN A stated she had called Administrator (Admin) A, filled out an incident report, a SOC 341 (elder abuse report) and reported the incident to the next shift. LN A stated that Admin A never came to question her about the incident so she thought it had been taken care of.On 7/25/14 at 12:45 pm the Social Service Director (SSD) was interviewed. She stated that Resident 1's physician considered her competent to make her own health care decisions. Concurrently at 1 pm, SSD stated that she was never notified of the alleged abuse incident on 5/13/14 between Resident 1 and 2. On 7/25/14 at 11:30 am, Admin B and the Director of Nursing (DON) were interviewed. They both stated that they could not find any investigation or reports made to the Department regarding this abuse allegation between Resident 1 and 2. Therefore, the facility failed to report to the Department of Public Health within 24 hours of the abuse allegation that occurred on 5/13/14. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230011082 |
A |
20-Mar-15 |
UH4S11 |
12958 |
Title 22 72311(a)(3)(B) Failure to promptly notify the physician of any sudden and/or adverse change in signs, symptoms, or behavior.The facility failed to recognize, intervene, promptly notify the attending physician of, and provide treatment for Resident 24's sudden, adverse symptoms and change in condition, complaining of ongoing, severe chest pain, for more than eight hours. The facility failed to ensure prompt emergency care for Resident 24.These failures resulted in delayed relief of and medical intervention for Resident 24's severe chest pain, acute angina (chest pain resulting from an imbalance between oxygen supply and demand, commonly caused by the inability of narrowed/ blocked coronary (heart) arteries to deliver sufficient blood to the heart under conditions of increased heart muscle oxygen consumption). Resident 24 required emergency transfer to Hospital A's emergency room and subsequent hospitalization at Hospital B where Resident 24 was determined by a cardiologist (a physician who specializes in heart conditions) to require a percutaneous transluminal coronary angioplasty (PTCA-a procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle) with coronary stent (a tube placed in the coronary arteries that supply blood to the heart) placement. These failures placed Resident 24 at risk for worsening of an existing heart condition and heart attack and/or death.Resident 24, a 64 year old male, was admitted to the facility on 3/9/14 from the hospital (where he was treated for syncope (fainting caused by a lack of blood flow) and ischemic heart disease (occurs when blood flow to your heart muscle is decreased by a partial or complete blockage of your heart's arteries (coronary arteries) with angina (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) with diagnoses that included ischemic heart disease (CAD), irregular heartbeats, congestive heart failure (CHF-inability of the heart to keep up with the demands on it, with failure of the heart to pump blood with normal efficiency), high blood pressure (HTN), diabetes (DM), a history of a five vessel coronary artery bypass graft surgery (CABG-replacement of occluded, narrowed, or damaged arteries in the heart with blood vessels from another area of your body), in 2004, and implanted defibrillator (a small device that's surgically placed in the chest or abdomen used to help treat irregular heartbeats called arrhythmias).Record review indicated Resident 24 signed a form titled, "POLST" (Physician Orders for Life-Sustaining Treatment) on the day he was admitted to the facility, 3/9/14. POLST is a physician's order that residents may sign to communicate their wishes for treatment in the event of an emergency. Resident 24's signed POLST form indicated, in the event that Resident 24 has no pulse and is not breathing, the facility staff was to attempt resuscitation/CPR (provide breathing and chest compressions) and provide full treatment. Resident 24's physician's admission orders indicated Resident 24 had capacity to make his own health decisions and included several medications to treat his heart conditions: (Pacerone for arrhythmias, Imdur, Coreg, Cozar, Renexa and aspirin for CAD, Norvasc, Microzide, Aldactone for HTN, Furosemide for CHF, and nitroglycerin for angina). The facility's "Cardiac" and "Cardiac Pacemaker" care plans for Resident 24, dated 3/11/14, directed nurses to monitor Resident 24 for chest pain.During the initial tour of the facility on 3/24/14 at 10:30 am, Resident 24 stated, "Two days after I came here I had chest pain and it took nine hours for them to get an ambulance." Resident 24 stated his chest pain was "12 1/2 on a scale of one to ten, started at 2 pm, and they got me out at 12 am. I told them if they didn't call 9-1-1, I was going to call 9-1-1 myself." Per Resident 24, the ambulance took him to Hospital A to stabilize him then he was sent to Hospital B and a stent was placed. During an interview with Licensed Nurse (LN) M on 3/25/14 at 10:20 am, she stated she was assigned to care for Resident 24 on 3/11/14 from 2:00 pm to 10:30 pm. LN M reported Resident 24 complained of chest pain at 2:30 pm. LN M stated she offered Resident 24 Tylenol, but he wouldn't take it. LN M said, "I only had training by another nurse four or five shifts, and it was my first night on my own. I didn't think his chest pain was a problem, he just wanted to leave this place to get his medications, which she described as Ativan (medication used to treat anxiety) and his sleeping pills." LN M said she thought Resident 24 had heart burn, and knew Resident 24 had "a history of heart problems but she was never trained on emergencies." LN M said she understood that she doesn't need a physician's order to send someone to the hospital.When asked why the physician was not notified of the resident's chest pain complaints, LN M stated, "I didn't call the doctor, I probably should have. They never taught me in school how to call the doctor." After this statement, LN M further stated she attempted to page Resident 24's physician twice and then was told he uses a cell phone. LN M stated she saw the physician's cell phone number, but didn't think to call it. When asked if she would do anything differently given the same situation today, LN M replied, "Now I know to call the physician's cell phone and not his pager." During an interview with LN O on 3/25/14 at 3:00 pm, she stated, "On 3/11/14 at 9:30 pm, LN M came to me and said she couldn't reach the doctor for Resident 24." LN O stated, "I told her to call the Medical Director and tell him about the resident." LN O stated, LN M had called the physician's office phone and not his cell phone, further stating, "I told LN M what to do but she didn't do it."During an interview on 3/25/14 at 11:10 am, LN L stated, "(LN M) asked me if I could assess him (Resident 24). He had pain in the center of his chest." LN L stated, "(Resident 24) looked like he was hurting and scared. We were not ignoring his pain, but we didn't know what was going on and I was not sure how to reach the doctors. I was trained one to two days, then, I was on my own." LN L stated, "I did not take his vital signs (temperature, blood pressure, heart rate, and respiratory rate) because we did not have an Aide." LN L stated she "never received training on emergency procedures" while employed at the facility. LN L stated she "had to look and ask where phone numbers were for the doctors, but no one knew because there were so many new people."During an interview with LN K on 4/4/14 at 4:45 pm, she stated she started work on 3/11/14 at 10 pm and LN M told her Resident 24 had been having chest pain. LN K stated, she went to Resident 24's room and he said, "Where is the ambulance, I have had chest pain since 3 pm this afternoon." LN K stated, "He then told me he felt like he had a lot of bricks on his chest" (a symptom that should be recognized as possible ischemia/angina). LN K stated she left the room and immediately called the doctor and received the order to transfer Resident 24 to a hospital, then called 9-1-1 and sent him out to the hospital.Review of the facility's "Change of Condition Notification" policy, revised on 1/1/12, indicated, "Change of condition is defined by any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual, denote a new problem, complication or permanent change in status, and require a medical assessment, coordination and consultation with the attending physician and a change in treatment plan. In emergency situations, (e.g., a resident is experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal labs or x-ray) the Licensed Nurse will: a. Call the attending physician stat (now). b. If there is no response, the Licensed Nurse will call again in 20 minutes. If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director. If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital." During a record review and concurrent interview with LN M, it was noted that there was no documentation from LN M for her shift on 3/11/14 from 2:00-10:30 pm. When asked why there was no documentation of Resident 24's episode of chest pain or care she provided Resident 24 during her shift, she replied, "I don't think I wrote anything, I was so stressed." Review of Hospital A emergency care records indicated, while in the emergency room on 3/11/14, Resident 24 rated his chest pain as 7/10 (Zero means no pain, 10 reflects the worst possible pain, and 7/10 is considered severe pain) received Nitroglycerin paste (used to improve blood flow to relieve episodes of angina-chest pain) and supplemental oxygen (to improve blood oxygen concentration), Demerol (pain medication) and Phenergan (nausea medication). A chest x-ray and ECG (electrocardiogram-electronic tracing of the heart rate and rhythm) were ordered and Resident 24 was admitted to intensive care unit (ICU) for observation. Resident 24 was transferred to Hospital B on 3/13/14, and evaluated by a cardiologist (heart specialist).On 3/13/14, Resident 24 was transferred to Hospital B for a higher level of care and specialty treatment for his heart condition and diabetes. Hospital B document review indicated Resident 24 was diagnosed with a heart attack, an enlarged heart with congestive heart failure, diabetes, and hypertension. The treating cardiologist, a physician heart specialist, documented Resident 24 had abnormally elevated heart function values after several hours of chest pain. The cardiologist's impression was "Acute coronary syndrome with known ischmic cardiomyopathy, suspect graft closures and/or worsening of native disease." Resident 24 underwent a heart catheterization procedure (a medical test that involves passing a thin flexible tube (catheter) into the right or left side of the heart, allowing the physician to check blood flow in the coronary arteries and blood flow/blood pressure in the chambers of the heart, to find out how well the heart valves work and check for defects in the way the wall of the heart moves) which demonstrated "a high-grade lesion (occlusion) at the left anterior descending artery (LAD-the most important coronary artery in the human circulation because the LAD provides much of the blood flow for the left ventricle, which in turn provides much of the propulsive force for ejecting oxygenated blood to systemic circulation via the aorta, blockage of this artery is particularly associated with death) located after internal mammary insertion (the left internal mammary artery (LIMA) commonly used to bypass the left anterior descending artery), and stenting (placement of a coronary stent, as previously described) was performed through the graft (one of the artery bypass grafts from a previous surgery)." After the stent placement, Resident 24's elevated heart function values (troponin levels) decreased/improved. Additionally, the cardiologist noted that Resident 24 had a "moderate" abdominal aortic aneurysm (an enlarged area in the lower part of the aorta, the major blood vessel that supplies blood to the body. The aorta runs from the heart through the center of the chest and abdomen. Because the aorta is the body's main supplier of blood, a ruptured abdominal aortic aneurysm can cause life-threatening bleeding).Therefore, the facility failed to recognize, intervene, promptly notify the attending physician of, and provide treatment for Resident 24's sudden, adverse symptoms and change in condition, complaining of ongoing, severe chest pain, for more than eight hours. The facility failed to ensure prompt emergency care for Resident 24.These failures resulted in delayed relief of and medical intervention for Resident 24's severe chest pain, acute angina (chest pain resulting from an imbalance between oxygen supply and demand, commonly caused by the inability of narrowed/ blocked coronary (heart) arteries to deliver sufficient blood to the heart under conditions of increased heart muscle oxygen consumption). Resident 24 required emergency transfer to Hospital A's emergency room and subsequent hospitalization at Hospital B where Resident 24 was determined by a cardiologist to require a PTCA with coronary stent placement. These failures placed Resident 24 at risk for worsening of an existing heart condition and heart attack and/or death.These violations presented that imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230011084 |
A |
13-Mar-15 |
UH4S11 |
19172 |
Title 22 72311(a)(3)(B) Failure to promptly notify the physician of any sudden and/or adverse change in signs, symptoms, or behavior. Title 22 72315(h) Failure to provide the necessary fluids for hydration. The facility failed to recognize, intervene, promptly notify the physician of, and provide treatment for significant changes of condition and symptoms of aspiration, respiratory distress, infection, and dehydration (coughing when swallowing liquids, decreased appetite/oral intake, abnormal vital signs [Temperature (T), blood pressure (BP), heart rate (HR), and respiratory rate (RR)], and decreased level of consciousness), and to ensure the provision of sufficient fluids to maintain proper hydration and prevent dehydration for Resident 11.These failures resulted in Resident 11's further decline and hospitalization where a physician determined he was "in severe distress, hypotensive (low blood pressure), unresponsive, pale, and dehydrated (insufficient fluid in the body)" at Hospital A, and required transfer to a higher level of care, Hospital B, where a physician determined he was "extremely dehydrated ...profoundly dehydrated-appearing, appears somewhat unkempt...mucous membranes (tissue inside mouth) are very dry...skin is flaky and dry, dark amber, cloudy urine" and diagnosed with suspected hypovolemic shock (an emergency condition of severe blood/fluid loss that makes the heart unable to pump enough blood to the body), acute kidney injury, and sepsis (overwhelming infection). On 12/31/13, the discharging hospital physician documented Resident 11 died at Hospital B due to acute respiratory failure and septic shock.Review of admission documents showed that Resident 11 was admitted to the facility on 5/19/11, from a hospital, with diagnoses which included throat cancer, tracheotomy (surgical hole in the windpipe), difficulty swallowing, anemia, high blood pressure, depression, and dementia.Review of the facility's Minimum Data Set (MDS-a standardized assessment), dated 10/21/13, for Resident 11 indicated he had severe cognitive (ability to think and reason) impairment and required supervision (oversight, encouragement, cueing) from one staff person for meals (to eat and drink fluids). Resident 11 was receiving a mechanically altered diet (soft foods due to difficulty swallowing). According to the assessment, Resident 11 was not short of breath, did not have a fever, and was not dehydrated.Review of the facility's annual "Registered Dietitian Nutrition Assessment," dated 5/3/13, indicated Resident 11 required a dietary intake of at least 70% of meals to meet his nutritional requirements and 2040 ml (milliliters) total daily fluid intake to meet his fluid hydration needs, and had no signs and symptoms of dehydration. Review of a Nutrition Hydration care plan, dated 5/3/13, indicated treatment goals that Resident 11 would receive adequate hydration to maintain normal tissue/skin integrity, urine output, and vital signs and was to consume at least 70% of each meal. Care planned interventions included encouraging oral fluids and eating at each meal, offering fluids frequently, monitoring for signs and symptoms of dehydration, and notifying the physician, as indicated. Review of a Speech Therapy care plan, dated 7/23/13, indicated Resident 11 had difficulty swallowing and treatment goals included tolerating diet without choking or aspiration (food/fluid getting into the lungs) and maintaining adequate nutrition/hydration w/ aspiration safety precautions. Review of a Respiratory care plan, dated 10/22/13, indicated Resident 11 had pneumonia and an upper respiratory infection, was receiving an antibiotic (Doxycycline x 10 days), and could have supplemental oxygen, as needed, for blood oxygen levels that fall below 90%. The care plan directed nursing staff to notify the physician if the resident's condition worsens or does not resolve. A chest x-ray report, dated 10/25/13, indicated Resident 11 had worsened bilateral (both lungs) pneumonia, as compared to a previous chest x-ray report, dated 5/31/13.A review of the facility's 12/12-12/19/13 "Weekly Summary" indicated Resident 11's vital signs were within normal limits (BP 136/72, HR 76, RR 18, and T 97.8 F [Fahrenheit]), he was alert, lungs were clear with no change in respiratory function, his tracheal stoma (tracheotomy site) was intact, and he was incontinent (unable to control bowel or bladder). The Infection section was blank (not completed). Resident 11 was on a pureed (blended consistency) diet, consuming an average of 75% of his meals with limited assistance. "NA" (not applicable) was written in the fluid intake average section. Fluid intake averages were not documented. Resident 11's skin was "CDI" (clean, dry, intact).On 12/17/13, nursing notes indicated Physician A was notified that Resident 11 had brown drainage (abnormal and can indicate old blood or other abnormality) out of his right nostril and green and yellow phlegm (abnormal and can indicate bacterial infection) from his "Laryngectomy" site (removal of part of the throat-the larynx). Resident 11's oxygen saturation (O2 sat-percentage of oxygen in the blood) was 93-95% on room air (without oxygen supplementation). Resident 11's vital signs were BP 90/62, HR 85, RR 18, and T 98.3 F. On 12/20/13, nursing notes indicated Resident 11 had a congested, productive cough, was warm to touch, T was 100.9 F, lungs were congested, and was receiving supplemental oxygen at 2 liters (L) per minute (min) flow via "Trach mask" (delivery of oxygen using a mask via the tracheotomy site) with an O2 sat of 94%. At 1:00 pm, Physician A was notified and an antibiotic (Levaquin x 10 days) and inhaled breathing treatments were ordered for "cough."Review of a care plan for the Levaquin antibiotic use, dated 12/20/13, indicated Resident 11 was at risk for adverse effects of antibiotic medication and nursing and direct care staff were to encourage fluids and check skin turgor (condition of skin tissue) if fluid intake is poor, and inform the physician and family for any changes in condition. The Activities of Daily Living (ADL) charting for Resident 11 from 12/1/13 through 12/19/13 indicated Resident 11 generally required limited assistance of one staff member for transfers, was either independent (received no help or staff oversight at any time) with set up only (no assistance by staff) or received supervision (oversight, encouragement, cueing) with one person assistance for breakfast and lunch, and required limited assistance of one staff person for dinner.On 12/20/13, Resident had a significant decline in eating; total dependence requiring full assistance from one staff person and/or refusing meals. There was no evidence that the physician was notified of this significant change in Resident 11's condition. On 12/21/13, nurses notes indicated Resident 11 had continued lung congestion, requiring supplemental oxygen via "Trach mask" at 2L/min flow with O2 sat of 95%, requiring suction from his "Trach stoma" for moderate amounts of thick mucus, and "No meds given, did not drink med pass." There was no evidence of notification to the physician of this change.On 12/22/13, nursing notes indicated Resident 11's HR was elevated at 94 beats per minute (bpm), he continued on 2L/min O2, and had a cough producing green sputum with a T of 100.6 F. At 7:30 pm, Resident 11 was noted to be somnolent (decreased level of consciousness). There was no documentation that the physician was notified of this change in condition. On 12/23/13 at 1:35 pm, nursing notes indicated Resident 11 remained on antibiotics for "URI" (SIC: upper respiratory infection), had scattered wheezes in his lungs, and was having a problem with drinking thin liquid. At 7:00 pm, Resident 11's HR was 100 bpm, BP 95/56, RR 22, and he "continues somnolent." There was no documentation that the physician was notified of the resident's change in condition. On 12/24/13 at 6:50 am, nursing notes indicated Resident 11's Trach site was "crusted" with respiratory secretions and the resident was "in distress" during cleansing of the site. Resident 11 was coughing up green secretions and had course sounding lungs. BP was 106/64 and HR was 90 bpm. At 8:30 am, Resident 11's BP dropped to 78/40 and HR increased to 130 bpm. Resident 11 was not able to take oral fluids well. Two hours later, at 10:30 am, the physician was called and ordered Resident 11 to be transferred to Hospital A's emergency room for medical evaluation. Review of the ADL charting from 12/20/13 through 12/24/13 indicated Resident 11 did not get out of bed on any day, required total dependence requiring full assistance from one staff person and/or refused meals, and was subsequently transferred to the hospital. Resident 11 had significant changes of condition during this four day period.The meal monitor flow sheet for December 2013 indicated Resident 11's average oral intake (foods and fluids) was as follows: From 12/13 through 12/16/13, 84% of meals and 1020 ml liquid intake per day (only half the amount of fluid recommended by the RD to meet Resident 11 ' s fluid needs). On 12/20/13, 70 ml liquid intake and 0% intake of all three meals, a significant decrease, and the charge nurse was notified; On 12/21/13, 0% intake of all three meals and no fluid intake, and the charge nurse was notified; On 12/22/13, 120 ml fluid intake and 0% meal intake; and On 12/23/13, 140 ml liquid intake for the day.Resident 11's average oral intake from 12/20 through 12/23/13 was 5% meals and 65 ml liquid intake per day. Resident 11's four day average intake decreased from 84% to 5% of meals, and his liquid intake decreased from 1020 ml to 65 ml per day. During an interview with Certified Nurse Assistant (CNA) S on 3/26/14 at 8:30 am, she stated one of her duties was to assist residents with meal intake. She said Resident 11 had been coughing when staff attempted to give him liquids for a couple of days, before it was reported to the nurse, on 12/23/13, after lunchtime. (Coughing while attempting to drink liquids can be a sign of choking/aspiration). During an interview on 3/27/14 at 11:00 am, CNA R said she had cared for Resident 11 on 12/20/13. She stated he had been coughing during his meals, on liquids and even ice cream, and had been "out of it" for a few days, prior to 12/24/13. CNA R stated she "always" reported a meal intake of less than 50%, but his coughing was not reported because it was common knowledge, as it had been going on for a few days. During a concurrent record review and interview on 3/26/14 at 8:10 am, Licensed Nurse (LN) F reviewed her December 2013 nurses notes for Resident 11. She stated that on 12/23/13 at lunchtime, she was notified by the CNA that Resident 11 was coughing when attempting to swallow liquids, but she was not aware Resident 11 had no significant fluid intake and had refused meals daily for the previous four days. LN F stated the physician should be notified when a resident develops a problem swallowing liquids (such as coughing) but she did not call the physician to notify him, further stating she would have contacted Resident 11's physician by fax not by telephone. LN F stated she did not recall any change or improvement in Resident 11's condition since he started antibiotics on 12/20/14. LN F stated the usual expectation was to see some improvement towards health after a resident has been on an antibiotic for 24 hrs. LN F stated the nurse should notify the physician when the Resident does not respond to an antibiotic treatment after 24 hours.During an interview with LN G on 3/26/14 at 4:50 pm, she stated she had been Resident 11's nurse many times, prior to 12/22/13, and he was usually alert, interactive with staff, able to swallow without difficulty, and consumed meals (food and liquid) with staff assistance. LN G stated she had been Resident 11's nurse on 12/22/13 and she had charted he was "somnolent" and "over sedated" which was not usual for him. LN G stated she was not aware the CNAs had documented his entire fluid intake was less than 70 ml in the previous 2 days, and no fluid intake at all in the previous 24 hours. LN G stated she did not notify the physician of Resident 11's change in condition.LN G was also Resident 11's nurse on 12/23/13 and, during a concurrent record review, it was noted that she documented that Resident 11 was "somnolent," for the second day in a row and had a low BP of 92/56 and a high HR of 100 bpm. LN G stated those were not the usual vital signs for Resident 11 and she thinks "he was dehydrated." LN G stated she did not notify the physician of these significant changes (decreased and insufficient food/fluid intake, abnormal vital signs, change in level of consciousness, and symptoms of possible dehydration).During an interview on 3/27/14 at 9:30 am, NA E stated the facility expectation would be for the licensed nurse to call the physician on the telephone to notify him if a resident had any significant change in condition. NA E stated new difficulty swallowing is a change of condition to be immediately reported because the resident "can aspirate (get fluid into lungs) fairly quick." NA E stated the physician should be notified if a resident on antibiotics does not respond to treatment within 24 hours and/or continues to decline in condition, despite antibiotic treatment because the physician may need to change the treatment. NA E stated the physician should be notified when a resident's level of alertness changes from alert to somnolent, when the resident has a significantly decreased liquid intake, and more than three consecutive meal refusals. NA E stated he had reviewed all the records for Resident 11 and confirmed Resident 11 had changes of condition in areas of alertness, swallowing, intake and vital signs but none of these had been reported to the physician.The facility's "Change of Condition Notification" policy, dated 1/1/12, directed, "The facility will promptly...consult with the residents attending physician...when the resident endures a significant change in the condition. A change of condition related to attending physician notification...is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. A significant change is also described as a deterioration in health (or) mental status, ...life-threatening conditions or clinical complications."During an interview with Resident 11's attending physician (Physician U) on 3/27/14 at 1:55 pm, he stated he had not been notified by the facility that Resident 11 had a decreased food and fluid intake, somnolence, deterioration after the antibiotics started on 12/20/13, coughing on liquids or changes in vital signs, prior to being transferred to the hospital on 12/24/13. Physician U stated all of Resident 11's changes were significant and he would expect to be notified by telephone. Physician U stated it is "absurd" for them (facility staff) to fax instead of call on a "serious issue." Physician U stated he had spoken with the facility before regarding this because, "They don't call," him regarding a serious issue.A document titled, "Physician Orders for Life-Sustaining Treatment," dated 7/26/11, indicated based on Resident 11's wishes, he was to receive "medical treatment, antibiotics and IV fluids as indicated."Review of facility "Physicians Telephone Orders," dated 12/24/13 and timed 10:30 am, indicated the physician was notified of changes in Resident 11's condition and ordered Resident 11 to be transferred to Hospital A's emergency room for low BP. The order was received more than two hours after the facility identified Resident 11's BP was abnormally low (78/40) and HR was abnormally elevated (130 bpm).Review of the facility's "Patient Transfer Form," dated 12/24/13, indicated Resident 11 was being transferred for dehydration and low BP (75/40).A review of a "Clinical Report," dated 12/24/13, from Hospital A, indicated Resident 11 arrived at the hospital on 12/24/13 at 10:41 am. Resident 11's medical examination indicated he was "In severe distress, hypotensive, unresponsive, pale, and dehydrated." As Hospital A attempted to treat and stabilize Resident 11's medical condition plans were made to transfer him to Hospital B, a specialty care hospital trauma center designed to treat more critically ill patients. Resident 11 was transferred to Hospital B on 12/24/13 at 1:30 pm, having received IV (administered via a vein) antibiotics and continuous IV fluids while at Hospital A. Resident 11 required transfer to Hospital B on 12/24/13 at approximately 12:20 pm for a higher level of treatment. Resident 11's examination by the receiving physician (after being treated with IV fluids for at least three hours) indicated, Resident 11 was "extremely dehydrated...profoundly dehydrated-appearing, appears somewhat unkempt...mucous membranes (inside mouth) are very dry...skin is flaky and dry, dark amber urine." Impression of the physician included shock and sepsis (overwhelming infection). The physician documented, "he (Resident 11) has a high probability of succumbing to this..." A document titled, "Discharge Summary," dated 12/31/13, indicated Resident 11 died at Hospital B after having been admitted on 12/24/13 for suspected hypovolemic shock (an emergency condition of severe blood/fluid loss that makes the heart unable to pump enough blood to the body), acute kidney injury, and sepsis (overwhelming infection). Therefore, the facility failed to recognize, intervene, notify the physician of, and provide treatment for significant changes of condition and symptoms of aspiration, respiratory distress, unresolved infection, and dehydration (coughing w/liquids, decreased appetite and oral intake, abnormal vital signs [T, BP, HR, RR], and decreased level of consciousness), and to ensure the provision of sufficient fluids to maintain proper hydration and prevent dehydration for Resident 11.These failures resulted in Resident 11's further decline and hospitalization where a physician determined he was " in severe distress, hypotensive (low blood pressure), unresponsive, pale, and dehydrated (insufficient fluid in the body)" at Hospital A, and required transfer to a higher level of care, Hospital B, where a physician determined he was "extremely dehydrated ...profoundly dehydrated-appearing, appears somewhat unkempt...mucous membranes (tissue inside mouth) are very dry...skin is flaky and dry, dark amber, cloudy urine" and diagnosed with suspected hypovolemic shock (an emergency condition of severe blood/fluid loss that makes the heart unable to pump enough blood to the body), acute kidney injury, and sepsis (overwhelming infection). On 12/31/13, the discharging hospital physician documented Resident 11 died at Hospital B due to acute respiratory failure and septic shock.These violations presented that imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230011220 |
B |
19-Mar-15 |
N0GI11 |
4508 |
T22 DIV5 CH3 ART3 - 72315(b) Nursing Service - Patient Care(b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind.The facility failed to ensure an environment free from abuse and mistreatment when staff members took and sent undignified and disrespectful photographs and videos of residents. The videos included CNA B twerking (dancing to popular music in a sexually provocative manner involving thrusting hip movements and a low, squatting stance) over a resident's head and CNA A twerking in a resident's room. This resulted in abuse of residents when they were subjected to mistreatment that was undignified and humiliating. On 5/1/14, the facility's undated policy to address abuse prevention, indicated that the purpose of the policy was to protect residents from abuse, neglect and mistreatment. The policy indicated gestured language that was derogatory or disparaging, was considered abuse, regardless of the resident's age, ability to comprehend, or disability. The policy indicated "mental abuse", included humiliation and harassment of the resident.The facility's employee handbook, dated 4/2013, indicated that the use of personal communication devices, such as cellular (cell) phones, was prohibited during normal work hours and in all work areas.On 5/1/14 at 1:45 pm during a telephone interview, an anonymous complainant explained that videos were sent by cellphone of Certified Nursing Assistant B (CNA B) twerking over a residents head, and a photo was sent of a resident (Resident 1), who was only wearing a brief, being carried by CNA B up over his shoulder. The anonymous complainant stated the photographs and videos were sent by CNA A using the snap-chat application (app) (enables real time photographs and video to be displayed for a few seconds on another person's cellphone, but is not saved on either device).On 5/5/14 at 9:30 am during an interview, CNA G explained that on 4/29/14, during the day shift, she made a report to the Administrator. CNA G reported that CNA A had been snap-chatting photographs of residents that were inappropriately exposed and/or appeared to be deceased. CNA G added that she was absolutely disgusted by the lack of respect this showed for human life and for a person who had passed. CNA G went on to explain that, "our residents are mothers, fathers, sisters, brothers and are all humans that love and have feelings." CNA G stated that it was amazing to her that a person could be so uncaring for a laugh. CNA G stated that she had received abuse training in the facility. CNA G stated that this constituted abuse to residents, which was why she had reported it to the Administrator. CNA G stated that she was surprised to find out that CNA B was still scheduled to work with residents after this had been reported.On 5/14/14 at 1:30 pm during an interview, CNA C, confirmed that while working in the facility she had received video on her cellphone through the snap-chat app of CNA B twerking over the head of a resident and of CNA A twerking over a recliner that was located in a resident room. CNA C stated staff frequently used the snap-chat app to communicate by texting words to others. CNA A explained that a photo of the background was always included with the text since the snap-chat app was designed for sending real time photos and videos. CNA C stated that many times the background in the photos included partial photographs of residents. CNA C stated that photographs were sent, using snap-chat, on many occasions to multiple staff in the facility.CNA C stated that the resident in the video where CNA B was twerking over his head was not identifiable from the photograph and did not appear to be aware of what was happening. The resident appeared to be sleeping or unconscious. However, CNA C explained that after thinking it through, she realized the behavior in itself was undignified and humiliating towards the resident. On 7/14/14 at 4:15 pm during a telephone interview, the facility's New Administrator stated that the Department of Justice (DOJ) investigators had taken staff cell phones to retrieve deleted data, and were able to provide the facility with information that included which residents and CNAs were involved (Residents 1, 2, 3 and 4) in the abuse incidents. Resident 1 was identified as the resident being carried over the shoulder of CNA B. The New Administrator stated the facility had fired five CNAs who had been involved. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230011221 |
B |
19-Mar-15 |
N0GI11 |
5327 |
1418.91(a) Health & Safety Code: Fail to Report Alleged Abuse(a)A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.The facility failed to operationalize their abuse prevention policies when incidents of abuse and mistreatment of residents were not investigated or reported to the department within 24 hours. This resulted in the offending CNAs continuing to work with residents which jeopardized resident safety and well-being.On 5/1/14, the facility's undated policy to address abuse prevention, investigation, and reporting indicated that any allegations of abuse would be investigated immediately. The policy indicated that the purpose of the policy was to protect residents from abuse, neglect and mistreatment. The policy indicated gestured language that was derogatory or disparaging, was considered abuse, regardless of the resident's age, ability to comprehend, or disability. The policy indicated "mental abuse", included humiliation and harassment of the resident. The policy indicated that facility staff who had witnessed or who believed that a resident had been a victim of mistreatment or abuse, must immediately report, or cause a report to be made of the mistreatment. The policy indicated that the facility staff must not knowingly fail to report an incident of mistreatment or other offense. The policy indicated that the allegation of abuse would be reported to the department of public health within 24 hours. The facility's employee handbook, dated 4/2013, indicated that the use of personal communication devices, such as cellular (cell) phones, was prohibited during normal work hours and in all work areas.On 5/5/14 at 9:30 am during an interview, CNA G explained that on 4/29/14, during the day shift, she made a report to the Administrator. CNA G reported that CNA A had been using the snap chat application (app) (enables real time photographs and video to be displayed for a few seconds on another person's cellphone, but is not saved on either device) to send pictures of residents that were inappropriately exposed and/or appeared to be deceased. CNA G added that she was absolutely disgusted by the lack of respect this showed for human life and for a person who had passed. CNA G went on to explain that "our residents are mothers, fathers, sisters, brothers and are all humans that love and have feelings." CNA G stated that it was amazing to her that a person could be so uncaring for a laugh. CNA G stated that she had received abuse training in the facility. CNA G stated that this constituted abuse to residents, which was why she had reported it to the Administrator. CNA G stated that she was surprised to find out that CNA B was still scheduled to work with residents after this had been reported.On 5/14/14 at 1:30 pm, during an interview, CNA C, confirmed that while working in the facility she had received video on her cell phone through the snap-chat app of CNA B twerking (dancing to popular music in a sexually provocative manner involving thrusting hip movements and a low, squatting stance) over the head of a resident and of CNA A twerking over a recliner that was located in a resident room. CNA C stated staff frequently used the snap-chat app to communicate by texting words to each other. CNA A explained that a photo of the background was always included with the text since the snap-chat app was designed for sending real time photos and videos. CNA C stated that many times the background in the photos included partial pictures of residents. CNA C stated that the pictures and videos were sent on many occasions to multiple staff in the facility. CNA C confirmed that these incidents had not been reported. When asked why she did not report the incidents, CNA C stated that the resident in the video where CNA B was twerking over his head was not identifiable from the picture and did not appear to be aware of what was happening. The resident appeared to be sleeping or unconscious. CNA C explained that now after thinking it through, she realized it should have been reported since the behavior in itself was undignified and humiliating towards the resident. On 5/1/14 at 5:15 pm during an interview, the Administrator confirmed that CNA G had informed him on 4/29/14 that CNA A had sent inappropriate pictures of residents using the snap-chat app. The Administrator stated that he had not started an investigation process or reported the incident because there was no concrete evidence that it had occurred. The Administrator confirmed that he had not spoken with CNA A. The Administrator stated that CNA A was currently clocked in and working in the facility. The Administrator confirmed that the facility's abuse prevention policy had not been followed when CNA C and other staff, did not report the alleged mistreatment of residents by CNA A and CNA B.On 7/14/14 at 4:15 pm during a telephone interview, the facility's New Administrator stated that the Department of Justice (DOJ) investigators had taken staff phones to retrieve deleted data, and were able to provide the facility with information that included which residents and CNA's were involved. The New Administrator stated the facility had fired five CNAs who had been involved. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230011222 |
B |
14-Jan-15 |
P9EH11 |
2709 |
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. The facility failed to ensure that all incidents of alleged or suspected abuse were reported to the Department of Public Health (Dept) within 24 hours. The facility failed to implement their written policies and procedures that incidents of alleged abuse or suspected abuse of a resident of the facility would be reported to the Dept. within 24 hours. Resident 1, a 79 year old female, was admitted to the facility on 7/29/11 with diagnoses which included diabetes and anxiety. She was described in the facility's records as being capable of making her own health care decisions. Resident 2, a 55 year old female was admitted to the facility on 1/26/12 with diagnoses which included chronic airway obstruction and schizophrenia. She was described in the facility's MDS (Minimum Data Set-an assessment tool) as being moderately cognitively impaired. A record review showed that on 12/24/14 at 9:39 am, the facility sent a fax notification to the Department of Public Health reporting an allegation of abuse which had occurred on 12/5/14, between Resident 1 and Resident 2. The fax acknowledged that they had not reported Resident 1's abuse allegation on 12/5/14. This was 19 days after the required 24 hour reporting time frame requirement. The facility policy titled, "Reporting Abuse to Administrator," dated 1/1/12, indicated "The Administrator will report the alleged incident to the Department of Public Health within twenty-four (24) hours." During an interview with the Director of Nursing (DON) on 12/31/14, at 11:45 am, DON stated that Resident 1 had reported on 12/5/14, to her nurse and the nurse had then reported to the Administrator and DON that Resident 2 had punched her. DON stated a decision was made to not report the abuse allegation to the Department of Public Health at that time. DON stated a couple weeks later when she read the facility abuse reporting policy it became clear to her the abuse allegation on 12/5/14 should have been reported to the Department within 24 hours. DON stated the facility reported the abuse allegation 19 days after its occurrence. During an interview on 12/31/14 at 12:45 pm, Resident 1 stated that she remembered being hit in the arm. Therefore, the facility failed to follow the regulation and failed to implement the facility's abuse policies and procedures by failing to notify the Dept of the abuse allegation within 24 hours. The violation of this regulation had a direct relationship to the health, safety or security of residents. |
| 230000041 |
Gridley Healthcare & Wellness Centre, LLC |
230011477 |
B |
29-May-15 |
CYA511 |
2170 |
1418.91 (a) Health & Safety Code: Fail to report alleged abuse (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report to the California Department of Public Health (CDPH) abuse allegations for Patient 1 and 2, within 24 hours. On 4/10/15, the CDPH received a complaint that on 4/9/15, Licensed Nurse (LN) A had physically restrained Patient 2 by holding her arms tightly to her chest against her will, while Certified Nursing Assistants (CNAs) B and C changed her brief (adult incontinent wear). On 4/10/15, the CDPH received a second complaint that LN A had physically restrained Patient 1 on 4/3/15, by holding his arms to his chest against his will, while CNAs D and E changed his brief. Record review showed that Patient 1 was an 80 year old male, who was admitted to the facility on 3/29/10 with diagnoses that included schizophrenia and manic depression.During an on site visit to the facility on 4/10/15, it was discovered that those abuse allegations had not been reported to the CDPH. On 4/10/15 at 3 pm, the Director of Nurses (DON) was interviewed. The DON stated that on 4/9/15 at 7 pm, she received "an abuse allegation" from Registered Nurse (RN) F regarding Patient 2 and did not report it to the CDPH. The DON stated she had no knowledge of an abuse allegation involving Patient 1. Record review showed that Patient 2 was a 55 year old female who was admitted to the facility on 3/30/12, with diagnoses that included dementia with behavior problems and a mood disorder. On 4/10/15 at 3:55 pm, the Administrator (Admin) was interviewed. The Admin confirmed that the abuse allegations involving Patient 1 and 2 and LN A on 4/3 and 4/9/15, were not reported to the CDPH. On 4/10/15 at 3:10 pm, RN F was interviewed. RN F stated that both incidents of suspected mistreatement by LN A to Patient's 1 and 2 had been directly reported to her and confirmed that she had not reported those allegations to the CDPH.Therefore the facility failed to report the allegations of abuse to the CDPH within 24 hours. |
| 240001446 |
GLENDA SHAKLEE HOUSE |
240012165 |
B |
06-Apr-16 |
WZ6G11 |
9359 |
REGULATION VIOLATION: Welfare and Institution Code 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States constitutions 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 five (5) of five (5) individuals with intellectual disabilities (characterized by significant limitations both in intellectual functioning with reasoning, learning, problem solving, and in adaptive behavior, which covers a range of everyday social and practical skills, originating before the age of 18), dependent on staff for all care needs, were free from neglect when the direct care staff (DCS 1) assigned to care for them left the facility, leaving the five individuals alone. When the Facility Manager (FM) arrived at the facility on April 16, 2014, at 4:30 AM, DCS 1 was not in the facility and DCS 1's time card indicated she clocked out at 3:35 AM, 55 minutes prior to the arrival of the FM.During a review of the Entity Reported Incident (ERI) dated April 16, 2014, the report indicated on April 16, 2014 at 3:35 AM, the Facility Manager (FM) received a call from the direct care staff (DCS 1) assigned to provide care for the five clients during the night shift of April 16, 2014. DCS 1 informed the FM, "this is not going to work out." The FM asked the direct care staff to remain in the facility with the clients until he arrived and DCS 1 agreed. When the FM arrived at the facility on April 16, 2014 at 4:30 AM, the direct care staff was not in the facility. The FM checked the clients and they were asleep. Based on a review of DCS 1's time card, she clocked out at 3:35 AM, leaving the five clients without supervision or assistance if needed for 55 minutes, before the FM arrived. A telephone interview was conducted on April 17, 2014, at 11:25 AM, with the FM. He stated DCS 1 was new and had been working at the facility for about one week. The FM stated that he spoke to DCS 1 the morning of April 15, 2014, and she stated that she liked her job. On April 16, 2014, at 3:30 AM, he received a telephone text from DCS 1 that read, she (DCS 1) was quitting, could not handle the job, and that it was not for her. The FM asked DCS 1 to wait at the facility until he could arrive at around 5:00 AM. DCS 1 agreed. When the FM arrived at the facility on April 16, 2016, at 4:30 AM, DCS 1 was not in the facility. The door of the facility was locked and the five clients were asleep in their beds. The FM stated that a review of DCS 1's time card noted that she clocked out at 3:35 AM. This was 55 minutes prior to the arrival of the FM at the facility.An onsite visit was conducted on April 17, 2014 at 11:35 AM, and a tour of the facility, accompanied by the Assistant Manager was conducted. All five clients were observed at the day camp, participating in the swimming program. The Assistant Manager stated she was with DCS 1 for eight hours on April 11, 2014, and that DCS 1 stated she was excited about the job. The Assistant Manager stated that she could not believe that DCS 1 abandoned the clients on the night of April 16, 2014. A review of the facility's policy entitled, "[name of facility] Attendant Training Policy," signed and dated by Employee 1 on April 8, 2014, indicated, "All [Name of facility] Direct Care Staff (DCS) working in ICF-DD-N (intermediate care facility nursing), will be required to complete an Attendant Training Course within 6 months of hire. The training is held every Thursday of the month....The training will include 50 hours of theory and 100 hours of clinical. The clinical work will be performed at [Name of facility] residential homes and facilitated by supervisory personnel." A review of Employee 1's "Employee Orientation Record," signed and dated by Employee 1 on April 8, 2014, indicated the first eight hours of training included the job duties and review of client rights. The second eight hours of training focused on administrative issues, and nursing policies and procedures. There was no documentation to demonstrate the number of hours a new employee was proctored by senior employees until they were familiar with the clients and their individual needs and routines. Employee 1 was hired on April 7, 2014, which would have provided the ability to attend only the first attendant training sessions which was held on Thursday April 10, 2014, before walking off the job without waiting for the FM to relieve her of duty.On April 17, 2014, at 1:30 PM, a concurrent review of DCS 1's personnel file and an interview with the Director of Administration (DOA) was conducted. DCS 1 was hired on April 7, 2014, completed orientation on April 8, 2014, and began to work with clients starting April 9, 2014. DCS 1 subsequently quit on April 16, 2014 at 3:35 AM, without completing her shift.A review of the facility "Attendant Training Policy and Procedure," signed by Employee 1 on April 8, 2014, indicated the course must be completed within six months of hire. The procedure outlines the course for Attendant training will take 14 weeks and includes 50 hours of theory and 100 hours of clinical which will be provided at the facility , "and be facilitated by supervisory personnel..."In addition, the training will include a two day course in First -Aid and CPR (cardiopulmonary resuscitation)." A review of Employee 1's personnel file as provided by the facility on April 17, 2014, indicated Employee 1 attended orientation and CPR on April 7, 2014, and April 8, 2014, then began her first shift for client care on April 9, 2014. No other shifts were listed. On April 16, 2014, Employee 1 clocked out of work at 3:35 AM, and was terminated the same day. There was no documented evidence that Employee 1 was under the direct supervision or training with any other staff. The DOA stated that DCS 1's employment was terminated on April 16, 2014, and DCS 1 was not eligible for rehire. During review of DCS 1's personnel file, it was noted that on April 7, 2014, DCS 1 signed the "Direct Care Staff Job Description and the Elder Justice Act Acknowledgement, Rights of Individuals with Developmental Disabilities." On April 8, 2014, DCS 1 signed the Employee Code of Conduct which included: "The following Code of Conduct is effected this date in order to protect the rights and safety of All employees and Clients at (the company). Violations of any of the following will constitute cause of discharge: ...4. Failure to obtain permission from the supervisor to leave your job or premises during working hours."A review of the agency policy and procedure entitled, "Rights-Protection from Abuse, Adult/Elder Abuse Reporting," undated, indicated the following: a. "It shall be the policy of this agency to fully protect the rights of the individuals for whom we provide services, any form of abuse and neglect will not be tolerated." b. "Neglect - means failure to exercise that degree of care, which a reasonable person in like position would exercise. It includes failure to assist in personal hygiene or provision of food and clothing, failure to provide medical care for physical and mental health needs, failure to protect from health and safety." A review of Clients 1,2,3,4 and 5's records were reviewed and showed the following: a. Client 1- Diagnoses of moderate intellectual disability, cerebral palsy (trauma during or after birth resulting in physical and mental disabilities); Hydrocephalus with V/P shunt (fluid on the brain drained into the abdomen); blind, seizure disorder, quadriparesis (decreased sensation in limbs). b. Client 2-Diagnoses of mild intellectual disability, cerebral palsy, quadriplegia (paralysis from neck down), asthma (respiratory disorder with narrowing of airway), neurogenic bowel and bladder (no control of bowels or bladder), dislocated patella (kneecap) c. Client 3- Diagnoses of profound intellectual disability cerebral palsy, upper extremity spasticity (inability to control) d. Client 4- Diagnoses of moderate intellectual disability, cerebral palsy and seizures. e. Client 5- Diagnoses of mild intellectual disability, cerebral palsy, rheumatoid arthritis (painful, swelling of joints), anemia (low red blood cells which carry oxygen in the blood). Therefore, the facility failed to ensure that five of five clients who were dependent on staff for all activities of daily living (feeding, bathing, toileting) were free from neglect on the night of April 16, 2014, when they were abandoned and left alone by the direct care staff, placing them at risk for injury, skin breakdown from incontinence (inability to control bladder and bowel), and or unnecessary anxiety from a delay in their needs being met as follows: The facility's failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 250000622 |
GARRISON HOUSE |
250010202 |
B |
24-Oct-13 |
Q3DT11 |
4465 |
W&I 15610.07 "Abuse of an elder or dependent adult" means either of the following: (a) Physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering. The facility failed to protect Client A from physical, verbal, and psychological abuse from the facility's van driver on January 4, 2013. On January 17, 2013, an unannounced visit was made to the facility to investigate an entity reported incident, "Two employees that work at the Day Program, observed the bus driver, aggressively pulling and pushing client down the vehicle stairs while she held the rails." Client A, a 66-year-old female, was re-admitted to the facility on 4/4/12 with diagnoses that included: 1. Moderate intellectual disability 2. Schizoaffective (mental problem, loss of contact with reality and mood problems) disorder 4. Osteoporosis (bone become fragile and likely to fracture) 5. Degenerative arthritis (cartilage loss in a joint causing pain and stiffness) On January 17, 2013, at 10 a.m., the Facility Manager (FM) was interviewed. The FM stated the Day Program Director (DPD) called the Qualified Intellectual Disabilities Professional (QIDP) and stated that the DPD reported two day program staff (DPS) saw Client A getting off the bus. The bus driver was roughly pulling on Client A's arms to get the client off the bus on January 4, 2013. The FM stated, "The bus driver was terminated."On the same date at 11 a.m., the QIDP was interviewed. The QIDP stated per the DPD, the two day program staff (students) observed the bus driver roughly pulling on Client A's legs and arms to get the client off the bus.On January 17, 2013, at 1:15 p.m., Day Program Staff (DPS) 1 voluntarily gave her declaration that indicated the following:"On January 4, 2013, the facility van came and (DPS 1) and (DPS 2) went out to help unload the clients...The driver was telling her "Come on (Client A) hurry up." (Client A) refused a little but she was going when she was stepping down she was scared so (DPS 2) suggested he (driver) should use the lift he said "No!!!" I (driver) don't have time for that. She (Client A) needs to get off now. "Hurry up (Client A). He (driver) told her he was gona (sic) call her sister so she (Client A) was like no and tried getting down. She then turned around trying to get down...the driver was just in a hurry to get her off he grabbed her (Client A) waist and pulled with force (Client A) yelled with fear and she didn't let go of the rails. The driver was just yelling at her to let go (Client A) yelled "Im scared." He (driver) pulled her by her leg so hard she could have hit her face if she wasn't holding on to the rails. Me (DPS 1) and (DPS 2) escorted her inside she (Client A) was crying "I want my sister."On January 17, 2013, at 1:25 p.m., DPS 2 voluntarily gave her declaration that indicated the following:On Friday January 4th...van driver wanted (Client A) to get off the van. He put the steps down and instructed (Client A) to go down, she said no, that she was scared and that she couldn't walk down the steps... I (driver) don't have time for this today, what do you want for me to carry you, well that is not going to happen, you (Client A) have to go down the steps, (Client A) kept telling him no and that she was scared he (driver) said Sometime you have to force her to do things and he grabbed her arm and tried to pull her hand off of the rail while pushing her from behind (Client A) still refused to go down the steps, she told him she needed the ramp and he (driver) said no... yanking her arms trying to get her off the rail...he (driver) had (Client A) turn around and tried to get her to go down backwards, (Client A) said no...He (driver) got off of the van and got behind her put his arms around her waist and kept yanking her...to release her grip on the rails, she wouldn't let go so he reached down and grabbed her leg and tried to yank it off of the step (Client A) almost fell face first into the van that still didn't work so he yanked her arms again telling her how bad she was and that he was going to call her sister, so we (DPS 1 and DPS 2) were able to get (Client A) down safely..."Therefore, the facility failed to protect Client A from physical, verbal, and psychological abuse from the facility's van driver on January 4, 2013. The above violation had a direct or immediate relation to Client A's health, safety, or security. |
| 970000133 |
GRAND PARK CONVALESCENT HOSPITAL |
910010049 |
B |
01-Aug-13 |
SGY811 |
7702 |
72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 Patients?Rights (a)(4) The right to consent to or to refuse any treatment or procedure. The Department received an entity reported incident (ERI) on April 19, 2010, which indicated a patient (Patient 1) complained that a nurse held his finger down against his will and resulted in a fracture to Patient 1?s right hand 5th metacarpal finger (pinky finger) with swelling and bruising. Based on observation, interview, and record review, the facility failed to follow its policy and procedure and did not allow Patient 1 to exercise his right to refuse care.Patient 1?s right hand was held down for a finger stick to check the patient?s blood sugar, despite the patient?s refusal. This resulted in a fracture of the patient?s pinky finger. On May 10, 2010, at 1 p.m., an unannounced ERI investigation was conducted. At 1:15 p.m., during an interview, the director of nursing (DON) stated she was informed on April 19, 2010 that on April) to obtain a sample of blood to test Patient 1?s blood glucose level. The DON stated Patient 1 continued to refuse and tried to hit LVN 1. LVN 1 asked a certified nursing assistant (CNA 1) to hold the patient?s hand so she could stick his finger to obtain the blood sample for the test. The DON stated CNA 1 attempted to hold Patient 1?s hand, but he continued to resist and he struck his hand on the side rail of the bed and broke his right pinky finger. The DON further stated if the patient was refusing the test the nurses should have respected Patient 1?s decision and should not have attempted to hold his hand down against his will to do the test. At 1:30 p.m., on May 10, 2010, during an interview, the director of staff development (DSD) stated if a patient refuses care the nurse should not force and hold the patient down. The DSD stated the nurse should return later and ask the patient again. At 2 p.m., on May 10, 2010, Patient 1 was observed sitting in a wheelchair in the hall next to his room. His right hand had a splint (used to keep the joint in place) in place.A review of Patient 1?s Admission Sheet indicated the patient was a 70 year-old male initially admitted to the facility on January 21, 2009 and last re-admitted on September 11, 2009. His diagnoses included chronic renal failure (slow loss of kidney function), congestive heart failure (condition in which the heart can no longer pump enough blood to the rest of the body), hypertension (high blood pressure) and diabetes (a chronic disease marked by high levels of sugar in the blood). A review of a quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 24, 2010, indicated the patient was modified independent in cognitive skills for daily decision-making. The MDS indicated Patient 1 was able to make himself understood and could understand others. According to the MDS, Patient 1 had no mood or behavioral problems. A review of the licensed nurses progress notes, dated April 18, 2010, at 12 noon, written by a registered nurse (RN 1), indicated the patient refused the finger stick to the index finger and offered another finger, but the nurse grabbed his right pinky finger and twisted it downward. The note indicated the patient complained of pain to his right hand with bruising and swelling observed. Another licensed nurse?s progress note, dated the same day and timed at 12:30 p.m., indicated the patient?s physician was notified and ordered right hand x-rays. According to another note, on April 18, 2010, timed at 10:15 p.m., the x-rays were taken.A review of the x-ray report, dated April 18, 2010, taken at the facility, indicated Patient 1 had an oblique (an angled fracture; according to American Academy of Orthopedic Surgeons (AAOS) angled fractures are usually caused by twisting or trapping of one bone) linear fracture involving the 5th metacarpal (broken bone of the pinky finger) with slight displacement and soft tissue swelling. A review of the facility?s investigation report, dated April 19, 2010, indicated Patient 1 stated LVN 1 held his hand while sticking his right index finger and he stated LVN 1 twisted his fingers. The report indicated the patient?s hand was bruised and swollen. Another investigation interview of RN 1 indicated the patient told her a Korean nurse grabbed and twisted his pinky finger downward. CNA 2 who was assigned to care for Patient 1 on April 18, 2010, (day shift) was also interviewed and stated the patient complained of pain to his right hand at 9:30 a.m., on April 18, 2010, but she was busy and forgot to report the patient?s complaint until over two hours later at 12 noon. The facility also interviewed CNA 1, who stated LVN 1 attempted to prick the patient?s finger again because she did not get enough blood the first stick and the patient swung with his right hand at LVN 1 and hit the bed?s side rail. CNA 1 stated LVN 1 asked her to hold the patient?s right hand. A review of a telephone order dated April 19, 2010, and timed at 9 a.m., indicated the primary physician ordered an orthopedic (a physician who specialize in treating conditions and injuries involving bones and connective tissue, including tendons, and ligaments) consult for the patient.According to an orthopedic physician?s order, dated April 22, 2010, and timed at 12 p.m., a splint was placed to the patient?s right hand with follow-up orders to be seen by the orthopedic physician in three weeks.On June 30, 2010, at 2:15 p.m., during a telephone interview, RN 1 stated on April 18, 2010, at 12 p.m., Patient 1 approached her at Nursing Station 2 complaining of pain in his right hand. RN 1 stated on her assessment of the patient?s right hand she observed swelling and bruising to the lateral side of the right hand, and he complained of pain when the right hand was touched. RN 1 further stated when she asked Patient 1 what happened to his hand he stated a Korean female nurse, wearing a white uniform on the night shift was attempting to stick his finger, but he wanted her to stick a different finger than the one she had chosen. RN 1 stated the patient then refused to have the finger LVN 1 had chosen to be stuck and LVN 1 had a CNA to hold the patient?s hand down and twisted his pinky finger downward to obtain a blood sample. RN 1 stated she notified the physician and received a telephone order to do an x-ray of the patient?s right hand.On June 30, 2010 at 4:10 p.m., during a telephone interview CNA 1 stated on April 18, 2010, at 6:30 a.m., she observed LVN 1 trying to do an accu-check on Patient 1. CNA 1 stated Patient 1 was refusing to have his finger stuck and tried to hit LVN 1. CNA 1 stated LVN 1 asked her assistance in holding the patient?s right hand so she could obtain a blood sample. CNA 1 stated she knew it was wrong to hold the patient?s hand against his will, but because LVN 1 was the charge nurse, she thought she had to do what she was asked to do. A review of the facility?s undated policy and procedure titled, ?Resident Rights? indicated it is the policy of the facility that employees treat all patients with kindness, respect, and dignity. It also stipulated a resident has the right to refuse treatment and exercise their rights and privileges to the fullest extent as possible.The facility failed to follow its policy and procedure and did not allow Patient 1 to exercise his right to refuse care, resulting in a fracture of the patient?s pinky finger.The above violation had a direct relationship to the health, safety and security of Patient 1. |
| 910000007 |
Greenfield Care Center of Gardena |
910010197 |
B |
17-Oct-13 |
H03H11 |
7582 |
F225483.13(c)(2) The facility must ensure that all alleged violation involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. 483.13(c)(4) The results of all investigation must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On January 4, 2012, the Department of Public Health (DPH) made an unannounced visit to investigate a complaint regarding a resident (Resident A), who was admitted to a general acute care hospital (GACH) with facial swelling and trauma. Upon investigation of the allegation it was determined that Resident A was found with a large hematoma (bruise) to the middle of her forehead. The resident was transferred to a GACH for evaluation of a possible fall; however, the facility did not report to the DPH or investigate when the resident was found with an injury of an unknown origin.Based on interview and record review the facility?s nursing staff failed to: 1. Investigate when they found Resident A with a large hematoma to the middle of her forehead. 2. Report an injury of unknown origin to the DPH A review of Resident A?s Admission records indicated she was a 64 year-old female, who was admitted to the facility on November 14, 2005, with diagnoses including a fracture of the neck of the femur (hip fracture), anemia, hypertension, diabetes, chronic kidney disease, renal dialysis, cerebral vascular accident (CVA[stroke]), congestive heart failure (CHF[when the heart can't pump enough blood to meet the body?s needs]), hyperlipidemia (excessive amounts of fatty substances such as cholesterol and triglycerides in the blood) and myositis (inflammation of skeletal muscles).A Minimum Data Set (MDS) Assessment, a standardized assessment and care screening tool, dated August 26, 2011, indicated Resident A required supervision with set up help only to transfer, walk in the room, corridor and on and off of the unit. She was assessed with a functional limitation in range of motion [(ROM) the distance and direction a joint can move to its full potential] to one side of her lower extremities (hip, knee, ankle, foot).Licensed Personnel Progress Notes, dated November 9, 2011, at 7:00 a.m., indicated Resident A was observed with a large (no measurements were taken) hematoma on her forehead. Continued documentation at 7:30 a.m., indicated the physician was notified. Physician?s Orders, dated November 9, 2011, at 9 a.m., indicated to send Resident A to a GACH emergency room for evaluation of a possible fall. A History and Physical, from the GACH, where Resident A was sent for evaluation, dated November 9, 2011, indicated the following: Chief Complaint: A large ecchymosis (bruise) on her forehead. History of Present Illness: Nursing home staff reported they noticed the patient (resident) with a large bruise on her forehead, a bruise on her upper lip and over her right eye. There was no witnessed fall. The resident is at high risk of fall and ambulates with assistance at the nursing home. We suspect the patient (resident) must have fallen at the nursing home during the night. Physical Examination: The resident?s right upper eyelid is mildly swollen. She has a 2-inch area of ecchymosis on her forehead. Her upper lip has a superficial bruise with ecchymosis.On January 4, 2012, at 10:20 a.m., during an interview, the Director of Nursing (DON) stated he came to the facility before the 7 a.m.-3 p.m., shift started and observed Resident A with a large (approximately quarter size) hematoma with pooling of fluid underneath it, in the middle of the resident?s forehead. He stated the resident was normally alert and oriented and understood what was going on and what was said, but she was not able to say if anything had happened during the night. He stated the hematoma was flat and darkish in color and because of the location (middle of her forehead), he did not think it was an injury caused by a fall or abuse, but that it was something internal, which was why he did not report it the DPH. He questioned the staff who worked on the 11 p.m., to 7 a.m., shift to see if anything had occurred during the night, but did not write anything down or follow up with the administrator. He stated if the resident had fallen and hit her head she would have had trauma to the surrounding areas on her face and not just the middle of her forehead. The DON could not produce written documentation that an investigation, to rule out the cause of bruising (injury of an unknown origin) to the resident?s head, was conducted.Photographs taken at the GACH, where Resident A was transferred, dated November 9, 2011, (no time) indicated a large, round reddened/purplish area to the middle of the resident?s forehead located slightly over her right eyebrow. The resident?s eyes appeared bruised (reddish/purplish discoloration) and swollen shut. She had bruising (reddish/purplish discoloration) to the right side of her nose and mid right side of her lip. On October 10, 2013, at 5:58 a.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident A was slightly confused but could make most of her needs know. She was able to walk with assistance but stated he could not recall if she had a history of falls. LVN 1 stated he normally did rounds throughout the night and the night prior to Resident A being transferred to the GACH he did not witness her fall, observe her on the floor nor was he aware of any injuries or bruises until it was brought to his attention by the DON, the day she was transferred to the GACH (November 9, 2011). He stated no one reported to him that Resident A had fallen or had any accidents/incidents during the night. A facility policy on Care of Accident and Incident, dated November 2004, indicated the purpose is to investigate the cause of all marks, discolorations, skin breaks and injuries that have not been witnessed. General guidelines for assessment may include, but are not limited to: examine the entire skin surface, interview the resident, interview any witnesses, measure vital signs, redness, swelling, edema, tenderness, breaks, assess range of motion to all joints assess any change in mental and cognitive status neuro-check as necessary, measure the size, depth, color and location of any skin condition identified., attempt to determine the cause of any condition identified.Therefore,the facility?s nursing staff failed to: 1. Investigate when they found Resident A with a large hematoma to the middle of her forehead. 2. Report an injury of unknown origin to the DPHOn November 9, 2011, Resident A was observed with a large hematoma to the middle of her forehead.She was transferred to a GACH emergency room for evaluation of a possible fall; however, the facility did not investigate the resident?s injury of unknown origin or report it to the DPH. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of Resident A. |
| 910000275 |
GARDENA CONVALESCENT CENTER |
910010214 |
B |
17-Oct-13 |
B4OD11 |
4782 |
Title 22 72651(d) Water supply and Plumbing Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by patients to attain a hot water temperature in compliance with section T 17-210(e),Title 24 California Administrative Code (CAC). On October 2, 2013, at 9:30 a.m., an unannounced visit was conducted to investigate a complaint that the facility did not have hot water since September 24, 2013. The facility has 29 patient rooms. Patients in 18 out of 29 rooms share the restrooms. The facility has a total of three water heaters, two of the three water heaters provide hot water to all 29 patient room sinks, two shower rooms, and one tub room. One of three water heaters provides hot water to the laundry room and kitchen. Based on observations, interviews, and record reviews, the facility failed to maintain the water distribution system in accordance with Title 24 CAC which requires maintaining a water temperature range of 105 to 120 degrees Fahrenheit (F) for patients in order to provide a comfortable water temperature. On October 2, 2013, between 9:36 a.m. to 11:00 a.m., during a general observation tour of the facility with the maintenance supervisor, the hot water temperatures at the following locations were measured: * Patient Room 14 sink, at 9:52 a.m., 83.3 degrees Fahrenheit. * Patient Room 16 sink, at 9:58 a.m., 74.5 degrees Fahrenheit, after 2 minutes, 73.2 degrees Fahrenheit. * Patient Room 18 sink, at 10:01 a.m., 86.8 degrees Fahrenheit, after 2 minutes, 87.4 degrees Fahrenheit. * Patient Room 24 sink, at 10:17 a.m., 88.9 degrees Fahrenheit, after 3 minutes, 97.1 degrees Fahrenheit. * Patient Shower Room #1, at 10:36 a.m., 92.4 degrees Fahrenheit. * Patient Room 17 sink, at 10:40 a.m., 73.5 degrees Fahrenheit. On October 2, 2013, at 9:43 a.m., during an interview with the maintenance supervisor, he stated that one of two patient-room water heaters was not working on September 27, 2013 afternoon. He also stated that the inoperable water heater was replaced with a new water heater on the evening of September 30, 2013, and is ?working?; however he was unable to provide written evidence that he had measured the water temperatures for any patient restroom sink, nursing station hand washing sink, and the shower rooms from September 30th, 2013, to October 2, 2013. On October 2, 2013, at 10:05 a.m., during an interview, Patient 1 stated that the water ?was cold? during a morning shower today. At 11:00 a.m., during an interview, Patient 2 stated, ?The water is warm, getting better but not hot,? during a shower today. On October 2, 2013, at 11:10 a.m., during an interview, Patient 3 stated, ?They are working it out,? when asked about the hot water in the restroom and shower room. Patient 3 also stated the facility had not had hot water for three days. On October 2, 2013, at 11:20 a.m., during an interview with a housekeeping staff (H1), he stated that a nurse (unable to identify) informed him on the morning of September 28, 2013, that the water heater was not working and there was no hot water. He also stated he had called H2 on the phone that morning to inquire about the water heater. H2 had told H1 the hot water and the water heater was ?off and on, not working? when he was working during the week. On October 2, 2013, at 11:30 a.m., during an interview with the district manager for housekeeping and maintenance services, he stated the maintenance supervisor informed him the morning of September 30, 2013, that there was no hot water in the facility. The district manager also stated that a new water heater was installed that evening between 6:00 p.m. to 10:00 p.m. On October 2, 2013, at 12:00 p.m., during an interview with the administrator, he stated the maintenance supervisor had notified him on September 30, 2013, that the water heater was not working. He also stated that the maintenance supervisor found out that the water temperature was low, not hot, by patients.The ?24 Hour Maintenance Report? dated September 26, September 27, and October 1, 2013, had documentation that there was no hot water in the facility. On October 2, 2013, a record review of a work invoice, dated October 1, 2013, revealed a water heater was installed. According to the facility?s undated hot water policy and procedure, hot water used by patients shall be between 105 and 120 degrees Fahrenheit. Therefore, the facility failed to maintain the water distribution system in accordance with Title 24 CAC which requires maintaining a water temperature range of 105 to 120 degrees Fahrenheit (F) for patients in order to provide a comfortable water temperature. This violation had a direct relationship to the health, safety, and security of all patients. |
| 910000275 |
GARDENA CONVALESCENT CENTER |
910010259 |
B |
26-Nov-13 |
MYZN11 |
3945 |
Title 22 Section 72541-Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal.On April 8, 2013, the Department of Public Health (DPH) received an anonymous complaint alleging Patient 1, who was a wanderer, was found outside the facility where she fell and sustained a right arm fracture. An unannounced complaint investigation was conducted on April 8, 2013.Based on interview and record review, the facility failed to report an unusual occurrence to the Department within 24 hours that resulted in Patient 1?s unwitnessed fall, sustaining a right humeral neck fracture (is a break in the neck of the upper arm bone, near the top, just under the shoulder joint).A review of Patient 1's medical records indicated she was a 91-year-old female admitted to the facility on August 5, 2010. Her diagnoses included history of hip fracture, dementia (cognitive and intellectual deterioration), and schizophrenia (psychotic disorder marked by severely impaired thinking, emotions, and behaviors). The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 18, 2012, indicated the resident?s cognition was severely impaired.According to the MDS she required extensive assistance from staff with one person assist for activities of daily living (ADLs), such as transferring, walking, dressing, personal hygiene and toilet use. The MDS also indicated Patient 1 gets around the facility by wheelchair.A review of the facility Incident Investigation Summary and Results dated April 2, 2013, indicated on April 1, 2013, at about 3:05 p.m., the front office staff heard a loud bang and ran to the front of the building and found Patient 1 lying on the floor at the bottom of the ramp. The patient was alert, confused and was complaining of pain in the right arm. The physician was notified and ordered the patient to be transferred to a general acute care hospital (GACH) emergency room (ER) for evaluation. A review of the right shoulder x-ray result obtained from the GACH dated April 1, 2013, indicated right humeral neck fracture.In an interview on April 8, 2013, at 3:20 p.m., the business office coordinator stated she did not see what happened, but was sitting in the front office, which is next to the front entry door of the facility. She stated she heard a loud noise as if something hit something really hard. She went outside and found Patient 1 on the ground.In an interview on April 8, 2013, at 3:40 p.m., the director of nursing (DON) stated Patient 1?s fall was not witnessed. The DON was asked why she did not report the incident, she stated she didn?t think it was required to be reported.A review of the facility's policy and procedure titled "Reporting of Abuse and Unusual occurrences? revealed that unusual occurrences must be reported to the Department within 24 hours, which included major incidents or any occurrence which threatens the health of the patients.The facility failed to report an unusual occurrence to the Department within 24 hours that resulted in Patient 1?s unwitnessed fall, sustaining a right humeral neck fracture.The above violation had a direct relationship to the health, safety and security of Patient 1. |
| 910000275 |
GARDENA CONVALESCENT CENTER |
910010261 |
A |
26-Nov-13 |
MYZN11 |
9271 |
F 323 483.25 (h) Accidents The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On April 8, 2013, the Department of Public Health received a complaint alleging Resident 1, who had dementia (decreased intellectual functioning such as loss of memory, language, judgment and reasoning) and a wandering behavior, was found on the ground outside the facility with a right arm fracture. An unannounced complaint investigation was conducted on April 8, 2013. The facility failed to ensure Resident 1, who had a diagnosis of dementia and who had a history of elopement risk and wandering behavior, had a safe environment and received adequate supervision to prevent accidents by failing to: 1. Develop a care plan based on the assessment to address Resident 1?s behavior of wandering and risk of elopement (leaving the facility unattended). 2. Update the care plan to include the elopement risk after the incident on April 1, 2013, to prevent another accident from occurring.As a result, Resident 1 left the facility unattended on April 1, 2013, fell and sustained a right humeral fracture (a break in the neck of the upper arm bone, just under the shoulder joint). She was hospitalized and was readmitted to the facility on April 8, 2013, with multiple bruising on her back and arms, a fractured right arm and a right arm immobilizer.According to Resident 1's medical records, she was originally admitted to the facility on August 5, 2010. The resident's diagnoses included history of hip fracture, dementia, and schizophrenia (a severe mental disorder characterized by reality distortions resulting in unusual thought patterns and behaviors).A review of the Licensed Personnel Progress Notes dated November 7, 2010, indicated Resident 1 made several attempts to leave the facility, was highly agitated and tearful, had repetitive questions and was confused.There was a care plan, titled, ?Elopement Risk?, dated November 7, 2010. The goal was for Resident 1 to remain in a secure environment every day for 90 days and re-evaluate by February 2011; however, there was no re-evaluation done on that date.The care plan approach was to re-direct Resident 1, monitor her whereabouts, and give medications; however, the care plan did not indicate how frequent Resident 1 will be monitored and how the staff will monitor her whereabouts.The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 18, 2012, indicated the resident was severely cognitively impaired (never/rarely made decisions) with short and long term memory problems.According to the MDS she required extensive assistance from staff with one person assist for activities of daily living (ADLs), such as transferring, walking, dressing, personal hygiene and toilet use. The MDS also indicated she gets around the facility by wheelchair.A review of the Fall Risk Assessment forms from August 2010 through April 2013, indicated Resident 1 was a high risk for falls.The Social Services Quarterly assessment form dated February 26, 2013, had notations that the resident was confused and disoriented, had episodes of wandering, asking for help, and requiring reassurance "that she is o.k." A review of the Psychiatrist Physicians Progress Note dated March 22, 2013, indicated Resident 1 was confused, disoriented, disorganized, and restless.A review of the Licensed Personnel Progress Notes dated April 1, 2013, at 3 p.m., indicated Resident 1 fell from her wheelchair with complaints of right arm pain. The note did not indicate the resident's pain level. The physician was made aware, and ordered to transfer the resident to the general acute care hospital (GACH) emergency room (ER) for an evaluation secondary to a fall.A review of the facility Incident Investigation Summary and Results dated April 2, 2013, indicated that on April 1, 2013, at about 3:05 p.m., the front office staff heard a loud bang and ran to the front of the building where Resident 1 was found lying on the floor at the bottom of the ramp. The notes indicated the resident was alert, confused and was complaining of pain in her right arm. The resident was helped back into her wheelchair and then placed back in her bed.A review of the GACH- ER Physician History and Physical (H&P) Record dated April 1, 2013, indicated Resident 1 was transferred from the nursing home after a fall. The H & P record indicated Resident 1's right upper extremity had about 1+ edema (swelling) all the way to the shoulder and was very tender to touch and she was unable to move her right arm.The GACH X-ray Report of the right shoulder dated April 1, 2013, indicated a right humeral neck fracture.A review of the Licensed Personnel Progress Notes dated April 8, 2013, indicated Resident 1 was readmitted to the skilled nursing facility with multiple bruising on her back and arms, a fractured right arm with right arm immobilizer.The Elopement Risk Assessment dated April 8, 2013, which was completed the same day of the Department's investigation and five days after the resident had been readmitted from the GACH, indicated Resident 1 was alert, confused and was not capable of making decisions. The assessment indicated Resident 1 had "no history" of elopement attempts, even though she was found unattended and outside of the facility on April 1, 2013.A review of Resident 1's medical records indicated there was no current Elopement Risk Assessment done until April 8, 2013. On April 8, 2013, at 3:25 p.m., an interview was conducted with the social service designee (SSD). When asked to describe Resident 1's mental status, the SSD stated that the resident was confused and wandered inside the facility all the time. She also stated Resident 1 would wander into the male resident room next to hers. A care plan was not initiated to address Resident 1's behavior of wandering. On April 16, 2013, at 3:00 p.m., an interview was conducted with a certified nursing assistant (CNA 1), who was asked if Resident 1 wandered, and he stated, "Yes." CNA 1 also stated a couple of months ago Resident 1 was seen going outside in the back parking lot by herself. When asked if he reported the incident to anyone he stated, "No."In an interview on April 16, 2013, at 3:41 p.m., CNA 2 stated about a month ago prior to Resident 1?s fall incident, the housekeeper told her that Resident 1 was in the back parking lot, so she went and wheeled her back inside.At 3:50 p.m., during an interview the housekeeper confirmed that she had seen Resident 1 outside the back parking lot about a month ago and asked her to come in, but she refused, so she went and told CNA 2. When asked if she told anyone else about this incident she stated, "No."On April 16, 2013, at 3:58 p.m., Resident 1 was observed in the dining room sitting in her wheel chair with a sling to her right arm. She was unable to be interviewed due to her dementia. In an interview on July 30, 2013, at 11:00 a.m., the director of nursing (DON) stated she was the one who completed the Elopement Risk assessment for Resident 1 on April 8, 2013. She also stated that after the resident was found outside, staff should have completed an assessment to include a history of elopement. When asked if Resident 1 had a current care plan for her wandering behavior, the DON was unable to find one in the resident's medical record. There was a care plan titled " High Risk for Fall " , dated April 8, 2013 (after the fall incident), the goal was to minimize risk of injury for 90 days. The approach plan was to have visual checks every 2 hours, call light within reach, assist during all transfers, low bed and alarm, and wander guard (device that alarms to notify staff when the resident is approaching an area) applied to the left hand as physician ordered on April 15, 2013.A review of the facility's policy and procedure titled "Wandering Resident and subject titled "Elopement/Missing/Against Medical Advice (AMA)", dated February 14, 2011, indicated the safety and well-being of all residents with a potential for wandering is ensured at all times. All residents who are at risk for harm because of wandering behavior should have an assessment and care plan that addresses the issue.The facility failed to ensure Resident 1, who had a diagnosis of dementia and who had a history of elopement risk and wandering behavior, received adequate supervision to prevent accidents by failing to: 1. Develop a care plan based on the assessment to address Resident 1?s behavior of wandering and risk of elopement (leaving the facility unattended). 2. Update the care plan to include the elopement risk after the incident on April 1, 2013, to prevent another accident from occurring.As a result, Resident 1 left the facility unattended on April 1, 2013, fell and sustained a right humeral fracture (a break in the neck of the upper arm bone, just under the shoulder joint). She was hospitalized and was readmitted to the facility on April 8, 2013, with multiple bruising on her back and arms, a fractured right arm and a right arm immobilizer.The above violation presented either imminent danger that death or serious harm would result to Resident 1. |
| 910000043 |
GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA |
910010483 |
A |
21-Mar-14 |
WC6611 |
11352 |
483.25 F309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On March 9, 2012, at 12:50 p.m., an entity reported incident (ERI) was investigated regarding Resident A, who choked while eating. Resident A was transferred to a General Acute Care Hospital (GACH) where he subsequently expired.Based on interview and record review, the nursing staff failed to perform a life-saving procedure, the Heimlich maneuver, (a procedure used to help dislodge foreign objects from the airway that prevents a person from breathing), correctly and effectively. On February 11, 2012, Resident A was observed choking on food, and required the Heimlich maneuver to be performed. Resident A became unresponsive, emergency medical services [(EMS) 911] arrived and transported him to a GACH, where he was subsequently pronounced dead.A review of Resident A?s admission record indicated a 69 year-old male admitted to the facility on January 12, 2011. According to the Nurse?s Admission Record dated January 12, 2011, Resident A had no teeth and no dentures.A physician?s order, dated August 1, 2011, indicated Resident A was to receive a mechanical soft diet (a diet containing ground or pureed foods that are easy to chew, often eaten by people who have dental problems or have missing teeth. It can contain any foods allowed in a regular diet but is easy to chew and swallow), with nectar-thick liquids. Aspiration precautions were to be observed. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 25, 2012, indicated Resident A required limited assistance with setup help to eat. MDS documentation indicated Resident A had a swallowing disorder evidenced by coughing or choking during meals or when swallowing medications. Nutritional approaches included a mechanically altered diet (a diet that requires a change in texture of food or liquids).A review of the Licensed Personnel Progress Notes (Notes) dated February 11, 2012, at 7:50 a.m., indicated a certified nursing assistant (CNA 1) found Resident A had stopped eating. The Resident looked pale and had food particles on his clothes protector. Licensed vocational nurse 1 (LVN 1) was called to the Resident?s room and on arrival found the Resident could not talk. It was documented that LVN 1 opened the Resident?s mouth and found masticated (chewed) food. LVN 1 suctioned out some of the chewed food from the Resident?s mouth, however ?the Resident still was not able to talk.? The Heimlich maneuver was started with a small amount of vomited food observed. Resident A became weak and had ineffective breathing. The Notes indicated that oxygen was administered through a non-rebreathing mask, no pulse could be obtained, cardio pulmonary resuscitation (CPR) was started, and 911was called.On March 17, 2012, at 2:40 p.m., during a telephone interview, CNA 1 stated, on February 11, 2012, he assisted Resident A with his breakfast by raising the head of his bed and setting up his tray. CNA 1 stated he left the room to assist other residents when he saw the call light in Resident A?s room on. When he entered the room he saw Resident A had vomited and had food on his shirt and bib. CNA 1 stated the resident looked pale and he did not answer when his name was called.CNA 1 called RN 1 to the room and was instructed by RN 1 to get LVN 1. CNA 1 stated when he and LVN 1 returned to Resident A?s room, RN 1 was pushing on the resident?s abdomen with two hands while standing on the left side of the Resident?s bed. LVN 1 obtained the O2 and crash cart. Resident A was laid down on his bed and CPR was started. On March 17, 2012, at 2:18 p.m., during a telephone interview RN 1 stated, on February 11, 2012, CNA 1 called her to check Resident A. RN 1 stated when she went to Resident A?s room he looked pale, was able to move his head from the middle to the right but could not speak. RN 1 stated she thought the resident was choking and started the Heimlich maneuver. She asked CNA 1 to call LVN 1, while she continued the Heimlich maneuver. When LVN 1 arrived, RN1 asked him to get oxygen while she was suctioning the resident. RN 1 said Resident A was sitting up in bed at a 90 degree angle, she stood to his left side and pushed on his stomach with flat hands, one on top of the other, in an upward motion and saw food in his mouth. She put oxygen on him while continuing with the Heimlich maneuver. RN 1 then checked the resident?s pulse but could not find one so she laid him down in his bed and began CPR. The resident attempted to open his eyes and his skin color improved, 911 was called. RN 1 was asked what she was taught about performing the Heimlich maneuver, and stated she should have gotten on the bed behind the resident, made a fist with one hand and pushed forcibly in an upward thrusting motion. On April 7, 2012, at 2:30 p.m., during an interview, RN 1 stated Resident A was sitting upright in bed, with his legs flat on the mattress stretched out in front of him. The resident?s back was resting against the headboard. She said he looked very bad and she knew something had happened. She called to him, ?are you O.K.? can you talk?? She stated he was very pale and did not respond verbally but moved his head slightly and shook his legs. RN 1 stated she saw food on his clothes protector and a small amount of food on the inside and outside of his mouth.RN 1 then demonstrated using the Surveyor to show how she performed the Heimlich maneuver on Resident A. She placed her left hand flat on the Surveyor?s abdomen while the Surveyor sat upright in a chair with her legs in front of her. She then placed her right hand flat on top of her left hand and proceeded to push in on the Surveyor?s abdomen without much force. She stated Resident A did not respond and she asked CNA 1 to put the resident?s head down while she got the suction machine. RN 1 suctioned the resident?s mouth and asked CNA 1 to get LVN 1. She then put the head of the resident?s bed up; standing to his left side she did more abdominal thrusts with her left hand fisted and her right hand on top of the left one pushing up. She checked the resident?s pulse but could not find one, she then asked CNA 1 to call 911. Both LVN 1 and RN 1 put the resident?s head down and began CPR until the paramedics arrived and took over. On March 9, 2012, at 1:50 p.m., during an interview, LVN 1 stated on February 11, 2012, he was in the dining room between 8 a.m. and 8:15 a.m., when CNA 1 reported RN 1 needed his help. He stated Resident A was in bed, in a sitting position with his back to the headboard; his face was whiter than normal and he observed RN 1 standing next to the resident pushing on his stomach. RN 1 asked him to get the oxygen tank, which he did. When he returned to the room, RN 1 asked him to get the crash cart, which he did. RN 1 then asked him to start CPR. LVN 1 straddled the resident?s legs and began compressions while RN 1 used the Ambu-bag (a trademark used for a self-reinflating bag used during resuscitation) to breath for the resident. He stated food began to come out of the resident?s mouth and his face began to pink up. The paramedics arrived and took over. On April 7, 2013, at 3 p.m., during an interview with Resident B, who was Resident A?s roommate, he stated Resident A started coughing really hard, it was not normal, and when he called him to see if he was all right he did not speak or yell out. Resident B then pressed the call light and CNA 1 came. A review of the Emergency Medical Services Report form, dated February 11, 2012, indicated emergency service was dispatched at 8:03 a.m., and reached the resident at 8:08 a.m. The form indicated from 8:08 a.m. through 8:20 a.m., the resident?s vital signs were zero for blood pressure, pulse and respirations. The resident?s pupils were fixed and dilated (indicating unconsciousness or severe neurologic impairment). His Glasgow Coma Scale (a tool medical professional?s use to objectively evaluate the degree to which a person is conscious or comatose. It operates on a scale of 3 to 15, where 15 is best response and 3 is totally unresponsive) was three. Eye, motor and verbal responses were scored with one (1) point each, indicating Resident A?s eyes remained closed, and he was silent and immobile. According to the GACH?s Physician Documentation form dated February 11, 2012, at 8:44 a.m., paramedics intubated Resident A prior to arrival to the emergency room. Documentation indicated that ?EMS? pulled out debris and food with forceps prior to intubation. The form indicated the resident had no respirations, his eyes were fixed and dilated, he did not follow commands and there was no motor movement. The physician?s documentation indicated Resident A?s vital signs were zero, his Glasgow Coma Scale was 3 and he was pronounced dead at 8:38 a.m. A direct laryngoscopy (a procedure used to obtain a view of the vocal cords and the glottis) was performed, which showed solid food was present in the resident?s posterior pharynx (part of the throat).The facility?s policy titled ?Choking-Heimlich Maneuver? revised September 2009, indicated the Heimlich maneuver is performed on victims whose airway is obstructed by a foreign object. Stand behind victim and wrap arms around victim?s waist. Grasp one fist with the other hand and place thumb side of your fist in the midline slightly above the navel. Press fist into abdomen with quick inward and upward thrusts. Each thrust is delivered decisively, with the intent of relieving the obstruction. If the airway remains obstructed, straddle victim?s thighs, place heel of one hand on abdomen in the midline above the navel and well below the tip of the xiphoid, place second hand directly on top of first hand. Press into abdomen with quick, upward thrusts and perform six to ten thrusts. A review of RN 1?s personnel file revealed she was certified on April 12, 2011, in successful completion of Basic Life Support (BLS) course in accordance with the curriculum of the American Heart Association. In the BLS course, healthcare professionals learn to recognize life-threatening emergencies, provide CPR to victims of all ages and relieve choking in a safe, timely and effective manner. On February 24, 2014, at 11:15 a.m., during a phone interview with the director of staff development (DSD) she stated RN 1 was introduced to the facility?s policies and procedures during her orientation process dated July 20, 2011. The DSD stated all of the facility?s policies and procedures are stored at the nursing stations and available to the licensed nurses for reference. Therefore, the facility?s nursing staff failed to perform a life-saving procedure, the Heimlich maneuver, correctly and effectively. On February 11, 2012, Resident A was observed choking on food, and required the Heimlich maneuver to be performed. Resident A became unresponsive, emergency medical services [(EMS) 911] arrived and transported him to a GACH, where he was subsequently pronounced dead.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. |
| 910000007 |
Greenfield Care Center of Gardena |
910012133 |
B |
23-Mar-16 |
WJP511 |
7655 |
F 203CFR 483.12(a)(4) Notice Before Transfer Before a facility transfers or discharge a resident, the facility must? (i)Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for move in writing and in a language and manner they understand. CFR 483.12(a) (5) Timing of the notice (i) Except when specified in paragraph (a) (5) (ii) of this section, the notice of transfer or discharge required under paragraph (a) (4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Based on observation, interview, and record review, the facility failed to provide a written notice of transfer to Resident 13, and/or a family member or a legal representative at least 30 days before the resident was transferred to another facility. The facility initiated a construction project to install a new automatic transfer switch (ATS) and emergency outlets in existing residents? Rooms 1, 2, 3, 4, 5, 6, 7, and 8 for a new subacute unit, which required residents transfer. Transfer of resident with less than a 30 day notice was a violation of the resident?s rights and had a potential to affect the resident?s safety.On December 17, 2015, at 8:00 a.m., the Department of Public Health (DPH), Licensing and Certification Division, received a complaint alleging the facility was remodeling and had begun construction to change the skilled nursing level of care (a facility type where health care provided by a skilled nursing staff (registered nurse (RN) or licensed vocational nurse (LVN)) to manage, observe, and evaluate care) to a subacute level of care ((subacute care is a level of care needed by a patient who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility).The complainant indicated residents were notified about construction project during the Resident Council meeting on November 30, 2015, and some residents were transferred to other facilities on the same day.A review of the Office of Statewide Health Planning and Development (OSHPD) Building Permit dated October 30, 2015, indicated to install new ATS and emergency electrical outlets in existing residents? rooms for the construction of a new subacute unit. On December 18, 2015 at 7:30 a.m., and on January 13, 2016, at 8:30 p.m., upon arrival to the facility parking area loud noises of hammers and saws were heard. During a tour of the facility, accompanied by the activity director, the south west-side was observed with ongoing construction. The area was taped off with a clear vinyl like material sealing off residents? rooms numbers three through eight. The activity director stated that it gets very noisy in the morning and some residents complain they have been awakened by the noise at 7:00 a.m. Room one and room two was observed with two residents in each room across from the construction site. According to the admission record, Resident 13 was admitted to the facility on August 18, 2015, with diagnoses that included dementia (a progressive decline of mental and physical functioning), and Parkinson disease (problems caused by central nervous system disorders, which include tremors, slow movement, and stiffness of the arms and leg). Resident 13 was placed in Room 1. According to the History and Physical (H&P) dated August 21, 2015, Resident 13 had no capacity to understand and to make decision.A review of the Bio Ethics Committee note, dated August 18, 2015, indicated the resident had no family. According to the document the Interdisciplinary Team (IDT) designated the facility?s medical director and the primary care physician to make any medical or financial decision for the resident.A review of IDT Care Conference notes, dated August 25, 2015, indicated IDT members along with Resident 13?s primary care physician would make the decisions for what is best for the resident as resident had no capacity to understand or make decisions. According to the Social Service Assessment notes, dated December 1, 2015, the resident was alert, but appeared disoriented, was able to make needs known and required a total nursing care with activities of daily living (ADL) including bathing, grooming, and dressing.According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 3, 2015, the resident had severely impaired cognitive skills for daily decision making. At the time of investigation Resident 13 was not available for interview. There was a physician?s order dated December 2, 2015, to send Resident 13 to another skilled nursing facility (SNF) owned by the same company.A review of Notice of Proposed Transfer/Discharge, dated December 2, 2015, indicated Resident 13 had no known family or friends and the resident?s personal affairs were handled by IDT. According to this document the resident required a transfer to protect the resident?s well-being because the resident?s needs could not be met at the facility. There was no documented evidence the resident?s transfer was initiated due to construction project and the resident?s health and safety could have been affected. There was no documented evidence indicating the resident?s transfer was temporary for the duration of project only and there was a plan for the resident?s return.A review of the licensed nurses progress notes, dated December 3, 2015, indicated the Resident 13 was transferred to another facility owned by the same company. A review of Resident 13?s clinical record indicated there was no documented evidence the resident was provided with a 30 day notice prior to transfer to another SNF.On December 18, 2015, at 9:30 a.m. during an interview with the director of nursing (DON), stated a letter dated November 23, 2015, was posted on the Bulletin Board, and was given to residents by the administrator during the November 30, 2015, Residents? Council meeting.During an interview with the administrator on December 18, 2015, at 12:15 p.m., stated the facility was in need of repairs and a Memorandum was posted on the Bulletin Board on November 23, 2015, indicating to staff and residents the facility would be undertaking a major renovation and reconfiguration in multi-phase remodeling project. The administrator confirmed he did not notify the DPH regarding the facility remodeling project. The facility policy titled ?Admission/Transfer/Discharge-General Policy? dated December 2004 indicated that written notice of transfer or discharge would be provided to each resident or family member/legal representative before the resident is would be transferred or discharged from the facility. According to the policy a written notification would be transmitted to the appropriate persons within 24 to 48 hours of transfer/discharge decision or as soon as practicable prior to transfer unless the transfer/discharge was based on safety or health endangerment, urgent medical needs, and residing in the facility less than 30 days. According to the policy the facility had to ensure a safe and orderly transfer or discharge from the facility, and the facility would provide sufficient preparation and orientation prior to transfer/discharge. The facility failed to provide a written notice of transfer to Resident 13, and/or family member or legal representative at least 30 days before the resident was transferred from the facility.The above violation had a direct relationship to Resident 13?s health, safety and security. |
| 910000007 |
Greenfield Care Center of Gardena |
910012139 |
B |
23-Mar-16 |
WJP511 |
6961 |
F203 CFR 483.12(a)(4) Notice Before Transfer Before a facility transfers or discharge a resident, the facility must- (i)Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for move in writing and in a language and manner they understand. CFR 483.12(a) (5) Timing of the notice- (i) Except when specified in paragraph (a) (5) (ii) of this section, the notice of transfer or discharge required under paragraph (a) (4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Based on observation, interview, and record review, the facility failed to provide a written notice of transfer to Resident 15, and/or family member or legal representative at least 30 days before the resident was transferred to another facility. The facility initiated a construction project to install a new automatic transfer switch (ATS) and emergency outlets in existing residents? rooms 1, 2, 3, 4, 5, 6, 7, and 8 for a new subacute unit, which required the residents transfer. Transfer of resident with less than a 30 day notice was a violation of the resident?s rights and had a potential to affect the resident?s safety.On December 17, 2015, at 8:00 a.m., the Department of Public Health (DPH), Licensing and Certification Division, received a complaint alleging the facility was remodeling and had begun construction to change the skilled nursing level of care (a facility type where health care provided by a skilled nursing staff (registered nurse (RN) or licensed vocational nurse (LVN)) to manage, observe, and evaluate care) to a subacute level of care ((subacute care is a level of care needed by a patient who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility). OKThe complaint indicated that residents were notified about construction project during a Resident Council meeting on November 30, 2015 and some residents were transferred on the same day. A review of an attached building permit dated October 30, 2015 from the Office of Statewide Health Planning and Development (OSHPD) indicated installed new ATS and emergency electrical outlet in existing residents? rooms for the construction of a new sub-acute unit. A review of the Office of Statewide Health Planning and Development (OSHPD) Building Permit dated October 30, 2015, indicated to install new ATS and emergency electrical outlets in existing residents? rooms for the construction of a new subacute unit. On December 18, 2015 at 7:30 a.m., and on January 13, 2016, at 8:30 p.m., upon arrival to the facility parking area loud noises of hammers and saws were heard. During a tour of the facility, accompanied by the activity director, the south west-side was observed with ongoing construction. The area was taped off with a clear vinyl like material sealing off residents? rooms numbers three through eight. The activity director stated that it gets very noisy in the morning and some residents complain they have been awakened by the noise at 7:00 a.m. Room one and room two was observed with two residents in each room across from the construction site. According to the admission record, Resident 15 was admitted to the facility on September 3, 2015, with diagnoses that included dementia (a progressive decline of mental and physical functioning), major depression (mood disorder causing a persistent feeling of sadness and loss of interest) and allergies. Resident 15 was placed in Room 2. According to the History and Physical (H&P) dated September 4, 2015, Resident 15 had impaired cognitive skills for daily decision making.The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 16, 2015, indicated the resident?s cognitive skills for daily decision-making were moderately impaired.There was a physician?s order dated January 8, 2015, at 9:52 a.m., to transfer Resident 15 to another skilled nursing facility (SNF) owned by the same company.A review of Resident 15?s social service progress notes, dated January 8, 2016, indicated the resident would be transferred for comfort due to room renovation, noise level and dust. On December 18, 2015, at 9:30 a.m. during an interview with the director of nursing (DON),stated a letter dated November 23, 2015 was posted on the Bulletin board, and was given to residents by the administrator during the November 30, 2015, Resident Council meeting.During an interview with the administrator on December 18, 2015, at 12:15 p.m., stated the facility was in need of repairs and a Memorandum was posted on the Bulletin Board on November 23, 2015, indicating to staff and residents the facility would be undertaking a major renovation and reconfiguration in multi-phase remodeling project. The administrator confirmed he did not notify the DPH regarding the facility remodeling project. A review of the Notice of Proposed Transfer/Discharge, dated January 8, 2016, indicated the Resident 15 was going to be transferred to another facility owned by the same company. The Interdisciplinary Team Bioethics Committee was placed under the person to be notified.According to Resident 15?s clinical record review there was no documentation indicating the resident had a family or a responsible party. On January 13, 2016 at 8:30 p.m., upon entering the facility, the south west-side was observed completely taped off with a clear vinyl like material sealing off residents? rooms one through room eight.A review of Resident 15?s clinical record indicated there was no documented evidence the resident was provided a 30 day notice prior to transfer to another facility.The facility policy titled ?Admission/Transfer/Discharge-General Policy? dated December 2004, indicated a written notice of transfer or discharge would be provided to each resident or family member/legal representative before the resident is would be transferred or discharged from the facility. According to the policy a written notification will would be transmitted to the appropriate persons within 24 to 48 hours of transfer/discharge decision or as soon as practicable prior to transfer unless the transfer/discharge was based on safety or health endangerment, urgent medical needs, and residing in the facility less than 30 days. According to the policy the facility had to ensure a safe and orderly transfer or discharge from the facility, and the facility would provide sufficient preparation and orientation prior to transfer/discharge. The facility failed to provide a written notice of transfer to Resident 15, and/or family member or legal representative at least 30 days before the resident was transferred from the facility.The above violation had a direct relationship to Resident 15?s health, safety and security. |
| 910000007 |
Greenfield Care Center of Gardena |
910012143 |
B |
23-Mar-16 |
WJP511 |
2815 |
72605 Notice to Department The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. On December 23, 2015, at 10:00 a.m., an unannounced visit was made to the facility to investigate a complaint regarding the remodeling of the facility. The licensed capacity of the facility is 50 beds. Based on observations, interviews and record reviews, the facility failed to: 1. Notified Health Facilities Inspection Division prior to remodeling the facility which started December 1, 2015 of a new sub-acute unit. During a tour of the facility on December 23, 2015, at 10:30 a.m., the evaluator observed the following:A. Installation of new emergency electrical wall outlets, electrical boxes, new drywall, and flooring in existing patients? rooms (Rooms 3, 4, 5,6, 7, and 8) in progress.During an interview with Employee A at the time of the observation, she stated the construction was started on December 1, 2015. The Office of Statewide Health Planning and Development (OSHPD, a department that reviews health facility construction plans to ensure they meet California building codes and state seismic safety standards mandated by law) Building Permit was issued for the construction and remodeling of the facility. She further stated that nine patients were moved from their rooms (Rooms 3, 4, 5, 6, 7, and 8) to other rooms prior to the construction and remodeling. A review of an OSHPD Building Permit document indicated a permit was issued to the facility on October 30, 2015 for the installation of emergency electrical outlets in existing patients? rooms for the construction of a new sub-acute unit. On December 23, 2015, a review of an OSHPD Notice of Start of Construction document indicated construction start date to commence by the facility on November 2, 2015 submitted by the facility?s corporate senior project manager. On December 23, 2015, during an interview with the assistant administrator, she stated that the administrative staff was not aware of the requirement to notify the department prior to any construction or remodeling of the facility. The facility failed to notify the department in writing prior to construction, remodeling or alterations of the following area of the facility: A. Installation of new emergency electrical wall outlets in existing patients? rooms (Rooms 3, 4, 5,6, 7, and 8). B. Installation of conduit boxes in existing patients? rooms (Rooms 3, 4, 5, 6, 7, and 8).C. Installation of new drywall and new flooring in existing patients? rooms (Rooms 3, 4, 5, 6, 7, and 8).These violations had a direct relationship to the health, safety, and security of all patients of the facility. |
| 910000007 |
Greenfield Care Center of Gardena |
910012533 |
A |
24-Aug-16 |
UL2911 |
8600 |
F223 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. On July 12, 2016, the Department received a complaint alleging Family Member 1, a relative of the Director of Nurses, abused Resident 1. On July 12, 2016, an unannounced visit was made to the facility to investigate the allegation of abuse. The facility failed to implement its abuse and visitor policies and procedures by failing to: 1. Ensure Family Member 1 did not willfully physically and mentally abuse Resident 1, by arguing with Resident 1 and throwing salsa into Resident 1?s eyes and on his upper body. This resulted in Resident 1 complaining of burning and pain in his eyes, which caused him to feel afraid and fear for his life. A review of the admission record indicated Resident 1 was admitted to the facility on August 13, 2014, with diagnoses that included left eye legal blindness (certain amount of vision loss), right eye missing, cerebral vascular accident (stroke), contracture (limitation in movement) of wrist, left hemiplegia (paralysis of one side of the body), and schizophrenia (mental illness). The Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated May 27, 2016, indicated Resident 1 had no cognitive impairment and required extensive assistance for activities of daily living. During an interview on July 12, 2016, at 4:45 p.m. Housekeeper 1 stated on July 7, 2016, at 12:45 p.m., while cleaning the shower room near Resident 1's room, she witnessed Family Member 1 enter Resident 1?s room, leave the room, return to the room, enter the room again, and then leave the room quickly. Employee 1 stated she then went inside Resident 1's room because she overheard the resident calling for help. Employee A stated Resident 1 told her Family Member 1 threw Salsa on his face. Employee 1 then notified Employee 8. During a telephone interview on July 13, 2016, at 10:45 a.m., the Primary Care Physician (PCP) stated that he had been at the facility on July 12, 2016, but the Employee 2 never mentioned anything about the incident. He also stated that if he was told about the incident, he would have transferred Resident 1 to GACH for an eye examination. During an interview on July 12, 2016, at 3:00 p.m., Employee 3 stated Employee 7 had informed her earlier on July 7, 2016, Resident 1 hit her. However, the DSS stated that Resident 1 told her he struck out and hit Employee 7, because she startled him by grabbing the back of his wheelchair. The DSS stated on July 7, 2016 at 12:30 p.m., Employee 8 reported to her that a man went into Resident 1's room and threw salsa on Resident1?s face. The DSS then witnessed salsa on the resident's face, and bed. During an interview on July 12, 2016, at 3:15 p.m., Resident 1 stated on July 7, 2016, at an unspecified time, while he was in his bed, Family Member 1 entered his room and started arguing and then threw salsa into his eyes. The resident also stated he could never forget the burning and pain he experienced. The resident stated he could not see out of his left eye and he feared for his life. During an interview on July 12, 2016, at 3:25 p.m., Employee 4 stated Employee 1 told her she witnessed FM 1 enter Resident 1's room, and then she heard Resident 1 scream for the nurse. Employee 1 also stated she saw Family Member 1 wiping his hands before leaving the resident's room. Employee 4 also stated the Employee 6 informed the Employee 2 to notify their Employee 5. During an interview with Employee 8 on July 12, 2016, at 3:30 p.m., he stated he was working near Station 2 on July 7, 2016, at 12:00 p.m., when a man asked for Employee 7. Employee 8 stated he told the man Employee 7 was in her office. Employee 8 stated immediately the man walked away, Employee 1 called him in to Resident 1?s room, where he saw Resident1 with red sauce, like ?salsa? on his face. When he asked the resident what happened, Resident 1 stated a man came into his room and threw salsa on his face. Resident 1 requested assistance to his wheelchair so he could report the incident. Employee 8 stated he told the resident he would notify Employee 3, Employee 4, and the Employee 2 about the incident. During an interview with the Employee 4 on July 12, 2016, at 3:40 p.m., she stated on July 7, 2016, at 12:15 p.m. Employee 8 informed her about an incident involving Resident 1. Employee 4 stated when she interviewed Resident 1, he told her that a man came into his room and threw salsa on his face. Employee 4 stated Resident 1 told her that the man was Family Member 1. Employee 4 stated she notified the Employee 5 immediately. During an interview on July 12, 2016, at 3:40 p.m., the Employee 2 stated that on July 7, 2016, Employee 8 informed her of an urgent incident involving Resident 1. When she went to Resident 1's room, she observed sauce on the resident?s face, shoulder, and bed sheets. The Employee 2 stated the resident told her a man threw food on him. She stated the facilities closed circuit video, recorded on July 7, 2016 at 12:28 p.m., revealed it was Family Member 1. The Employee 2 stated Employee 5 was not notified. During an interview on July 12, 2016, at 4:00 p.m., the Employee 5 stated on July 7, 2016, based on his interview with Employee 1, Employee 3, Employee 8, and Resident 1, Family Member 1 entered Resident 1's room and threw salsa on to the resident's face. On July 12, 2016, at 4:30 p.m., during an observation of facility?s closed circuit video dated July 7, 2016, at 12:28 p.m., a man with short dark hair with a baseball cap, wearing a greenish long sleeved shirt and a dark pants, was observed standing outside of Resident 1's room. The man in the video was observed entering the resident?s room, exiting quickly, and then walking towards Employee 1 and Employee 8. Employee 1 was observed going inside Resident 1's room, but quickly came out of the room. Employee 1 was thereafter seen talking to Employee 8. During a telephone interview on July 12, 2016, at 5:55 p.m., Employee 9, who was in charge of Resident 1, on the day of the incident, stated that no one told her the resident had salsa in his eyes. A review of telephone text message indicated that the Employee 2 asked the Employee 5 if the salsa incident should be reported, to which the Employee 5 stated no. There was no documented evidence regarding the physical and mental abuse that occurred between Resident 1. The Department, the law enforcement, and the Ombudsman office (representing the interests of the public by investigating and addressing complaints), were never informed about the physical and mental abuse. There was no evidence the Employee 5 provided approval per the facility's policy and procedure for Family Member 1 to freely enter the facility, and have continuous access to enter the facility as he pleased. A review of the facility's policy titled Personal Visitors dated February 2016, indicated the facility prohibits employees from having personal visitors while on duty. It further stipulated for liability and safety reasons, visitors are not allowed into the facility without prior approval from the Administrator. All unauthorized persons and those without proper identification may be asked to leave the premises. A review of the facility's undated policy and procedure titled abuse prohibition indicated the facility would prohibit abuse, and mistreatment, for all residents. The policy also indicated abuse is defined as the willful infliction of physical pain, injury, and mental anguish. The facility failed to implement its abuse policies and procedures by failing to: 1. Ensure Family Member 1 did not physically abuse Resident 1, by throwing salsa into Resident 1?s eyes and on his upper body. This resulted in Resident 1 complaining of burning and pain in his eyes, which caused him to feel afraid and fear for his life. 2. Ensure Family Member 1 did not freely and continuously have access to enter the facility, which placed Resident 1 and all other residents at risk of being abused. The facility?s failure to implement their abuse policies and procedure resulted in Resident 1 being physically and mentally abused, placing the resident, and all the other residents in the facility at risk for further abuse. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 910000007 |
Greenfield Care Center of Gardena |
910012535 |
B |
24-Aug-16 |
UL2911 |
3908 |
F157 483.10 (b) (11) ? Notification of Changes. (i) A facility must immediately inform the resident: consult with the resident?s physician: and if known, notify the resident?s legal representative or an interested family member when there is-- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention: (B) A significant change in the resident?s physical, mental, or psychological status (i.e., deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). On July 12, 2016, an unannounced visit was made to the facility to investigate an allegation that Family Member 1, who is the spouse of Employee 1, entered the facility and physically abused Resident 1. Based on interview, and record review, the facility failed to immediately notify and consult with the attending physician when Family Member 1 physically abused Resident 1, by throwing a red liquid substance (Salsa) into Resident 1?s eyes and onto his upper body. A review of the admission record indicated Resident 1 was admitted to the facility on August 13, 2014, with diagnoses that included left eye legal blindness, a missing right eye, cerebral vascular accident, contracture of the left wrist, left hemiplegia and schizophrenia. The Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated May 27, 2016, indicated Resident 1 had no cognitive impairment, and required extensive assistance from staff for activities of daily living. During an interview on July 12, 2016, at 3:15 p.m., Resident 1 stated on July 7, 2016, (unspecified time), while he was in his bed, Family Member 1, (Employee 1?s spouse) entered his room and started arguing. Family Member 1 then threw ?Salsa? in to his eyes. The resident also stated he would never forget the burning and pain he experienced and he could not see out of his left eye. He further stated his primary care Employee 10 was not contacted to conduct an evaluation of the burning and the pain he felt and he was never transferred to a hospital for evaluation. During an interview on July 12, 2016 at 4:30 p.m. Employee 1 stated on July 7, 2016, at 12:45 p.m., while cleaning the shower room near Resident 1's room, she witnessed Family Member 1 enter inside Resident 1?s room, leave the room, return to the room, come back again, and then leave quickly. Employee 1 stated she then heard Resident 1 calling for help and went inside the room, at which time, Resident 1 told her Family Member 1 threw salsa in his face. During an interview with Employee 8 on July 12, 2016, at 3:30 p.m., he stated he was working near Station 2 on July 7, 2016, at 12:00 p.m., when Employee 1 called him in to Resident 1?s room, where he saw Resident1 with red sauce, like ?salsa? on his face. When he asked the resident what happened, Resident 1 stated a man came into his room and threw salsa on his face. During a telephone interview on July 13, 2016, at 10:45 a.m., with Employee 10 he stated he had been at the facility on July 12, 2016, but Employee 2 never mentioned anything. He also stated that if he was told about the incident, he would have transferred Resident 1 to the hospital for an eye examination. A review of the facility's undated policy and procedure titled abuse prohibition indicated that the facility would report the suspected abuse immediately to the attending physician. There was no documented evidence that that the facility immediately notified Employee 1. The facility failure to immediately notify and consult with the attending physician, when Family Member 1 physically abused Resident 1, caused a delay in treatment and services and placed the resident at risk for complications. This violation had a direct relationship to the health, safety, or security of residents. |
| 910000007 |
Greenfield Care Center of Gardena |
910012536 |
B |
24-Aug-16 |
UL2911 |
6248 |
F 225 483.13 (c) (1) (ii), (c) (2) ? (4) Investigate/Report Allegations/Individuals The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if alleged violation is verified appropriate corrective action must be taken. F 226 483.13 (c) Staff Treatment of residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On July 12, 2016, an unannounced visit was made to the facility to investigate an allegation that Family Member 1, who is the spouse of Employee 1, entered the facility and physically abused Resident 1. On July 12, 2016, an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged resident abuse Based on interview and record review, the facility failed to implement their abuse policies and procedures by failing to: 1. Implement measures to prevent further potential physical abuse of Resident 1 by Family Member 1 after Family Member 1 entered into Resident 1?s room and threw Salsa into Resident 1?s eyes and upper body. 2. Immediately report the abuse incident to the Department. 3. Conduct a thorough investigation of Resident 1?s allegation of abuse. A review of the admission record indicated Resident 1 was admitted to the facility on August 13, 2014, with diagnoses that included left eye legal blindness, a missing right eye, cerebral vascular accident, contracture of the left wrist, left hemiplegia and schizophrenia. The Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated May 27, 2016, indicated Resident 1 had no cognitive impairment, and required extensive assistance from staff for activities of daily living. During an interview on July 12, 2016, at 3:15 p.m., Resident 1 stated on July 7, 2016, (unspecified time), while he was in his bed, Family Member 1, (Employee 1?s spouse) entered his room and started arguing. Family Member 1 then threw ?Salsa? in to his eyes. The resident also stated he would never forget the burning and pain he experienced and he could not see out of his left eye. He also stated he feared for his life. During an interview with Employee 4 on July 12, 2016, at 3:30 p.m., he stated he saw Resident 1 with a red sauce, like ?salsa? on his face. When he asked the resident what happened, Resident 1 stated a man came into his room and threw salsa on his face. Maintenance Supervisor 1 stated he told the resident he will notify the Employee 6, Employee 7 and Employee 2 about the incident, which he did. During an interview on July 12, 2016 at 3:40 p.m., Employee 2 stated that on July 7, 2016, Employee 4 informed her of an urgent incident involving Resident 1. When she went to Resident 1's room, she observed sauce on the resident?s face, shoulder, and bed sheets. Employee 2 stated the resident told her a man threw food on him. Employee 2 further stated on July 7, 2016 at 12:28 p.m. the facilities closed circuit video recording revealed it was Family Member 1, the relative of Resident 1. Employee 2 stated that the Employee 5 was not notified. During an interview on July 12, 2016 at 4:00 p.m., the Administrator stated on July 7, 2016, based on his interview with Employee 2, Employee 3, Employee 4, and Resident 1, Family Member 1entered Resident 1's room and threw salsa on to the resident's face. However, the Administrator further stated he failed to report the incident to the Department, the law enforcement, and the Ombudsman?s office. A review of the facility's undated policy and procedure titled ?Abuse Prohibition? indicated the facility would report the suspected abuse immediately to the administrator and other officials in accordance with state law. The policy further notes upon receiving a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the administrator or designee would report the incident by telephone within 24 hours to law enforcement agency, provide a written report to the local ombudsman, the licensing & certification program district office, and the law enforcement, utilizing the report of suspected adult/elder abuse form and initiate an abuse allegation investigation that focuses on interventions to prevent further injury, and that the investigation would be thoroughly documented on the centers investigation forms/logs. A review of the facility's policy titled ?Director of Nursing Resident's Rights Functions,? the director of nursing would report and investigate all allegations of resident?s abuse and or misappropriation of resident property. There was no documented evidence in the clinical record regarding the abuse that occurred between Resident 1 and Family Member 1. There was no documented evidence that an investigation had been initiated or conducted. There were no measures put in place to prevent further abuse to Resident 1 by Family Member 1. The facility failed to implement their abuse policies and procedures by failing to: 4. Implement measures to prevent further potential physical abuse of Resident 1 by Family Member 1 after Family Member 1 threw Salsa into Resident 1?s eyes and upper body. 5. Immediately report the abuse incident to the Department, local law enforcement agency and the Ombudsman. 6. Conduct a thorough investigation of Resident 1?s allegation of abuse. These violations had a direct relationship to the health, safety, or security of residents. |
| 910000007 |
Greenfield Care Center of Gardena |
910013235 |
AA |
11-Jul-17 |
1GGU11 |
24911 |
F157
? 483.10 (g) (14) Notification of changes
A facility must immediately inform the resident; consult with the resident?s physician; and if known, notify the resident?s legal representative or an interested family member when there is
(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);
F309
?483.25 Quality of Care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following:
?488.301 Definitions
Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.
On 2/24/17, an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1, who was found deceased in her bed.
Resident 1, who was receiving dialysis treatments (a process of filtering the blood of impurities), left the facility on 2/16/17 to have an outpatient surgery for an AV Shunt (an access for dialysis treatments). Resident 1 returned to the facility at 10:15 p.m., after having surgery, and was put to bed. Resident 1?s vitals were not taken throughout the night and when a certified nurse assistant (CNA 1) entered her room at 5 a.m., the next morning (XXXXXXX 17), Resident 1 was unresponsive. Cardiopulmonary resuscitation (CPR) was attempted after a 15 minute delay and upon the paramedics arriving Resident 1 was pronounced dead.
Based on observation, interview, and record review, the Department determined that the facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to meet the needs of the resident, including but not limited to:
1.Failure to follow its policy and procedure to provide the necessary care and services, which included a thorough and continuous assessment after a surgical procedure (right arm arteriovenous fistula [AVF] a connection of an artery [carries blood away from the heart] and a vein [carries blood back to the heart]).
2. Failure to notify Resident 1?s physician upon her return back to the facility, that the resident had a change in condition after surgery.
3. Failure to follow its policy and procedure to provide cardiopulmonary resuscitation (CPR) timely, after Resident 1 was found unresponsive.
4. Failure to monitor Resident 1?s vital signs ([V/S] clinical measurements of blood pressure, heart rate, respiratory rate, temperature, and site of surgery for bleeding out) post-surgery.
These failures of the nurses, not continually and thoroughly assessing Resident 1, notifying the physician of the resident?s change in condition, and not performing CPR in a timely efficient manner resulted in a delay in care and treatment and the resident being found seven hours after returning to the facility unresponsive and later expiring.
A review of Resident 1?s closed record Admission Face Sheet indicated the resident was a 61 year-old female who was initially admitted to the facility XXXXXXX 15 and re-admitted on XXXXXXX 15. Resident 1?s diagnoses included end stage renal disease ([ESRD] a progressive loss of kidney function) requiring dialysis treatment (a medical procedure that cleans the blood of impurities), and diabetes mellitus (high blood sugar).
A review of Resident 1?s Minimum Data Set (MDS), an assessment and care screening tool, dated 12/2/16, indicated Resident 1 was able to make needs known had the ability to understand and be understood. The MDS indicated Resident 1 was independent in locomotion on and off the unit using a motorized wheelchair. According to the MDS, the resident's Brief Interview for mental Status (BIMS) scores 15 (score of 9-15= interviewable).
A review of Resident 1's Physician's Orders for Life-Sustaining Treatment ([POLST], outlines a plan of care reflecting a resident's wishes concerning care during the end of life]) dated 2/10/16, indicated Resident 1 requested for CPR and full treatment for prolonging life by all medically effective means necessary.
A physician's order, originally dated 11/12/15, and recapped for the month of 2/2017, indicated for Resident 1 to receive dialysis treatment three times a week (Tuesday, Thursday, and Saturday).
A physician's order, dated 2/21/16, indicated to monitor Resident 1's dialysis access site at the chest area (dialysis catheter [a tunnel placed under the skin of the chest with an opening for dialysis]) every shift for swelling, pain, bleeding, and for any signs and symptoms (S/S) of infection. The physician?s orders also stipulated to document changes and refer to physician if needed.
A review of Resident 1?s care plan titled, "At Risk for Complications Secondary to receiving Dialysis,? dated 7/24/16, indicated the staff interventions included to assess the resident and the right upper chest access site, evaluate pain, numbness/tingling, redness, drainage and/or any S/S of infection of the right upper chest site, and notify the physician and the resident?s representative for any change of condition (COC).
A review of a nurses' note, dated 2/16/17, and timed at 7 a.m., indicated Resident 1 went out on pass and stated she had a doctor's appointment and would be having surgery that day. The nurses? note indicated Resident 1 was in stable condition without any complaints of pain, shortness of breath (SOB), skin clear and intact, afebrile (without fever), and the right upper chest catheter was intact without bleeding. The nurses? note did not indicate what type of surgery Resident 1 was having and if and when the resident was returning to the facility.
A review of the nurses' notes, dated 2/16/17, and timed at 11:11 p.m., written by Licensed Vocational Nurse 1 (LVN 1) indicated Resident 1 returned from the doctor's appointment at 10:15 p.m. on 2/16/17. The note indicated Resident 1 denied having pain, but stated she was tired and went straight to bed. LVN 1 documented the resident?s vital signs were blood pressure 130/71 (normal reference range [NRR] less than 120/80 mm/hg [millimeter of mercury]); heart rate at 70 (NRR 72 bpm [beats per minute]); respiratory rate was at 18 (NRR 12-20 breaths per minute) and a temperature of 96.7 (NRR 97.7?99.5 øF [Fahrenheit]). The note further indicated all needs were met and the call light was within reach.
On 2/24/17 at 11:18 a.m., during an interview and review of the Director of Nurses (DON) written declaration, the DON stated during her investigation the staff (LVN 1, LVN 2 and the CNAs (CNA 1 and 2) admitted to her that Resident 1's vital signs upon her returned to the facility were not obtained, but falsely charted in the resident's records and they did not assess the resident post surgery. The DON stated LVN 2 did not assess the resident's respiratory status, after Resident 1 called to be elevated in bed, during the early morning (2:20 a.m.) and should have. The DON stated instead of the staff initiating CPR they called her at home and she had to instruct them to start CPR, which was a delay of approximately 15 minutes according to the facility?s surveillance video. The DON further stated the staff did not use any artificial manual breathing and administer oxygen to the resident. The DON stated LVN 1, who was on duty when Resident 1 returned to the facility (XXXXXXX17), did not assess the resident upon return to the facility, as indicated in the surveillance video.
On 2/24/17 at 2 p.m., during an interview, the Social Service Director (SSD) stated he was responsible for scheduling transportation for residents' appointments. The SSD stated he was not sure where Resident 1 went on the morning of 2/16/17.
On 2/24/17 at 3:24 p.m., during an interview, Resident 1's roommate (Resident 2) stated Resident 1 looked good that morning before she left for her procedure. Resident 2 stated Resident 1 returned to the facility at approximately 10:15 p.m. and the staff had to help the resident drive the motorized/electric wheelchair. Resident 2 stated Resident 1 was weak and was leaning over to one side in the wheelchair. Resident 2 stated Resident 1 began moaning when the nurses used the Hoyer lift (mechanical lift used for transferring residents) to put her in the bed and Resident 1?s arm was wrapped and it looked like it was bleeding a lot. Resident 2 stated on the morning of 2/17/17, she heard Resident 1 make a yawning noise. CNA 1 entered the room shortly thereafter and Resident 2 stated, "I heard the CNA (CNA1) call the resident's name, run out the room and called the charge nurse. I got into my wheelchair and left the room."
A review of Resident 2's MDS, dated 3/8/17, indicated Resident 2 was alert with her cognition intact and had a BIMS score of 15. According to the MDS, Resident 2's memory was intact and had good recall.
At 4:13 p.m., on 2/24/17, during an interview, a Certified Nursing Assistant 1 (CNA1) stated she was assigned to Resident 1 on the 11-7 a.m. shift for 2/16/17. CNA 1 stated Resident 1 was sleeping at the start of her shift (11 p.m.) and she was told that the resident had surgery earlier that day. CNA1 stated she checked the resident three times during her shift and on 2/17/17, at approximately 1 a.m. Resident 1's call light was on. CNA1 stated she entered the resident's room and Resident 1 asked her to adjust her shoulder to elevate the head of bed. CNA 1 stated the resident looked "kind of weak" and saw blood on the right arm bandage. CNA 1 was asked if she notified LVN 2 of the resident?s change in condition and she stated, ?No.? CNA 1 stated she returned to Resident 1's room at approximately 5 a.m. to see if the resident needed anything. When the resident did not respond, CNA1 stated she called the resident by name and asked "Are you ok, are you ok" while shaking the resident's leg. CNA1 stated she then called for the charge nurse (LVN 2) who came and started CPR.
On 2/24/17, at 4:36 p.m., during an interview, LVN 1 stated Resident 1 went out to the general acute care hospital (GACH) on the morning of 2/16/17 for an outpatient surgical procedure and returned between 9:45 p.m. and 10:15 p.m. that same day. LVN 1 stated she went to the resident?s room to check the blood pressure and the new AVF site for bleeding, charted the resident's arrival, and asked if the resident wanted any pain medications. LVN 1 stated Resident 1 had a dressing to the right arm, which was clean and dry. LVN 1 stated Resident 1 was alert and laughing upon her return to the facility. LVN 1 stated Resident 1 had no discharge papers from the GACH and told the nurse on the next shift (11 p.m.-7 a.m.) to follow-up because the GACH did not call to give a report on the resident. LVN 1 further stated she was going to call the GACH, prior to the resident's return, but saw that Resident 1 had arrived. LVN 1 stated she documented in the facility?s communication book for the resident to be monitored for pain and bleeding.
On 2/28/17 at 2 p.m., during an observation of the facility's surveillance video with the DON, the DON verified the events and the various staff members on the video, which indicated the following occurred on 2/16-2/17/17:
? At 5:45 a.m., Resident 1 was observed driving her motorized wheelchair in the hallway in an upright position.
? At 10:01 p.m., An Access van pulled into the facility's parking lot near the rear entrance, and dropped Resident 1 off, the facility's activities director (AD) was present on the video.
? At 10:06 p.m., the AD was observed maneuvering Resident 1's wheelchair from the parking lot into the facility and down the hallway. Resident 1's head was observed tilted to the left side. LVN 1 was observed on the computer at Nurse's Station 2, when Resident 1 passed the station. LVN 1 stood and observed the resident and the AD passed her and returned to the computer.
? At 10:16 p.m., LVN 1 entered Resident 1's room for the first time since the resident's return.
? At 5:10 a.m., CNA 1 entered Resident 1's room.
? At 5:12 a.m., CNA1 was walking out the resident's room and down the hallway towards Nurse's Station 1.
? At 5:13 a.m., LVN2 and CNA1 were observed entering Resident 1's room. LVN 1 ran out the room to Nurse's Station 2, grabbed a medical chart, looked down the hallway twice towards the direction of Resident 1's room and ran towards Nurse's Station 1.
? At 5:14 a.m., LVN 2 returned to Station 2 with CNA2.
? At 5:15 a.m., LVN 2 and CNA2 were observed at Station 2. CNA2 was on her cell phone and LVN 2 was on the computer.
? At 5:16 a.m., LVN 2 observed pushing a linen cart down the hallway.
? At 5:17 a.m., LVN 2 and CNAs 1 and 2 were at Nurses' Station 2.
? At 5:18 a.m., CNA1 was on her cell phone. CNA2 holding her cell phone. LVN 2 seated at Nurse's Station 2. Resident 2 (Resident 1's roommate) observed self-propelling from the room in her wheelchair down the hallway.
? At 5:19 a.m., LVN 2 on the facility telephone then retrieved the crash cart with CNA2, after hanging up the phone.
? At 5:20 a.m., LVN 2 and CNA2 entered Resident 1's room with the crash cart.
? At 5:24 a.m., LVN 2 exits Resident 1's room
? At 5:25 a.m., LVN 2 and CNA2 observed walking down the hallway away from the resident's room.
? At 5:28 a.m., LVN2 and CNAs 1 and 2 were observed out of the resident's room.
? At 5:29 a.m., CNA2 observed running down the hallway with a key in hand.
? At 5:30 a.m., Paramedics entering the facility on scene.
On 2/28/17, at 3:35 p.m., during an interview, the AD stated Resident 1 did not look like herself when she returned from the surgical procedure on 2/16/17. The AD stated the resident was unable to maneuver her wheelchair, so she had to use the controls to drive the resident to her room, because Resident 1 was leaning 'slouched' to one side. The AD stated the resident was "dead weight" during a transfer with the Hoyer lift to the bed. The AD stated Resident 1 normally helped with the transfer, but was so weak. The AD stated she informed the charge nurse (LVN 1) that Resident 1 did not look like herself. The AD stated she thought LVN 1 was going to handle the situation, so she did not call the DON.
A review of the facility's policy and procedure titled, "Surgery-Related (Pre-and Postoperative) Management- Clinical Protocol," dated 7/2016, indicated under Monitoring, the staff would do the following:
?After readmission to the facility postoperatively, the physician and staff would maintain appropriate communication with the referring surgeon to ensure that the resident receives adequate postoperative care and that the staff and Attending Physician receive relevant medical information.? The policy also indicated ?the staff would assess the resident for pain and continue to monitor the resident for changes in level of pain? and ?the staff and physician will monitor for, and address, postoperative risks and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, and failure of the surgical wounds to heal, ?etc.?
A Nurses' Note written by LVN 2 on 2/17/17, and timed at 8:12 a.m., as a late entry (L/E) for 2/16/17 at 11:30 p.m., indicated the resident was in bed, awake and alert, and was able to make needs known. The L/E note indicated Resident 1 ?denied pain and shortness of breath (SOB); checked the AV Shunt S/P (status-post) surgery; no bleeding or drainage noted; No S/S of infection noted and will continue to monitor.?
The review of the facility's surveillance video footage indicated LVN 2 did not enter Resident 1's room throughout her shift until 2/17/17 at 5:13 a.m., after the resident was found unresponsive, which was verified by the DON watching the facility?s surveillance video.
A review of the facility's Charge Nurse Job Description indicated nurses were responsible for accurate observations, evaluations and reporting resident's symptoms, reactions and progress to the director of Nurses (DON), Administrator, and others participating in the care and treatment of the residents.
A review of the facility's policy and procedure titled, "Rounds/Licensed Staff," dated 12/2004, indicated it is the policy of this facility to ensure the safety and comfort of the resident, and to assist in continuity of care and to identify possible change in condition.? Under Procedures, the facility shall do the following: ?1. The nurse will check residents every two (2) hours? 7. Check that assignments and charting are completed, if applicable.? There was no documentation that Resident 1 was assessed every 2 hours.
A Nurses' Note, dated 2/17/17, and timed at 12 a.m., indicated Resident 1 was sleeping, had no SOB and vital signs were as following blood pressure 120/70, temperature 97.2, heart rate 78, respiration 20, and 0/10 pain (10 being the worse). No bleeding noted at right AV shunt area.
A Nurses' Note, dated 2/17/17, and timed at 1:30 a.m., indicated CNA1 answered Resident 1's call light and elevated the head of bed (HOB). The note indicated Resident 1 had no complaints of pain or SOB.
At 7:09 a.m., on 3/1/17, during an interview, CNA 2 stated she saw Resident 1 on 2/16/17 at 11 p.m. CNA2 stated she took the resident's vital signs at 11:30 p.m. on 2/16/17, while she was sleeping. CNA 2 stated she took vital signs on all the residents in facility. According to the facility?s surveillance video, CNA 2 was not seen on the video going in and out residents? rooms, as confirmed by the DON. CNA 2 stated on 2/17/17 between the hour of 5 a.m. and 5:30 a.m., she was informed by CNA1 that Resident 1 was having a change of condition (COC). CNA2 stated LVN 2 retrieved the crash cart (movable collection of emergency equipment and supplies meant to be readily available for resuscitative effort) from the hallway but the cart was locked. CNA2 called another co-worker on her cell phone to help locate the crash cart key and found the key in nurse's Station 1. LVN 2 opened the crash cart and placed a backboard under Resident 1 and started chest compressions. CNA2 stated she attempted to take the residents vital signs but the numbers were too low, while CNA 1 called the DON and 911. CNA 2 stated there was no AMBU bag (a resuscitator bag used to assist ventilation) in the crash cart, so LVN 2 stopped the CPR, and placed Resident 1 on oxygen.
On 3/7/17, at 4:17 p.m., during an interview, LVN 2 stated she was the 11-7 a.m. charge nurse on duty on 2/16/17. LVN 2 stated she made rounds at the beginning of the shift and spoke with Resident 1. LVN 2 stated she received a report from LVN 1, indicating the resident had returned from surgery to the facility at 10:30 p.m., on 2/16/17. LVN 2 stated did not receive any aftercare instructions regarding Resident 1. LVN 2 stated CNA1 called her between 5 a.m. and 5:15 a.m., because Resident 1 was unresponsive. LVN 2 stated she checked the resident's vital signs, but was unable to obtain. The resident had no heartbeat. LVN 2 stated she went to the crash cart, but could not open it and called out to CNA 2 for assistance in locating the key. LVN 2 stated she started chest compressions on Resident 1. LVN 2 stated she was the only licensed nurse on duty, so she stopped performing CPR on Resident 1, contrary to the facility?s policy (Emergency Procedures, dated 7/2012), and went to call 911 and the resident's physician, before continuing to perform CPR on the resident. LVN 2 stated the CPR was unsuccessful.
According to an electronic nurse?s note, dated 2/17/17, and timed at 10:48 a.m., Resident 1 was pronounced deceased by the paramedics on 2/17/17 at 5:30 a.m.
A review of the paramedics? Prehospital Care Report Summary, dated 2/17/17, indicated the paramedics were called at 05:22 a.m. and arrived on scene at 05:29 a.m. The paramedics? Narrative History indicated the following: ?61 y/o female found in cardiac arrest asystole (no heart beat) in two leads with rigor (one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen). Pt last seen at 0200 (2 a.m.) complaining of SOB (shortness of breath) per the staff. Pt was released to ?pd? on scene.?
The 911 call, audio recording, provided from the Fire Department, indicated the facility?s staff member stated, ?We need an emergency 911.? The 911 operator asked the staff what is wrong with the patient?? and the staff responded, ?She can?t talk.? The 911 operator asked the staff was the patient having problems breathing and the staff member stated, ?Yes.?
A review of the facility's policy and procedure titled, "Emergency Procedures," dated 7/2012, indicated the purpose of the policy is ?to provide immediate medical care to a resident whose condition indicates a need,? which includes the following:
1. Do not leave the resident alone.
2. Use the call bell or by calling out for assistance.
3. Check for the ABCs:
A - Airway
B - Breathing
C - Circulation - if indicated, begin CPR procedures
4. Take vital signs.
5. Notify the resident's attending physician or his alternate immediately.
6. If the attending or alternate physician is not available, contact the medical director.
7. If the services of the paramedics are needed, activate facility emergency notification system (911).
On 5/22/17 at 10:15 a.m., during a telephone interview, the facility?s charge nurse (LVN 3) stated if there was an emergent change in a resident?s condition the physician and 911 should be called immediately. LVN 3 stated she would also check the resident?s POLST status and follow the criteria for 911. In regards to Resident 1, LVN 3 stated if a resident returned from the GACH status-post surgery the physician, DON, and the resident?s family should be notified. LVN 3 also stated if a resident returned without any aftercare instructions the nurse should call the GACH about the resident?s pre and post-op status and request for the aftercare instructions.
A review of the facility?s policy titled, ?Plan of Care for Resident Concern and/or Change in Condition,? with a revised date of 11/2004, indicated under ?Objective? is ?to observe record and report any concern or condition change to the attending physician so that proper treatment will be implemented.? Under ?Policy? it states ?it is the policy of the facility to document in the medical record any concern and/or change of condition/ accident/ incident regrading a resident which may or may not involve an injury. ?1. If there is any concern/change of condition and / accident/ incident to a resident, the physician must be notified. Document date, time, method of communication and name of person contacted.?
A review of Resident 1?s death certificate, signed by the physician on 3/3/17, indicated the resident expired on 2/17/17 at 5:30 a.m. The immediate cause of death was cardiopulmonary arrest with sequential conditions listed as diabetes mellitus 2 and diabetic peripheral vascular disease.
In violation of the above cited licensing standards, the facility failed to provide Resident 1 with necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to meet the needs of the resident, including but not limited to:
1.Failure to follow its policy to provide the necessary care and services, which included a thorough and continuous assessment after a surgical procedure (right arm arteriovenous fistula [AVF] a connection of an artery [carries blood away from the heart] and a vein [carries blood back to the heart]).
2. Failure to notify Resident 1?s physician upon her return back to the facility, that the resident had a change in condition after surgery.
3. Failure to follow its policy and procedure to provide cardiopulmonary resuscitation (CPR) timely, after Resident 1 was found unresponsive.
4. Failure to monitor Resident 1?s vital signs ([V/S] clinical measurements of blood pressure, heart rate, respiratory rate, and temperature, and site of surgery for bleeding out) post-surgery pursuant to the policy and procedure ?Rounds/Licensed Staff.?
These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and has a direct proximate cause of death for Resident 1. |
| 920000018 |
Griffith Park Healthcare Center |
920007870 |
A |
12-Apr-13 |
N8UW11 |
13290 |
Title 22 CCR ? 72311(a)(1)(A)(B)(C)(2) Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following:(A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.(B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited.(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.(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.The facility failed to provide effective care and services to manage Patient 1's diabetes mellitus (DM). On January 28, 2010 at 11:45 p.m., the paramedics transferred the patient to the general acute care hospital for treatment after the blood sugar/glucose level reached 600 mg/dL. The patient quickly deteriorated and went into acute respiratory failure which required endotracheal intubation (an emergency medical procedure in which a tube is placed into the trachea through the mouth or the nose to open the airway for mechanical breathing). On January 31, 2010, the patient died and the death certificate listed, "severe diabetic ketoacidosis? as the primary cause of death. The facility failed to develop, review, evaluate and update the individualized comprehensive assessment and plan of care to effectively manage Patient 1?s diabetes mellitus (DM), to monitor the signs and symptoms associated with the patient's abnormal blood sugar/glucose levels, and to provide prompt notification to the patient?s physician of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by the patient, by failing to: 1. Monitor the patient's blood sugar level for hyperglycemia (high glucose levels.) 2. Provide adequate staff training to monitor and recognize the signs and symptoms of complications associated with unmanaged diabetes mellitus and respond with appropriate interventions to manage abnormal blood glucose levels. 3. Notify the physician of the signs and symptoms associated with unmanaged diabetes mellitus (lethargy, refusal to eat unresponsive except for painful stimuli) and obtain an alternate treatment plan from the physician. 4. Assess the patient's response to the oral diabetic medication (Metformin 500 mg/dL twice a day). On March 17, 2010, the Department received an anonymous complaint allegation that Patient 1, whose diagnoses included diabetes, was not routinely assessed for his blood sugar which was frequently above 500 mg/dL. On March 22, 2010, an unannounced visit was made to the facility to initiate the investigation of this allegation.A review of the admission record indicated Patient 1 was admitted to the facility from an acute care hospital on January 6, 2010, with diagnoses that included diabetes Mellitus type II (disorder that is characterized by high blood glucose) without control, Parkinson's disease, (a degenerative disorder of the central nervous system that often impairs the motor skills, speech, and other functions), and schizophrenia (mental disorder characterized by abnormalities in the perception or expression of reality). The Minimum Data Set [(MDS) [a standardized comprehensive assessment of the patient's problems and conditions], dated January 18, 2010, indicated the patient had short and long-term memory problems, was moderately impaired in cognitive skills for daily living, required supervision with eating and walking, limited assistance with dressing, toilet use, and personal hygiene, and required extensive assistance with bathing. According to the facility?s copy of the patient's acute hospital history and physical record, dated December 22, 2009, the patient had a blood sugar level of 699 mg/dl, and diagnosed with uncontrolled diabetes mellitus type II. The facility developed a plan of care on January 7, 2010, to manage the potential for hypoglycemic [a drop in blood glucose below normal levels: (Reference range 60-110 mg/dl)] or hyperglycemic episodes (excessive blood sugar with symptoms that include excessive urination, hunger and thirst) secondary to diabetes mellitus. The goal was to maintain the blood sugar level within the limits of 65 mg/dl to 115 mg/dl. The care plan approaches included to monitor the patient's intake, monitor the patient for thirst, excessive appetite or voiding, changes in the level of consciousness or mood, and perspiring, and report to the physician promptly. However, the plan did not include an approach for how the nursing staff were going to monitor the blood sugar levels to ensure they were maintained within the given limits specified in the care plan goal. According to a laboratory report, dated January 11, 2010, the patient had a high fasting glucose level of 287 (reference value 70 to 110 mg/dl). The physician was notified and a new medication order was obtained. There was a physician's order dated January 12, 2010, for Metformin 500 mg two times a day by mouth for diabetes mellitus, and a 1600 calorie DM diet. A review of the Nurses Note(s) from January 11, 2010 to January 28, 2010, revealed there was no documentation to indicate the patient's blood sugar level was rechecked after the order of Metformin was obtained on January 12, 2010. There was a physician order dated January 17, 2010 to change the diet to 1500 calorie ADA diet.The Nurses Note dated January 28, 2010 at 3:20 p.m., indicated the patient appeared drowsy but responsive to painful stimuli, had no signs and symptoms of hypo/hyperglycemic reactions noted, and was not able to eat. The notes indicated that Registered Nurse 2 (RN 2), who worked the 7 a.m. to 3 p.m. shift on January 28, 2010, called and spoke to the PA (Physician?s Assistant) about the patient's change in condition. The PA gave an order to hold the PRN (as needed) medication of Haldol with Ativan, and to hold the Ativan. Both medications were to be held for two days due to drowsiness manifested by sleeping most of the day and not being able to eat. There was no evidence documented that the licensed nurses checked the resident?s blood sugar level when the patient was showing these signs in order to fully inform the physician about the patient's change in condition, and in order to obtain prompt instructions on the management of the patient's diabetes mellitus. A review of the Medication Administration Record (MAR) dated January 28, 2010,indicated all the patient's medications scheduled for administration at 9 a.m. and 5 p.m., including Metformin 500 mg, were not administered (circled on the record to indicate the resident did not receive the medication). The licensed nurse?s note at the back page of the MAR indicated ?unable to administer? the medication on January 28, 2010 at 9 a.m. and 5 p.m., because the patient was very drowsy and sleepy. ?MD aware?. According to the Nurses Notes, dated January 28, 2010 at 7 p.m., the patient's blood sugar level was not checked/monitored when the patient exhibited signs and symptoms of untreated diabetes. It was noted that the patient was unable to eat, responded only to painful stimuli, and his oxygen saturation level (a measurement of how much oxygen the blood is carrying as a percentage of the maximum it could carry) was 93 percent. According to the Nurses Note, there was no further assessment of the patient's condition and oxygen saturation level until 11 p.m. On January 28, 2010 at 11 p.m., the Nursing Note indicated the patient's blood sugar was checked for the first time since January 11, 2010, and was found to be elevated to 600 mg/dL, the oxygen saturation level was 80 percent, and the patient was noted to be ?very lethargic.?Physician?s orders were obtained to transfer the patient to the acute care hospital. The Nurse?s Note, dated January 28, 2010 at 11:45 p.m., indicated the paramedics transferred the patient to the acute care hospital. On January 29, 2010 at 12:31 a.m., the patient was admitted to the emergency room (ER). This was one and one-half hours after the patient was known to have an elevated blood sugarlevel of 600 mg/dL. According to the ER laboratory report dated January 29, 2010 at 12:45 a.m., the patient's blood glucose level was 1235 mg/dL (reference range (65-115), the blood urea nitrogen (BUN) was 151 mg/dL (reference range 9-20), the creatinine was 6.5 mg/dl (reference range 0.3-1.3), the sodium was 159 mEq/l (reference range 135-145), the chloride was 120 mEq/l (reference range 96-106 mEq/ml, and the potassium was 6.2 mEq/ml (reference range 3.5-5.0). These abnormal laboratory results were indicators for dehydration. (Centers for Medicaid and Medicare Services (CMS) State Operations Manual, Guidance to Surveyors, Page 222). The acute hospital's Emergency Room Summary indicated the patient arrived in the emergency room on January 29, 2010 at 12:31 a.m.. The Physician Consultation, dated January 29, 2010, indicated the resident had diabetic ketoacidosis with a blood sugar level of 1235 mg/dl and large ketones [a by-product of fat metabolism (breakdown) that occurs when the body cannot metabolize carbohydrates due to the absence of insulin production] in the serum. The resident was also diagnosed with acute renal failure, ypernatremia (an elevated sodium level in the blood) and hyperkalemia (an elevated potassium level in the blood). The resident received two liters of normal saline in the emergency room, ten units of regular insulin two times intravenously (IV) and was started on IV regular insulin of 10 units per hour drip, and also normal saline at 125 milliliters per hour. The patient quickly deteriorated and went into acute respiratory failure which required endotracheal intubation (an emergency medical procedure in which a tube is placed into the trachea through the mouth or the nose to open the airway for mechanical breathing, using a machine that breathes for the resident while the tube is in place), and was transferred to the critical care unit on January 29, 2010 at 3:08 a.m. Another acute care hospital's Physician Consultation dated January 31, 2010, indicated the patient did not respond to resuscitation efforts and was pronounced dead on January 31, 2010 at 3:51 a.m., with a final diagnoses that included severe diabetic ketoacidosis with ketonemia (excess of ketones in the blood). A review of the Certificate of Death dated November 2, 2010, indicated the immediate causes of death included severe diabetic ketoacidosis.On March 22, 2010 at 2:10 p.m., during an interview Registered Nurse 2, who had worked the 7 a.m. to 3 p.m. shift on January 28, 2010, stated if a resident did not eat for two consecutive meals, the licensed nurses were allowed to check the blood sugar to find out if the patient had hypoglycemic or hyperglycemic action even if a patient does not have a physician's order to check the blood sugar level. The facility's diabetes mellitus monitoring and management protocol (no date) indicated that residents with type II diabetes mellitus controlled with oral hypoglycemic agents or a single injection of intermediate-acting insulin, may have their glucose levels tested before breakfast and before supper or at bedtime (twice a day monitoring). On March 22, 2010 at 2:35 p.m., during an interview, Registered Nurse 1 (RN 1) was asked how the facility planned to obtain the resident?s care plan goal for diabetes mellitus (blood sugar will be within the normal limits of 65 mg/dl-115 mg/dl) without checking the blood sugar level. He stated the licensed nurse should have assessed the patient's condition often, and should have clarified with the physician the need for checking the blood sugar level. There was no documented evidence in the nurse's notes that the patient's condition was continuously assessed on January 28, 2010 from 3:20 p.m. to 7 p.m., and from 7 p.m. to 11 p.m., for the signs and symptoms of hyperglycemia. There was no evidence the patient's blood sugar level was assessed between 7 p.m. to 11 p.m., until the patient became lethargic, and the resident's blood sugar level was 600 mg/dL, with an oxygen saturation level of 80 percent. The facility staff failed to develop, review, evaluate and update the individualized comprehensive assessment and plan of care to effectively manage Patient 1?s diabetes mellitus (DM) and provide prompt notification of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by the patient.The above violation presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Patient 1. |
| 970000085 |
GLENDALE HEALTHCARE CENTER |
920010179 |
B |
10-Oct-13 |
ZU3L11 |
12167 |
Title 22 Section 72311 (a)(2) (a) Nursing services shall include, but not limited to, the following: (2) Implementing of each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan. Based on interview and record review, the facility?s licensed nurses failed to monitor the patient after the fall for signs and symptoms of complications, complaints of pain and discomfort as care planned. The facility failed to stop physical therapy exercises after the patient complained of right hip pain after the fall that increased in intensity over time, and failed to evaluate if the patient?s right hip pain was related to a preceding fall.1. Patient 1, who was extensively dependent on staff for activities of daily living and had an unsteady gait, was exercised by the physical therapist (PT) after the fall while having right hip pain which was increasing in intensity until the patient was diagnosed with a right hip fracture.2. The facility failed to ensure the licensed nurses consistently monitor the patient after the fall for complications including pain and to report to the physician any increase in right hip pain intensity as care planned.On September 29, 2011 at 2 p.m., an unannounced visit was made to the facility to investigate an entity reported event about that on September 19, 2011, Patient 1 had increasing right hip pain assessed as a seven on a scale of zero to ten (where a zero was no pain and ten was excruciating pain) with the x-ray results indicating the patient had a right hip fracture.According to the admission record, the patient was admitted to the facility on June 3, 2011, with diagnoses that included difficulty in walking, end stage renal disease, diabetes mellitus, neuropathy, atrial fibrillation and a history of traumatic fracture. The Minimum Data Set (MDS) assessment, dated September 7, 2011, indicated the patient had moderately impaired cognitive skills in cognitive decision making and was extensively dependent on the staff and required one person to provide physical assistance for bed mobility, transfer between surfaces, walking in a room, dressing, toilet use, personal hygiene and bathing. MDS indicated the patient required limited assistance with a setup only for walking in corridor and supervision with the setup only for locomotion on and off unit and eating. The patient?s mobility devices were a walker and a wheelchair. The MDS also indicated the patient had no functional limitation in the range of motion in upper and lower extremities.According to the facility?s investigation report, dated September 5, 2011, the resident had a fall on September 5, 2011 on the 3 p.m. to 11 p.m. shift.Based on investigative report and an interview with the Director of Nursing (DON) on September 29, 2011 at 2:20 p.m., the patient sustained a fall on September 5, 2011, by tripping over the footrest on his wheelchair. It was documented that after the fall the patient complaining of right hip pain at two on a scale of ten (mild). The patient?s physician was notified on September 5, 2011 at 5 p.m. and then an order for of a right hip x-ray was carried out.The Diagnostic Laboratories x-ray report, dated September 5, 2011 at 7:24 p.m. of the patient?s right hip, indicated the patient did not have a fracture or dislocation. The report?s conclusion was that the patient had modest osteoarthritis of the right hip.There was a plan of care for the actual fall dated September 5, 2011. The intervention was to monitor for signs and symptoms of complications, complaints of pain or discomfort and notify the physician if it occurs.A review of the licensed nurse?s progress note, dated September 6, 2011 at 1:38 a.m., indicated the patient was under observation after the fall and the patient was complaining of mild pain (two out of ten) in a right hip which was relieved with a bed rest. At 8:06 a.m., it was documented that the patient was complaining of a right hip pain and was medicated with Tylenol 650 milligram (mg) for pain; however there was no documented evidence the patient?s pain intensity was evaluated.The facility pain rating system was based on zero to ten scale where a zero was no pain, one to two was a mild pain, three to four was moderate pain, five to six was moderate to severe pain, seven to eight was severe pain and nine to ten was excruciating pain.According to the licensed nurse?s note dated September 8, 2011 at 3:12 p.m., the patient was receiving PT exercises as ordered. It was documented that the patient was afraid to stand by himself due to previous fall and that the licensed nurse called the patient?s physician for a stronger pain medication. There was no documentation indicating the reason for obtaining stronger pain medication and that the patient?s pain severity was assessed.On September 8, 2011, there was a physician?s order for Vicodin 5-500 mg one tablet for pain prior to PT therapy and for Vicodin 5-500 mg one tablet every six hours as needed for pain (pain severity was not specified).During an interview on February 15, 2012 at 1:30 p.m., with the Licensed Vocational Nurse (LVN), who was a charge nurse, she confirmed contacting the patient?s physician to obtain an order for Vicodin but she could not recall the severity of the patient?s pain. The LVN said that Vicodin was usually given for moderate to severe, severe and excruciating pain. Also, LVN stated that she informed PT about changes in the patient right hip pain. LVN could not explain why the patient?s physician was not notified of changes in the patient?s right hip pain intensity.Based on the licensed nurse?s note, dated September 9, 2011 at 1:50 p.m., the patient was noted to have pain with movement and was medicated with Vicodin 5-500 mg for pain rated five out of ten (moderate to severe). On September 10, 2011 at 3:11 p.m., it was documented the patient was noted to have pain when moved and was medicated with Vicodin 5-500 mg before PT therapy. There was no documented evidence of the severity of the patient?s pain. According to the Medication Administration Record (MAR), the patient was also medicated with Vicodin 5-500 mg after the PT therapy at 1 p.m. on September 10, 2011 (the pain severity was not documented), for right hip pain.A review of the MAR revealed the patient was receiving Vicodin for right hip pain rated five out of ten (moderate to severe) on September 12, 14, 15 and 16, 2011.A review of the patient?s record indicated there was no documented evidence the licensed nurses communicated to the patient?s physician about changes in the intensity of the patient?s right hip pain.Also, there was no documented evidence the licensed nurses communicated to the PT about the escalated intensity of the patient?s right hip pain.During an interview with the DON on February 15, 2012 at 3 p.m., he confirmed the licensed nurses did not consistently assess the patient?s pain intensity and did not communicate to the patient?s physician about the patient?s increased right hip pain intensity.According to the physician?s order, dated June 6, 2011, for PT?s treatment, the patient was receiving therapy exercises with PT five times a week for gait training and safety due to difficulty in walking. The patient was medicated with Tylenol 500 mg thirty minutes before therapy as ordered on June 6, 2011, and starting September 8, 2011, the patient was receiving Vicodin 5-500 mg for pain management before PT therapy.According to the record review the patient was continuously receiving physical therapy exercises for lower extremities in spite of having right hip pain even after pre-medication with Vicodin.A review of the PT treatment record indicated the patient had zero pain during exercise sessions before September 6, 2011. It was documented in the PT treatment record that during exercises the patient was complaining of right hip pain rated in intensity as three out of ten (moderate) starting on September 6, 2011, and continued daily on September 7, 8, 9, and 10, 2011. On September 13, 2011, the patient was complaining of right hip pain rated six out of ten (moderate to severe pain).PT documented that the patient stated his pain was going away with bed rest. According to the PT?s functional status record dated September 14, 2011, the patient was complaining of right hip pain rated four out of a scale of ten (moderate) prior to therapy.It was documented the patient was provided with the exercise therapy and was applied an ice pack to the right hip for 15 minutes after exercises and that the patient?s pain went down in severity from four out of a scale of ten to two out of ten.On September 15, 2011, the patient was complaining of right hip pain rated three out of ten (moderate) with activity and was complaining of discomfort and stiffness in his right leg with activities. On September 16, 2011, PT documented the patient was complaining of stiffness in a right hip area.During an interview with the Registered Physical Therapist (RPT) on February 15, 2012, at 2:10 p.m., she said if the patient complains of pain during exercise session and his pain is gradually increasing in intensity over time, the PT should stop exercising the patient and in collaboration with licensed nursing staff should re-evaluate the cause of pain. RPT confirmed that the patient?s record does not demonstrate that it was done. RPT confirmed that the record indicated the patient had a zero pain at the start of exercise sessions and during the sessions until September 6, 2011.According to the Change of Condition Assessment dated September 19, 2012 at 9 a.m., the patient was complaining of right hip pain irated as seven out of ten (severe). It was documented the patient?s physician was informed and gave an orders for a right hip x-ray and an order to change Vicodin 5-500 mg one tablet for pain management from once daily to every eight hours.Also, it was documented that the patient was given pain medication before PT exercises at 10 a.m., that patient went to rehabilitation room and had his routine therapy.According to the patient?s clinical record and an interview with the RPT on February 15, 2012 at 2:10 p.m., there was no documented evidence about how the patient tolerated his exercise session on September 19, 2011.Based on x-ray of a right hip dated September 19, 2011, the patient had a fractured femur neck (hip). There was an addendum which stated that images from September 5, 2011, were compared to the images from September 19, 2011. On the earlier images the femoral neck was intact, but the September 19, 2011 image showed moderate displacement. There was a marked difference between the images on September 5 and 19, 2011.On September 19, 2011 at 9:23 p.m. the resident physician was informed of x-ray results and order to transfer the patient to the acute care hospital was carried out. The patient was transferred to the acute care hospital as ordered for a hemiarthroplasty of a right hip, (a surgical procedure for repair of an injured or diseased hip joint involving replacing the head of the femur with prosthesis without reconstruction of the acetabulum, Mosby's Medical Dictionary, 8th edition, 2009).The facility failed to stop physical therapy treatment when the patient was complaining of right hip pain which was increasing in intensity over time and to evaluate if the patient?s right hip pain could have been a result of a preceding fall. Patient 1, who was extensively dependent on staff for activities of daily living and had an unsteady gait, was exercised by the physical therapist (PT) after the fall while having right hip pain which was increasing in intensity until the patient was diagnosed with a right hip fracture. The facility staff failed to ensure the licensed nurses consistently monitor the patient after the fall for complications including pain and to report an increase in right hip pain intensity to the physician.The above violation had a direct relationship to the health, safety or security of Patient 1. |
| 920000086 |
GRANADA HILLS CONVALESCENT HOSPITAL |
920010778 |
B |
24-Jun-14 |
R1BH11 |
6077 |
Title 22, Division 5, Chapter 3, Article 6 ? 72601 (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshall.72603 Space provided for specific uses at the time of licensure shall not be converted to other uses without the approval of the Department.72605 The Department shall be notified in writing by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. Based on observation, interview, and record review, the facility failed to comply with the requirements of the Office of Statewide Health Planning and Development (OSHPD), the authority having jurisdiction for alteration and construction work in healthcare facilities. During the Life Safety Code survey of the facility on January 18, 2013, at 5:30 p.m., accompanied by maintenance supervisor (MS), the following was observed: 1. A new attached un-finished wood-frame laundry room approximately 15 by 20 feet, and a water heater closet approximately 4 by 12 feet. The room did not have sprinkler system coverage. According to Administrator, the contractor had applied for permit; however, he did not have the paperwork on-site. No paperwork for the room addition was subsequently submitted to the Department.2. Flexible metal Heating, Ventilation and Air Conditioning (HVAC) ductworks throughout the attic space. The Maintenance Supervisor stated he was not sure if there were fire dampers for the HVAC system. 3. Unsecured flexible electrical wires throughout the attic space. According to the MS, these were for the installation of the network cables and surveillance camera wires. A review of the OHSPD field visit report dated January 23, 2013, indicated:1. Installation, upgrade and/or alteration of the fire alarm system (added or altered panel with battery back-up) without required permits, plan approval, inspection, testing or approvals. 2. Construction of an un-approved Laundry Room addition in progress at the rear of the facility in use or occupied without required review, permits or approvals from OSHPD. In addition, the construction was noted with several deficiencies included but not limited to: 1. Wood framing or sills less than six inches above grade and installed without required weep screeds or exterior walls. 2. Installation of water-resistant gypsum board on ceilings. 3. Incomplete and/or incorrect installation of fire resistive roof-ceiling assembly. 4. Building addition is not protected by the installation of fire sprinklers. 3. Installation of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals. 4. Installation of several new and/or replacement HVAC systems without required permits, plan approval, inspection testing or approvals from OSHPD. 5. The HVAC appurtenances and related ducting has been replaced and/or altered without required inspection, review, permits or approvals from OSHPD. Replacement ductwork was noted incorrectly installed with factory-made flexible ducting. Also debris and discarded material was left in the attic space. 6. Installation of several apparent ceiling exhaust fans where the flexible ducting penetrates the bottom membrane of the fire resistive roof-ceiling assembly and are missing the required fire damper and/or smoke/fire damper and appears to have been altered without required review, permits or approvals from OSHPD. 7. Installation of new added and/or altered electrical circuits, wiring, boxes and others in various areas, especially in the attic space without required review, permits, or approvals from OSHPD. 8. Installation of wall-hung flat panel televisions in several locations, some of which appear to weigh over 20 pounds, without OSHPD plan approval, inspection, testing or approvals. 9. Installation of several ?attic fans? or ?whole- house fans? without required review, permits or approvals from OSHPD. 10. Installation of an apparent security surveillance system and several wall mounted televisions without required review, permits or approvals from OSHPD. 11. Installation of new vinyl replacement window and door assemblies without required review, permits or approvals from OSHPD. 12. Installation of new electrical ?air curtain? fans without required review, permits or approvals from OSHPD. 13. The installation and/or alterations of plumbing piping and drainage piping in various areas without required review, permits or approvals from OSHPD. The water piping does not appear to be part of the original construction and appears to have been re-piped with cooper piping material and the drainage vents and piping altered or replaced with plastic and unapproved material. 14. Installation and placement into service/use of large unsecured refrigeration equipment in the kitchen without required review, permits or approvals from OSHPD. On May 4, 2014, prior to the exit conference of the 2014 recertification survey, the Administrator and a corporate owner were unable to provide documentation that the above requirements had been corrected by the facility. According to the OSHPD Fire Marshal, as of May 12, 2014, the facility had applied for an Annual Building Permit (ABP) on February 13, 2013, but never applied for any projects under that ABP. The ABP is a fiscal year item that expires on June 30 each year. The facility did not apply for a project under that annual permit during the year it was issued, 2013, therefore has since expired.The facility failed to comply with the requirements from the Office of Statewide Planning Health Planning and Development, the authority having jurisdiction for alteration and construction work in healthcare facilities. These violations had a direct relationship to the health, safety, and security of all patients in the facility. |
| 920000018 |
Griffith Park Healthcare Center |
920011721 |
A |
25-Sep-15 |
MRQO11 |
23525 |
F309 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. F323 CFR 483.25(h) Accidents The facility must ensure that? (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility staff failed to provide supervision, operable doors and/or door alarms, and assistive devices [Wanderguard - a mechanical system that alerts staff when a resident approaches by activating an alarm (brand name was "Code Alert")], to prevent serious harm from accidents and injuries, by failing to: 1. Provide adequate supervision to residents with known wandering or elopement risks, or dementia (general term for a decline in mental ability severe enough to interfere with daily life that can lead to possible injury), as identified by the facility, to protect them from elopement and injury, when the Wanderguard system and/or the exit door was inoperable; and 2. Provide safety to all residents by securing two of five exit doors with an operable Wanderguard system and/or operable alarm, to prevent them from leaving the facility unsupervised. There were 22 residents identified by nursing as being at risk for elopement or wandering from the facility. Three of three discharged residents (1, 2, 3), who were unable to care for themselves, eloped (left without supervision) from the facility. Two residents were located by law enforcement (1, 2); the third resident (3) has never been located.On August 12, 2015, at 7:35 a.m., the Department of Public Health received a complaint alleging a resident (1), wearing a hospital gown, walked out of the facility, and was reported missing. The resident was found entering a freeway (134 Glendale freeway) ramp. On August 13, 2015, at 9:40 a.m., a physical tour and observation of the skilled nursing facility (SNF) was conducted, accompanied by the Maintenance Supervisor (MS). The double doors designated as "exit" doors located on the North West (NW) side of the building were not latched, and the door handles were tied together with yellow "caution" tape. An exit alarm control unit used as a Wanderguard alarm system, was installed on the wall next to the door frame, but there was no power or signal indicating the alarm system was activated or operating. On August 13, 2015, at 9:50 a.m., during an interview, the MS stated the NW doors were, "broken" and needed to be fixed. He stated he was in the process of changing the door frames and "tore the door down" the day before (August 12, 2015). The MS stated the Wanderguard alarm system had been inoperable for the last two to three weeks.On August 13, 2015, at 9:55 a.m., the Maintenance Supervisor removed the yellow caution tape, and walked out the NW exit door to the back patio, which had a five foot block fence around it and an iron gate with a latch on it. The MS stated he had installed an alarm on the gate, which was supposed to alert nursing station 1 when the gate was opened. The MS proceeded to unlatch and open the gate, and waited seven (7) minutes to see if facility staff would respond to the supposed alarm. There was no response from staff. At 10:10 a.m., 15 minutes later, nursing station 1 was observed, but there were no staff present, and no alarm was heard at the nursing station to indicate the gate had been opened. When the MS was asked why the gate didn't alarm as he indicated it would, he didn't have an answer.Two of the five exit doors observed with the MS created a risk to residents with dementia and/or wandering residents. The North West (NW) exit door was tied shut with yellow caution tape. There was no alarm on the door, and the Wanderguard system was inoperable. The North East (NE) laundry door had an alarm and a Wanderguard system. However, according to the MS, staff would disalarm the system all the time when taking laundry barrels in and out of the door, so it wouldn't alarm. The lobby door had a Wanderguard system on it, but there was no regular alarm applied for general traffic. The East door exiting towards the busy main street had an alarm and a Wanderguard system. The South West door (where the gate is) had an alarm and Wanderguard system on it. On August 13, 2015, at 1:30 p.m., an interview and review of records was conducted with the Assistant Administrator (AA). She provided the "List of Dementia Patients/Wanderers." There were 22 residents listed, some with dementia, some wandered, and some required Wanderguard bracelets (bracelet). Two residents were assessed as high risk for wandering out of the facility, seven residents were at high risk for eloping and required bracelets for safety, according to the AA. a1. On August 13, 2015, at 2 p.m., a review of the facility's incident report, written by and reviewed with the Assistant Administrator (AA), indicated Resident 1 was admitted to the facility on August 8, 2015, with diagnoses that included dementia (decrease in brain function causing problems with thinking and memory), and psychosis (mental illness that causes radical changes in personality and impaired functioning). The report indicated Resident 1 wandered out of the facility on August 9, 2015 (no time indicated). A review of the police report dated August 9, 2015, at 5:30 p.m. indicated the police had received a call from a male stating he had observed a man by the 134 freeway that looked confused and disoriented. The police found Resident 1 at the freeway ramp, and according to the report, they returned Resident 1 to the SNF.During the interview with the Assistant Administrator (AA) while reviewing the report, she stated she had completed the incident report. When asked about Resident 1 ' s elopement on August 9, 2015, she said he was in his room, eating breakfast, and then he was gone. She stated they didn't think the resident would leave. They had not talked to the family to gather any personal information regarding Resident 1. She stated Resident 1 was a new admit and they had not had time to assess whether he required a bracelet or not.When the AA was asked about the process followed for determining whether a resident is an elopement risk or required a bracelet, she stated nursing staff assess if a resident is a high risk for elopement. Nursing then contacts the physician for an order for a bracelet. When asked about the actual purchasing of the bracelets, she stated they have extra bracelets available. She proceeded to provide a full box of Wanderguard bracelets.A review of Resident 1's general acute care hospital (GACH) Psychiatric Evaluation dated August 5, 2015, indicated he had recently been hospitalized, and now returned to the emergency room (ER). The evaluation indicated Resident 1 was from a previous SNF (unknown), and indicated he was now in the ER on a 5150 (involuntary 72-hour hold for evaluation) due to being a danger to others and was gravely disabled (person, due to mental disorder, is incapacitated or rendered unable to carry out the transactions necessary for survival or otherwise provide for his or her basic needs of food, clothing, or shelter); he was confused and disorganized, with difficulty processing his thoughts. Resident 1 had gotten increasingly hostile and aggressive and he had been "hitting at other residents and his caregivers unprovoked."His impulse control and judgment were all impaired. The discharge criteria was that Resident 1 would not be homicidal, with discharge instructions to call 911 if he is feeling suicidal or homicidal; these instructions were signed by the resident. The GACH progress notes dated August 6, 2015, indicated Resident 1 had severe depression, dementia and psychosis, was awake and confused, and could not give a good history.A review of the SNF Comprehensive Resident Assessment dated August 8, 2015, upon admission at 2:40 p.m., with the IDON, indicated Resident 1 was ambulatory and independent, and the rest of the assessment was incomplete. Resident 1's Elopement Wandering Risk Assessment dated August 8, 2015, indicated a score of 7 (scoring 10 or above is high risk). According to the available information from the GACH, and Resident 1 ' s past and current mental status, the assessment was inaccurate and should have been 10 or more, indicating Resident 1 was a high risk for elopement and required a bracelet. There was no immediate or short-term care plan developed to incorporate the available GACH information to provide a safe environment and to prevent Resident 1 from eloping from facility. There was no indication the resident's primary physician was contacted to obtain an order for a Wanderguard bracelet for his safety, there was no bracelet applied to Resident 1 nor indication that 1:1 supervision had been considered or provided for the resident ' s immediate safety, as indicated in the facility's Elopement Prevention Program policy.According to Resident 1's SNF Psychotropic Assessment forms dated August 8, 2015, he was prescribed medications for aggression and combativeness, and for anxiety manifested by restlessness and agitation. His "Self Administration of Medication Assessment" dated August 8, 2015, indicated that he was not able to self-administer medications due to mentally disabled. The form also indicated Resident 1 was not alert and oriented to person, place, or time, and he is not physically able to administer the medications. This information was reviewed and verified with the interim Director of Nursing (IDON). She stated Resident 1's assessment information and care plan for immediate care should have been completed, but she could not locate any other information. The interim Director of Nursing (IDON) stated she was not employed when Resident 1 eloped on August 9, 2015.She stated the DON, administrator, staff developer, MDS (assessment) coordinator, and the registered nurse supervisor, had all resigned.Therefore they were not available for interviews.On August 14, 2015, at 2:30 p.m., during an interview with the certified nursing assistant (CNA 1), who was Resident 1's care giver the morning of August 9, 2015, he stated at 7 a.m. he went to drop off the breakfast tray for Resident 1.When he returned to pick up the tray at about 8 a.m., the resident was still there. CNA 1 stated about 10 min after he picked up the tray he heard staff yelling they could not locate Resident 1. Resident 1's room was closest to the lobby door and station 1. When asked if Resident 1 had given any indication he wanted to leave, CNA 1 said no. On August 14, 2015, at 10:30 a.m., during an interview with Resident 1's family member (FM), she stated she didn ' t know the resident was discharged from the hospital, and only found out when she called the hospital to visit Resident 1, on August 8, 2015. She was referred to the SNF, and when she called the SNF on August 9, 2015, she was informed that Resident 1 had already left the facility and was missing. She was very upset, and stated Resident 1 should have been discharged to a locked facility because he had always been in a locked facility. She stated Resident 1 had a tendency to wander, and she did not believe he was capable of making decisions. On August 14, 2015, at 11 a.m., the Administrator was interviewed regarding Resident 1 ' s GACH transfer information. He stated Resident 1 came from a locked facility and should have been sent to a locked SNF. He stated the GACH Facesheet was incorrect and indicated the GACH was "Not Locked," and no one knew Resident 1 required a locked facility until the family notified them after Resident 1 had already eloped.The Nurses Notes dated August 9, 2015, indicated Resident 1 was missing from approximately 9 a.m. and was returned by police at 7 p.m.He was sent back to the GACH with no apparent injuries at 9:30 p.m., and the family was present.The notes indicated that it was requested to send the resident back to the GACH because this SNF was not a "locked" facility, and the resident may elope again, per family request. On August 14, 2015, at 9 a.m. during an interview with the police department (PD) regarding Resident 1, it was revealed that two other residents had eloped recently (2, 3). The PD stated they had been called to the facility on numerous occasions, either for elopements or for abuse cases. This information lead to the information and investigation into the elopements of Resident 2 and Resident 3. a2. On August 13, 2015, at 2:30 p.m., a review of Resident 2's clinical record with the IDON, indicated he was 66 years old, admitted to the facility on October 8, 2013, with diagnoses that included chronic paranoid schizophrenia (false beliefs that a person may be plotting against them or members of their family). A review of the Physician Progress Record dated May 15, 2015, indicated Resident 2 was confused. There was no indication that he was oriented to person, place, or time; he ambulated without assistance. The Elopement/Wandering Risk Assessment dated September 2014 indicated Resident 2's Wanderguard bracelet was discontinued. On March 8, 2015, the assessment indicated he had intermittent confusion, but was not a risk for elopement.A review of Resident 2's Facesheet indicated a family member was his responsible party.A review of the Nurse's Notes dated June 1, 2015, indicated Resident 2 got a new order for "out on pass" with the responsible party for a court hearing. On June 14, 2015, at 11 p.m. the notes indicated Resident 2 was missing from the facility. He was last seen walking the halls around 10:30 p.m., "as usual". The notes indicated the oncoming (11 p.m. to 7 a.m. shift) certified nursing assistant (CNA) saw Resident 2 at the freeway ramp. The resident was brought back to the facility by local law enforcement. A review of the Incident Report with investigation, dated June 14, 2015, at 11 p.m., written by a licensed vocational nurse LVN (no longer employed), was provided by and reviewed with the Assistant Administrator (AA), on August 19, 2015, at 11 a.m. The report indicated Resident 2 was last seen walking in the hallway between 10 p.m. to 10:30 p.m. During rounds at 11 p.m. the resident was noted missing, who managed to get out of the facility between 10:30 p.m. and 11 p.m. The charge nurse drove around the vicinity, but could not locate the resident. The report indicated that a CNA (CNA 2) thought she saw Resident 2 by the freeway on-ramp when she came to work around 11 p.m.The conclusion was that he "managed to get out of the facility."There was no indication as to how the resident managed to elope from the facility, and there was no thorough investigation completed. The section for notifying the Department of the elopement was blank.There was no immediate care plan developed to incorporate the available GACH information to provide a safe environment and to prevent Resident 2 from eloping from the facility. There was no indication the resident's primary physician was contacted to obtain an order for a Wanderguard bracelet, there was no bracelet applied to the resident for his immediate safety, and there was no indication that 1:1 supervision had been considered or provided for the resident's safety, as indicated in the facility's Elopement Prevention Program policy.a3. On August 13, 2015, at 3 p.m., a review of Resident 3's GACH psychiatric unit History and Physical (H&P) dated August 1, 2015, was conducted with the assistance of the IDON. The H&P indicated Resident 3 was admitted to the psychiatric unit directly from another GACH. He had significant psychiatric decompensation and was gravely disabled (person, due to mental disorder, is incapacitated or rendered unable to carry out the transactions necessary for survival or otherwise provide for his or her basic needs of food, clothing, or shelter); he was depressed and was placed on a 5150 hold (involuntary 72-hour hold for evaluation). The Psychiatric Evaluation dated August 1, 2015, indicated Resident 3 had worsening aggression and combativeness, and was a "danger to others."He was confused and disorganized, rambling from one topic to another; he wanted to leave the psych unit immediately. He had a flat affect (lack of emotional response), was depressed, and his impulse control and judgement were impaired.The GACH Psychiatric Aftercare Plan dated August 6, 2015, indicated Resident 3 was being discharged to the SNF for "gravely disabled adult." There was no plan indicated because it was blank. The form was signed by the GACH discharge planner.Resident 3 was admitted to the SNF on August 7, 2015, with diagnoses that included paranoid schizophrenia (false beliefs that a person or some individuals are plotting against them or members of their family), depression, muscle weakness, and difficulty walking.The Elopement/Wandering Risk Assessment dated August 7, 2015, indicated Resident 3 was assessed at high risk for elopement. There was no immediate care plan developed to incorporate the available GACH information to provide a safe environment and to prevent Resident 3 from eloping from facility. There was no indication the resident's primary physician was contacted to obtain an order for a Wanderguard bracelet, there was no bracelet applied to the resident for his immediate safety, and there was no indication that 1:1 supervision had been considered or provided for the resident's safety, as indicated in the facility's Elopement Prevention Program policy.A review of the Nurse's Notes dated August 8, 2015, at 6 a.m., indicated Resident 3 wanted to call the cab and leave to go home. The notes indicated the resident walked out of the facility towards the main street and that staff were unable to stop him. According to the IDON, as of August 13, 2015, Resident 3 had not been located. On August 13, 2015, at 4:30 p.m., a review of the Resident Census and Conditions of Residents form completed by the facility, under Mental Status, indicated: 57 residents had documented psychiatric diagnosis excluding dementia and depression; 18 residents had dementia or Alzheimer's disease (type of dementia that causes memory, thinking and behavior problems); 20 residents had behavioral healthcare needs, and of the 20 residents, 4 had a behavioral care plan to support them; 11 residents had depression; and 5 were receiving health rehabilitative services for mental illness. On August 14, 2015, at 11 a.m., an interview was conducted with the administrative staff including the new Administrator, Assistant Administrator (AA), Interim DON (IDON), and the new Staff Developer. It was stated they had no record of Resident 2 or Resident 3 eloping from the facility. There was no record that the elopements were reported to the Department of Health. The AA stated that staff are supposed to inform administration when a resident is missing or elopes from the facility. A review of the Incident Log from February 2015 to August 9, 2015, indicated no documented evidence that Resident 2 or Resident 3 were included on the log. The AA was asked how Resident 1 and 2 were able to elope from the facility without staff intervention, or how they got out of the facility. She stated they were not able to determine how the residents wandered out of the facility. The AA was asked why Resident 3 was allowed to leave the facility unassisted, or why staff didn ' t attempt to stop him from leaving. She stated they couldn ' t stop him. During the administrative interviews, training records were requested with regards to how to handle residents with behavioral problems, residents who were at a high risk for elopement or wandering, or dementia-related training. And, when requesting interviews with staff who were employed at the time of Resident 2's elopement, the administrative staff stated the DON, administrator, staff developer, MDS (assessment) coordinator, admissions coordinator, and the registered nurse supervisor, had all resigned, including the staff developer. Therefore interviews could not be conducted, and no training records were available to provide. There was also missing clinical information regarding the elopements of Resident 2 and Resident 3. , which could not be provided because of inability to locate the information.On August 14, 2015, at 11 a.m., the Administrator was asked what the protocol was for admitting residents with psychiatric diagnoses and/or dementia, or wandering tendencies, and providing safety to them. He stated he was recently employed, and was still getting acquainted with the resident population. Three attempts were made to conduct an interview with the new admission coordinator (AC2), with the assistance of the Administrator, however AC2 was either not available or not there.On August 14, 2015, at 5 p.m., during a reinspection to ensure the facility's exit doors and alarm systems were operable, accompanied by the MS, the NE exit door Wanderguard system had been disarmed (by an unknown employee). When the MS attempted to reset the system, it wouldn't work. He stated the staff disabled the system all of the time when going in and out of the door with the laundry barrels; he stated this may be why it stopped working. The MS said it was the wiring, and began work on the system/door. At approximately 6:00 p.m., the NE and NW alarms/systems were operable. A review of the facility's policy and procedure dated May 2011, revised May 2014, titled "Elopement Prevention Program" , indicated residents identified at risk for elopement will have a plan of care implemented to maintain the highest practicable level of mobility and psychosocial well-being while maintaining the "safety and security" of the resident. Other interventions could include a Wanderguard bracelet, 1:1 (one to one) supervision, secured unit placement, family intervention, and environmental assessment.Therefore, the facility staff failed to provide supervision, operable doors and/or door alarms, and assistive devices to prevent serious harm from accidents and injuries, by failing to: 1. Provide adequate supervision to residents with known wandering or elopement risks, or dementia as identified by the facility, to protect them from elopement and injury, when the Wanderguard system and/or the exit door was inoperable; and 2. Provide safety to all residents by securing two of five exit doors with an operable Wanderguard system and/or operable alarm, to prevent them from leaving the facility unsupervised. The facility nursing staff had assessed and identified 22 residents as being at risk for elopement or wandering from the facility. Three of three discharged residents (1, 2, 3), who were unable to care for themselves because of impaired mental abilities, eloped (left without supervision) from the facility. Two residents were located by law enforcement (1, 2); the third resident (3) has never been located.This violation presented imminent danger of death or serious harm, or the substantial probability of death or serious physical harm to all residents with wandering tendencies or dementia-related cognitive disabilities. |
| 920000018 |
Griffith Park Healthcare Center |
920011782 |
B |
13-Oct-15 |
SRZF11 |
5501 |
483.12. (b) (1) & (2) Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.483.12 (b) (3) 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 9/18/15, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint related to the facility?s refusal to readmit Resident 1. Based on interview and record review, the facility failed to implement its bed-hold and readmission policy by failing to: 1. Provide Resident 1, at the time of transfer to a general acute care hospital (GACH) for evaluation, a written notice specifying the duration of the bed-hold policy during which the resident was permitted to return.2. Allow Resident 1 to return to the facility after the hospitalization leave exceeded the seven day bed hold. On 8/26/15, Resident 1 was transferred to a GACH for evaluation and upon transfer the facility did not provide the resident with a written notice specifying the duration of the bed-hold policy. On 9/4/15, when the resident was being discharged from the GACH, after seven days of leave, the facility refused to readmit Resident 1. Resident 1 not been able to return the facility of Resident 1?s preference and had a longer stay in the GACH.On 9/15/15, at 3:26 p.m., during a telephone interview, Resident 1 stated she was transferred to the acute hospital on 8/26/15 and was not provided with a notice of bed hold and the facility refused to readmit her. Resident 1 also stated she wanted to go back to the facility and was upset since she had no other place to go. On 9/18/15, a review of the clinical record disclosed Resident 1 was initially admitted to the facility on 12/15/14 and readmitted on 7/2/15, with diagnosis including hypertension and schizophrenia (a brain disorder in which people interpret reality abnormally). The Quarterly Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 7/10/15 indicated Resident 1 had no memory problems, was independent in cognitive skills for daily decision-making, required a walker and wheelchair as mobility devices to get around. The resident was assessed as having physical and verbal behavioral symptoms towards others. A review of the nursing note dated 8/26/15, at 8:45 a.m., indicated Resident 1 was noted with episodes of agitation and physical aggression, screaming, uncontrollable and attempting to hit other residents. At 11 a.m., the physician was notified and ordered to contact the crisis team to evaluate the resident. At 4:50 p.m., the crisis team arrived. At 5:30 p.m., the resident left the facility transported by the psychiatric emergency team (PET) to a GACH for evaluation.Further record review disclosed no evidence the facility provided the agency with a written notice of the bed hold. Upon discharge, there was no physician order indicating to hold the bed for seven days. Resident 1 was ready for discharge from the GACH on 9/4/15, but the facility refused to readmit. Resident 1 remained in the GACH and filed a readmission appeal.On 9/14/15, a Refusal to Readmit Appeal was conducted by the California of Department of Health Services Office of Administrative Hearing. The Appeals Decision Order dated 9/17/15 indicated the facility failed to offer Resident 1 a written bed-hold notice and failed to readmit the resident to the first available bed.On 9/18/15, at 4 p.m., during an interview, the administrator and director of nursing (DON) stated they would not readmit the resident because of the resident's history of abusive behaviors. A review of the facility's policy and procedure on Bed-Hold, dated 1997, indicated the facility must inform the resident, in writing of their right to exercise this bed hold upon admission and upon transfer to a general acute care facility or therapeutic leave. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. The policy also indicated the facility shall allow a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period (seven days), to be readmitted to the facility immediately upon the first availability of a bed in a semi-private room provided the resident still requires the services provided by the facility.The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000018 |
Griffith Park Healthcare Center |
920011836 |
A |
4-Oct-16 |
9TXR11 |
10653 |
F323 42 CFR 483.25(h) Accidents The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents. F325 42 CFR 483.25(i)(2) Nutrition Based on a resident's comprehensive assessment, the facility must ensure that a resident - (2) Receives a therapeutic diet when there is a nutritional problem. The facility failed to ensure Resident 1 was provided supervision and assistance with eating, and received a therapeutic pureed diet (mashed potato-like consistency) in a form that was safe and was ordered by the physician. Resident 1, who had a swallowing problem, required supervision and assistance with eating, and was prescribed a pureed diet with thickened liquids, was given a whole banana for a snack. When left unsupervised, he choked on the banana and subsequently died at the facility. On November 17, 2014, the Department of Public Health received an Entity Report Incident indicating Resident 1 was found in distress with a peeled banana next to him. Facility staff began life saving measures and called 911. The paramedics arrived and continued the life saving measures. Resident 1 was pronounced dead by the paramedics on November 17, 2014 at 11:16 a.m. According to the medical record, Resident 1 was originally admitted to the facility on October 17, 2009, and readmitted to the facility on October 17, 2014. He had diagnoses that included dysphagia (difficulty swallowing), head injury, abnormal posture, and confusion. Resident 1 also had Parkinson's disease, a movement disorder that affects the arms, legs, and head, which gets worse over time. A review of Resident 1's physician orders dated October 17, 2014, indicated to crush all crushable medications and give with applesauce. A physician order dated October 23, 2014 was to give a pureed pudding-thickened diet. A Comprehensive Resident Assessment dated October 17, 2014, indicated Resident 1 required assistance with eating. Duplicate care plans were developed October 17, 2014, October 22, 2014, and November 10, 2014, for Resident 1's risk for weight loss and alteration in nutritional status due to broken and missing teeth, difficulty swallowing, and being on a therapeutic pureed (mashed-potato consistency) diet. The interventions included providing Resident 1 cueing and encouragement during meals, setting up the resident's food tray, assisting him and giving verbal cues. The resident was also placed on a special nutritional program, and staff were to ensure optimal positioning (sitting up-right when eating to promote safety); resident was on thickened liquids (pudding-like consistency). A care plan dated October 17, 2014, indicated Resident 1 had a potential for respiratory distress related to acute respiratory failure manifested by shortness of breath, and distress. The intervention was to monitor the resident for abnormal breathing patterns and to position him for optimum comfort. A care plan dated October 17, 2014, indicated the concern of altered cognitive functioning manifested by impaired decision-making and the inability to understand others. He also had trouble focusing on what was being said. The interventions included frequent prompting and cueing during activities. An Interdisciplinary Team Conference dated October 18, 2014, under nutritional support/weight management indicated Resident 1 was on a pureed no added salt diet with pudding-thick liquids. A History and Physical Examination dated October 20, 2014, indicated Resident 1 did not have the capacity to understand and make decisions. The Medical Nutritional Therapy Recommendations or Comments dated October 23, 2014, indicated Resident 1 was to get double portion at lunch time, and to provide pudding thickened liquids. A review of a Minimum Data Set (MDS - a resident assessment and care screening tool), dated November 8, 2014, indicated Resident 1 was not able to perform his activities of daily living, which included eating, without significant physical assistance. The resident's swallowing problem was not identified on the MDS. The Interdisciplinary Weight Management care plan for Resident 1 dated November 10, 2014, indicated the problem of altered nutritional status manifested by the resident's medical condition. The approach indicated to assist the resident with eating and tray set-up as needed. The Nurses Notes dated November 17, 2014, at 7:30 a.m., indicated Resident 1 was fed by a CNA (Certified Nursing Assistant) in bed with the head of the bed up at 45 degrees. The Notes also indicated Resident 1 was on aspiration precautions (to prevent inhaling of liquids or objects into the lungs). The Notes indicated Resident 1 ate 100 percent of his food and had a good appetite. The Nurses Notes dated November 17, 2014, at 10:45 a.m. indicated the Activity Director found Resident 1 in distress. The registered nurse (RN 2) was informed, went to the activities room and found Resident 1 grunting; there was an open banana located next to him on the table. A blind sweep (check of the mouth) was done and nothing was found. The resident became cyanotic (blue in color due to lack of oxygen) and the Heimlich maneuver (emergency procedure for dislodging/removing foreign particles from the mouth) was initiated. Resident 1 coughed out a small piece of banana. The Nurses Notes dated November 17, 2014, at 10:50 a.m. indicated Resident 1 was unresponsive and transferred to the nearest vacant room, where life-saving measures of Cardio Pulmonary Resuscitation (CPR) were initiated. A licensed nurse called 911, and at 10:55 a.m., paramedics arrived and took over the CPR procedures. At 11:16 a.m., the paramedics pronounced Resident 1 expired. A statement written by Physical Therapist Assistant 1 (PTA 1), dated November 17, 2014, indicated after walking together, Resident 1 asked for a banana. PTA 1 asked the Rehabilitation Technician (RT 1 ) if she would get a banana for the resident. RT 1 got PTA 1 the banana and PTA 1 placed the unpeeled banana on the table in front of Resident 1, who was sitting in the activity room. PTA 1 then left to look for personnel to help Resident 1 eat the banana because PTA 1 had to be in the Rehabilitation room. The Activity Director came and told PTA 1 Resident 1 was in distress, and when PTA 1 went to the activity room, he saw the Restorative Nursing Assistant (RNA 1) and the registered nurse (RN 2) performing the Heimlich maneuver on Resident 1. Resident 1 was unresponsive, and PTA 1 helped the nurses transfer Resident 1 to a bed; nurses started CPR and continued until 911 paramedics arrived and took over the CPR procedures. The written statement by RT 1 dated November 17, 2014, indicated Resident 1 was getting physical therapy. After therapy, Resident 1 would occasionally ask for a banana, and as a positive reinforcement he would be given one. RT 1 stated PTA 1 asked her to go to the kitchen to get a banana for Resident 1, which she did, and gave the banana to PTA 1. The Interview Record written by Licensed Vocational Nurse 1 (LVN 1) on November 17, 2014, at 2 p.m., indicated at around 10:50 a.m., he went to the dining room and saw Resident 1 with four staff performing the Heimlich maneuver. He assisted the staff in bringing the resident to the nearest vacant room. The resident was already unresponsive, pale, and not breathing. Before starting CPR, the staff checked Resident 1's mouth and found small chewed particles and saliva. The Interview Record written by Activity Director 1 (AD 1), dated November 18, 2014, at 12:50 p.m., indicated at 10:10 a.m., Resident 1 was given coffee with thickener, and no cookies as part of his activity. At 10:20 a.m., a physical Therapy Technician came to pick up the resident for Rehabilitation in stable condition. At 10:40 a.m., Resident 1 was placed back in the activity room near the piano with a peeled banana. She also saw a little piece of banana on the floor. She went to ask Resident 1 how he was doing, and then he appeared to clear his throat three times. She indicated the resident's tongue was protruding through his lips. He was pale, his hands were on the table, but he was not gasping for breath. At 10:41 a.m., AD 1 called RN 2 who initiated an oral cavity (mouth) sweep and the Heimlich maneuver. Resident 1 was then transferred to a room, and CPR was initiated by RN 2 and LVN 1. An Interview Record written by a kitchen dishwashing staff, dated November 17, 2014, at 2:00 p.m., indicated he was asked by therapy staff for a banana, and he gave the staff a banana. In an interview with the MDS nurse while reviewing Resident 1's medical record on November 19, 2014, at 1:20 p.m., she stated that Resident 1 was assessed with difficulty swallowing. In an interview with the Dietary Services Supervisor on November 19, 2014, at 1:40 p.m., he stated Resident 1 is on a special diet. He stated Resident 1 can have a banana but, "we have to mush it." During an interview with PTA 1 on November 19, 2014, at 4 p.m., he stated on the day of the incident he took Resident 1 to the activities room and set him at the table closest to the television. He put a peeled banana in front of Resident 1. In an interview with the Director of Nurses, held November 19, 2014, she stated Resident 1 should never have been given a banana. In an interview with the Administrator on November 19, 2014, at 5:35 p.m., she stated during her investigation of this incident, she found out the staff had given Resident 1 a banana for positive reinforcement. When asked when this occurred, she said she didn't know how many times this had occurred. The Certificate of Death indicated the immediate cause of death was cardiorespiratory arrest for minutes, and sudden cardiac death for minutes. Therefore, the facility failed to ensure Resident 1 was provided supervision and assistance with eating, and received a therapeutic pureed diet (mashed potato-like consistency) in a form that was safe and was ordered by the physician. Resident 1, who had a swallowing problem, required supervision and assistance with eating, and was prescribed a pureed diet with thickened liquids, was given a whole banana for a snack. When left unsupervised, he choked on the banana and subsequently died at the facility. The violation of the 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 to Resident 1. |
| 920000018 |
Griffith Park Healthcare Center |
920011926 |
B |
31-Dec-15 |
DNJT11 |
5420 |
F32342 CFR 483.25(h) The facility must ensure that-- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide a safe environment, adequate supervision and assistive devices to prevent a resident (1) from leaving the facility unassisted. Resident 1, who was assessed at risk for elopement (leave unattended) and was wearing a wander guard device (alerts staff by alarming when the resident attempts to exit the facility), left the facility unsupervised on December 3, 2013, and was never located. The Department received and investigated an entity reported incident (ERI CA00393136) regarding Resident 1?s elopement. A review of the facility's ERI report indicated Resident 1 was alert and oriented times 3 with periods of confusion and disorientation. Resident 1 was able to make her needs known, required assistance with her care, ambulated with a steady gait, but did not have the capacity to understand and make decisions. There was no indication the facility had completed a thorough investigation into the elopement of Resident 1. According to the admission information, Resident 1 was admitted to the facility on October 17, 2013, with diagnoses that included high blood pressure and schizophrenia (a chronic, severe, and disabling brain disorder). The Elopement/Wandering Risk Assessment form dated October 18, 2013, indicated Resident 1 was admitted from a locked facility and was at risk for elopement. The physician's orders dated October 18, 2013, at 9 a.m., indicated Resident 1 may have a wander guard bracelet on her right or left hand to prevent her from leaving the facility unattended and check the wander guard every shift.Resident 1?s care plan for ?at risk for elopement and wandering out of the facility? dated October 18, 2013, indicated Resident 1 was at risk for elopement and wandering due to refusing to wear the wander guard. The interventions included to gently redirect the resident back to supervised areas, wander-guard bracelet, check alarm for functioning, visual checks by staff, and allow the resident to move around the hallways safely. There was no indication how often the visual checks were to be done, who was responsible for the checks, or alternative means for ?supervision? other than the wander guard to ensure the resident was protected and prevented from leaving the facility unsupervised.Resident 1's physician order dated October 18, 2013, at 9:30 a.m., indicated the nurses were to discontinue the wander guard order due to the resident refusing to wear it. There was no documentation indicating other consistent interventions for supervision were implemented to protect Resident 1 from elopement after ?refusal? to wear the wander guard bracelet, in accordance with the care plan.The History and Physical Examination form completed by the physician dated November 19, 2013, indicated Resident 1 did not have the capacity to understand or make decisions.The Nurses' Notes dated December 4, 2013, at 10:15 p.m., indicated Resident 1 was, "nowhere to be found". According to the notes, the registered nurse supervisor (RN-A) last saw the resident at 9 p.m. that evening. The staff searched the facility and could not find the resident. The police were called and they came to the facility and took a report. Resident 1's physician and conservator were informed of Resident 1's elopement. On April 14, 2014, at 3 p.m. during an interview, RN-A said the day of the elopement, Resident 1 had her wander guard on her wrist. He noticed the resident was missing at dinner time around 5:30 p.m. He stated if the residents tried to elope using the front door, the staff can hear the alarm. RN-A said if a resident tries to leave using the back door, if the resident knows the code to the door (from watching the staff) the alarm would not sound. When asked if the facility changes the code periodically, he stated he didn't have any idea, that it was the maintenance supervisor's responsibility. He was unable to explain how Resident 1 was able to leave the facility unnoticed. During an interview on April 14, 2014, at 3:30 p.m., the licensed vocational nurse (LVN-B) charge nurse, stated on the day Resident 1 eloped, he was passing medication around 5:30 p.m. and saw the certified nursing assistant (CNA-C) put Resident 1's dinner tray in her room. LVN-B last saw Resident 1 walk from the smoking area to her room. LVN-B stated CNA-C told him when she went to pick up Resident 1's dinner tray, it had not been touched, and said Resident 1 was missing. Several staff went looking around the facility and drove around the area, but did not locate Resident 1.As of December 28, 2015, there had been no update as to Resident's 1 location.The facility failed to provide a safe environment, adequate supervision and assistive devices to prevent a resident (1) from leaving the facility unassisted. Resident 1, who was assessed at risk for elopement (leave unattended) and was wearing a wander guard device (alerts staff when attempting to leave the facility), left the facility unsupervised on December 3, 2013, and was never located. The above violation had a direct relationship to the health, safety and security of all residents at risk for elopement, including Resident 1. |
| 920000018 |
Griffith Park Healthcare Center |
920011927 |
B |
31-Dec-15 |
DNJT11 |
4688 |
F32342 CFR 483.25(h) The facility must ensure that-- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide a safe environment, adequate supervision and assistive devices to prevent Resident 2 from leaving the facility unassisted. Resident 2, who was assessed at risk for wandering from the facility and was wearing a wander guard device (alerts staff by alarming when the resident attempts to exit the facility), left the facility unsupervised on March 30, 2014.The Department received and investigated an entity reported incident (ERI CA00393577) regarding Resident 2?s elopement and return to the facility by the police department. According to the admission record, Resident 2 was readmitted to the facility on January 6, 2014, with diagnoses that included schizoaffective disorder (a mix of mental health conditions, including schizophrenic and mood disorder features), bipolar disorder (serious mental illness characterized by extreme changes in mood, from mania[highs] to depression [low], that can lead to risky behavior and even suicidal tendencies), and dementia (a brain condition that causes problems with thinking and memory).Resident 2's care plan dated January 23, 2014, indicated she was at risk for elopement (leaving unaccompanied) and wandering out of the facility due to a history of wandering. The interventions included wearing a wander guard bracelet, redirect the resident to supervised areas, and provide activities that will divert the resident's attention from wandering. The History and Physical Examination form dated January 24, 2014, completed by the physician, indicated Resident 2 did not have the capacity to understand and make decisions. The Nurses' Notes dated March 30, 2014, indicated Certified Nursing Assistant D (CNA-D) informed the charge nurse [licensed vocational nurse (LVN-E)] at 5:25 a.m. that Resident 2 was missing. The staff checked the facility room by room. Some staff drove around the area looking for Resident 2. The police were called at 5:50 a.m. At 8 p.m., the facility received a call from the Sheriff?s Department that they found Resident 2 in a department store in Los Angeles. Resident 2 was returned to the facility by the Police Department.On April 24, 2014, during an interview, Resident 2 stated she left the facility because she wanted to go to the bank to get money to buy new glasses and dentures. She had upper dentures but no lower dentures. The resident also said she wanted to find a better place to live because she didn't like it at the facility. Resident 2 stated she left the facility through the back door. During an interview with CNA-D on July 28, 2014, at 11:45 a.m., he stated on the day of that Resident 2 eloped from the facility, he last saw her in the lobby around 5 a.m., and she was dressed up. He asked her where she was going, and she said she had to get out of the facility. CNA-D said he tried to talk her into going back to her room. CNA-D said he left her in the lobby because another resident had the call light on and he went to check on that resident. Afterwards he heard the alarm sounding, and went to Resident 2's room to check on her but she was not there. He reported this to LVN-E. They both went searching for Resident 2 inside the facility and in the neighborhood, but were not able to locate her. They called the police. CNA-D stated Resident 2 had eloped from the facility ?many times.?CNA-D was unable to explain how Resident 2 was able to leave the facility. There was no documented evidence that staff ensured Resident 2 was redirected to a supervised area, or provided activities to divert the resident's attention from wandering as indicated in her care plan. There was no documented evidence that staff, including CNA-D, provided supervision to prevent Resident 2 from eloping, even after the resident stated she was leaving the facility. There was no documented evidence Resident 2's care plan was revised to include approaches to keep her safe and from eloping from the facility. The facility failed to provide a safe environment, adequate supervision and assistive devices to prevent Resident 2 from leaving the facility unassisted. Resident 2, who was assessed at risk for wandering from the facility and was wearing a wander guard device (alerts staff by alarming when the resident attempts to exit the facility), left the facility unsupervised on March 30, 2014. The above violation had a direct relationship to the health, safety and security to Resident 2. |
| 920000055 |
Grand Valley Health Care Center |
920012181 |
B |
14-Apr-16 |
8RGX11 |
6934 |
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.On April 6, 2016, an unannounced visit was made at the facility to investigate complaint allegations involving the care of Resident 1. Based on record review and interview, the facility staff failed to: 1) Ensure Resident 1 had a bowel movement (BM) at least every 3 days.2) Implement Resident 1's care plan, to prevent the development of constipation (bowel movement that is infrequent and hard to pass) when the resident did not have a BM for 3 days. Resident 1 was diagnosed with constipation after not having BM for 6 days, from 6/22/15 to 6/27/15. The resident had to receive laxatives (medicine that loosens the bowel contents and encourages bowel movement), stool softeners, and required manual removal of accumulated stool in his rectum.A review of Nurse Practitioner (NP) 1's, Initial NP Visit note dated 6/20/15, indicated Resident 1 was admitted to the facility on 6/19/15, from General Acute Care Hospital (GACH) 1. Resident 1's diagnoses included history of heart attacks, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), protein calorie malnutrition, and metabolic encephalopathy (alteration of brain function due to other body organ failures). Resident 1's medications included: Flomax (medication to increase urination), Plavix (medication to prevent blood clotting), and Proscar (medication to treat enlarged prostate).No laxatives were ordered for Resident 1 on admission.A review of Resident 1's initial Minimum Data Set (standardized assessment form) dated 6/26/15, indicated Resident 1 was incontinent (inability to control ) of bowel and bladder, and required extensive assistance with one-person physical assist for toilet use. Resident 1 required extensive to total dependence on staff for bed mobility, transferring, locomotion, and walking. A review of Resident 1's Nutrition and Hydration Risk Assessment dated 6/19/15, indicated Resident 1's medications included heart medications and laxatives. There were no laxatives ordered for Resident 1 on admission. A review of Resident 1's care plan goal for risk of constipation due to decreased mobility and decreased intestinal motility related to aging process dated 6/19/15, was for Resident 1 to have bowel movement (BM) at least every 3 days in 90 days. The care plan interventions included: Give adequate fluids. Monitor and record BM every shift. Monitor BM for amount and frequency. Give laxatives as ordered or as needed. Assess for impaction (a large lump of dry, hard stool stuck in the rectum) and extract stool as ordered. A review of Resident 1's certified nurse assistant (CNA) flowsheet dated 6/21/15, indicated Resident 1 had medium size BM during the 3:00 p.m. to 11:00 p.m., shift. There was no documentation that Resident 1 had a BM until 6/28/15, during the 7:00 a.m. to 3:00 p.m. shift. There was no documentation that the CNA had informed the licensed nurses that Resident 1 did not have a bowel movement, three days after 6/21/15.A review of Resident 1's Medicare Skilled Documentation, Licensed Nurse Record indicated the following: 1. 6/21/15- last BM 6/21/15. 2. 6/22/15- last BM 6/21/15. 3. 6/23/15- last BM 6/21/15. 4. 6/24/15- no documentation of last BM. There was no documentation the physician was informed that Resident 1 did not have a BM for 3 days. There was no documentation of nursing interventions implemented to stimulate the resident to have a BM, like the need to administer laxative and provide adequate fluids.5. 6/25/15- no documentation of last BM. There was no documentation the physician was informed that Resident 1 did not have a BM for 4 days. There was no documentation of nursing interventions implemented, like assessing for the need to administer laxatives and to check for impaction.6. 6/26/15- last BM 6/21/15. There was no documentation the physician was informed that Resident 1 did not have a BM for 5 days. There was no documentation of nursing interventions implemented, like assessing for the need to administer laxatives and to check for impaction.7. 6/27/15- last BM 6/21/15.A review of Resident 1's physician's orders dated 6/27/15, at 11:25 a.m., indicated to administer: Milk of Magnesia (laxative) 45 milliliters now and repeat in 2 hours if no BM. Give Dulcolax (laxative) 10 milligram (mg) suppository per rectum and give every other day as needed for constipation. Docusate sodium (stool softener) 250 mg one capsule daily and Lactulose (laxative) 30 mg daily as needed for constipation. A review of NP 2's Visit and Patient Information notes dated 6/28/15, indicated the following: "Records reviewed and noted resident did not have a BM since 6/21/15, asked nurse to give 30 ml of Lactulose yesterday and ordered additional medications for constipation. Rectal exam done and the resident's rectum was full of hard stool. Disimpacted the resident. Still had stool higher in the rectum. Enema ordered and repeat Lactulose dose and add Miralax (laxative) 17 grams added to the bowel regime." A review of Physician 1's Visit and Patient Information notes dated 6/29/15, indicated the following: Constipation (primary encounter diagnosis) Status post disimpaction yesterday, moderate amount, residual stool was palpated at the superior pole of the rectum but beyond good reach. Status post enema and laxatives, BM this morning. Resident 1 single elevated blood test, BUN (blood urea nitrogen) (a test to check kidney function) is slightly elevated and is more likely to do with the constipation than dehydration. On 4/6/16, at 2:30 p.m., an interview was conducted with Employee 1 (director of nurses). Employee 1 stated the CNA were to notify the charge nurse if any resident did not have a BM for three days. The charge nurse would inform the physician and they would be placed on bowel management program, which would include starting the resident on laxatives or stool softeners. Employee 1 stated the licensed nurses should have noticed Resident 1 did not have a BM after 3 days, when they were completing their daily Medicare documentation. The facility staff failed to ensure Resident 1 had a bowel movement (BM) at least every 3 days, and failed to implement Resident 1's care plan, to prevent the development of constipation, after not having BM for 6 days, from 6/22/15 to 6/27/15. Resident 1 had to receive laxatives (medicine that loosens the bowel contents and encourages bowel movement), stool softeners, and required manual removal of accumulated stool in his rectum.This violation had a direct relationship to the health and safety of Resident 1. |
| 920000055 |
Grand Valley Health Care Center |
920012182 |
B |
14-Apr-16 |
8RGX11 |
7052 |
483.25(i) Maintain Nutrition Status Unless Unavoidable Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.On April 6, 2016, an unannounced visit was made at the facility to investigate complaint allegations involving the care of Resident 1. Based on record review and interview, the facility failed to implement the care plans for nutrition and dehydration for Resident1 and follow its policy and procedure on documenting meal intake by failing to: 1. Ensure the certified nursing assistants informed the licensed nurses of Resident 1's intake of less than 75% for three consecutive meals. 2. Ensure the licensed nurses monitored Resident 1's intake and initiate interventions to improve Resident 1's intake. Resident 1 had a weight loss of 6 pounds (lbs.), from 146 lbs. to 140 lbs. in five days.A review of Nurse Practitioner (NP) 1's, Initial NP Visit note dated 6/20/15, indicated Resident 1 was admitted to the facility on 6/19/15, from General Acute Care Hospital (GACH) 1. Resident 1's diagnoses included history of heart attacks, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), protein calorie malnutrition, and metabolic encephalopathy (alteration of brain function due to other body organ failures).A review of the initial Minimum Data Set (standardized assessment form) dated 6/26/16, indicated Resident 1 required supervision and set-up help only for eating. The active diagnoses included malnutrition or at risk for malnutrition (condition in which the body does not receive enough nutrients). Resident 1's height was 5 feet 6 inches and weight was 146 lbs. and had no weight loss of 5% or more in the last month or 10% or more in the last 6 months.A review of Resident 1's physician's orders dated 6/19/15, indicated the physician ordered mechanical soft cardiac diet and weekly weight for 4 weeks. On 6/20/15, the physician ordered: Hydration rounds (the resident will be offered extra fluids at every medication pass and nourishment times at 10:00 a.m., 2:00 p.m., and 8:00 p.m.), offer high protein nourishment (HPN) twice a day between meals, Pro-stat SF (protein supplement sugar free) 30 milliliters (ml) daily, and a speech therapy for swallowing evaluation. On 6/26/15, the physician discontinued previous nourishment order and ordered Boost (nutritional supplement) 120 ml three times a day and Pro-Stat SF (nutritional supplement) 30 ml twice a day. A review of Resident 1's care plan for risk for dehydration dated 6/19/15, indicated the goals included the resident will consume 75-100% of meals. The care plan interventions included: encourage resident to consume 75-100% of meals and monitor resident's intake and weights.A review of Resident 1's nutrition care plan dated 6/24/15, indicated the goals were for the resident to consume at least 75% of all meals and maintain planned weight between 140-150 lbs. The care plan interventions included: encourage the resident to consume 75% of meals, assist the resident at meal times as needed, offer substitute food, and monitor weight, lab results and appetite. A review of Resident 1's Nutritional Screening and Assessment dated 6/24/15, indicated: Resident 1's set weight goal was 140-150 lbs. Resident 1's ideal body weight was 137-147 lbs. Resident 1's albumin (blood protein) level was 2.8 grams/deciliter (normal 3.5-5 grams/deciliter, below normal reflects poor nutritional status). The goal was weight loss prevention as the resident is eating below standard needs. A review of Resident 1's CNA flowsheet indicated the following: 1. On 6/20/15, Resident 1 consumed only 60% of all three meals. 2. On 6/22/15, Resident 1 consumed 30% of lunch, 50% of dinner, and on 6/23/15, 60% of breakfast, and 40% of lunch (4 consecutive meals). 3. On 6/24/15, Resident 1 consumed 70% of breakfast, 70% of lunch, and 60% of dinner.4. On 6/27/15, Resident 1 consumed 30% of breakfast, 55% of lunch, and 40% of dinner. On 6/28/15, Resident 1 consumed 30% of breakfast, 30% of lunch and 60% of dinner. On 6/29/15, Resident 1 consumed 30% of breakfast, 40% of lunch, and 60% of dinner (9 consecutive meals). A review of Resident 1's clinical record indicated there was no documentation the CNAs had informed the licensed nurses that Resident 1's meal consumption was less than 75% for three consecutive meals. A review of Resident 1's Medicare Skilled Documentation, Licensed Nurse Record indicated the following: 1. 6/20/15- Consumed 60% 2. 6/22/15- Consumed 50% 3. 6/24/15- Consumed 60% 4. 6/25/15- Consumed 60% 5. 6/25/15- Consumed 60% 6. 6/27/15- Consumed 30% 7. 6/28/15- Consumed 30-40% 8. 6/29/15- No documentation of amount consumed. There was no documentation on the above referenced licensed nurse records that the licensed nurses were monitoring their documentation and had notified the physician or dietician of Resident 1's poor intake, or had implemented any nursing measures to increase Resident 1's intake.A review of Resident 1's Weight Records, indicated on 6/19/15 and 6/24/15, Resident 1 weighed 146 lbs. On 6/29/15, Resident 1's weight had decreased to 140 lbs. (4.1% weight lost in 5 days).On 4/6/16, at 2:30 p.m., an interview was conducted with the Director of Nurses (Employee 1). Employee 1 stated that the CNA should have informed the licensed nurses if any resident consumes less than 75% of their meals and offer an alternative if they did not like the food that was offered. Employee 1 stated the licensed nurses should have been aware of Resident 1's poor intake on their daily charting. A review of the facility's CNA Documentation policy dated 4/2/01, indicated: The CNA would indicate the percentage ( %) that the resident eats for breakfast, lunch, and dinner. If the resident eats less than 75% of the meal, the resident will be offered a substitute. If the resident's total meal intake is less than 75% for three consecutive meals, it needs to be reported to the charge nurse. A review of the facility Weight Change Protocol (not dated) indicated: The following criteria define significant weight changes: 2% weight loss in one week. The facility failed to implement the care plans for nutrition and dehydration for Resident1 and follow its policy and procedure on documenting meal intake by failing to: 1. Ensure the certified nursing assistants informed the licensed nurses of Resident 1's intake of less than 75% for three consecutive meals. 2. Ensure the licensed nurses monitored Resident 1's intake and initiate interventions to improve Resident 1's intake. Resident 1 had a weight loss of 6 pounds (lbs.), from 146 lbs. to 140 lbs. in five days.This violation had a direct relationship to the health and safety of Resident 1. |
| 920000020 |
Glendale Post Acute Center |
920012243 |
A |
13-May-16 |
4ZSQ11 |
9685 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 1/5/16, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility resulting in a fractured (broken) hip.Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed as high risk for falls due to history of falls, physical limitations, unstable balance, medications, diagnoses, and in need of one-person physical assistance for transfer and walking, was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries, including but not limited to:1. Failure to provide the supervision and support of one-person physical assistance during transfer and ambulation as identified in the resident?s comprehensive assessment. 2. Failure to develop and implement interventions to prevent falls, prevent avoidable decline, and address and manage fall risk factors as per facility?s policy and protocols.As a result, on 12/23/15, while left unattended sitting in a wheelchair in the hallway, Resident 1 attempted unassisted transfer and walking and fell on the floor sustaining a fractured right hip. Resident 1 required transfer to a general acute care hospital (GACH) where on the same day of the fall, he underwent surgery under general anesthesia. In addition, Resident 1 suffered uncontrolled post-operative pain which resulted in an additional procedure of a right hip and thigh peripheral nerve block (an anesthetic agent is injected directly near the nerve to block pain).According to the Admission Face Sheet, Resident 1 was admitted to the facility on 2/6/15, with diagnoses including weakness, Alzheimer's disease (a disease that affects memory and other important mental functions, anxiety disorder (nervousness), and high blood pressure.The Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 2/19/15, indicated Resident 1 was alert, confused, had communication deficit, unsteady balance, required extensive assistance for ADLs such as transfers, walking, dressing, toilet use, and personal hygiene requiring the support from one-person physical assist. Resident 1 was receiving anti-anxiety medications. The Care Area Assessment (CAA) summary indicated Resident 1 triggered the Care Areas for ADL Functional/Rehabilitation Potential and the Care Area for Falls, which required the development of care plan with interventions addressing the care needs to ensure the resident?s safety. Further record review disclosed no documented plan of care addressing triggered ADLs and Falls Care Areas. According to the Fall Risk Assessments, dated 2/6/15, 5/15/15, 8/15/15, and 11/15/15, Resident 1?s score was 20, which represented high risk for falls. The form indicated a prevention protocol should be initiated immediately and documented on the care plan. However, the clinical record had no documented prevention protocol addressing the resident?s fall risk. According to the Licensed Personnel Progress Notes, dated 12/23/15, timed at 5:15 a.m., Registered Nurse 1 (RN 1) documented Resident 1 was reading sitting in a wheelchair in the hallway by the Nurses Station. RN 1 documented when she went inside the medication room she heard a sound and found Resident 1 on the floor in a sitting position. The notes indicated the resident was assisted back to bed by four staff members. Resident 1 complained of pain on the right hip and Tylenol 650 milligrams (mg) was given. The attending physician, when notified, ordered an x-ray of the right hip which was done the same day and the result received at 7:15 a.m., indicated right hip fracture. At 10 a.m., Resident 1 was transferred to a GACH for further evaluation. On 1/5/16, at 2:08 p.m., during a record review with the MDS coordinator and a concurrent interview, the MDS coordinator was unable to locate a care plan for fall prevention for Resident 1. The MDS coordinator stated residents at high risk for falls should have a care plan to ensure staff provides proper interventions to prevent falls and injury.On 1/5/16, at 2:30 p.m., during a review of Resident 1's clinical record with the Director of Nursing (DON) and a concurrent interview, the DON was unable to find a plan of care to prevent falls developed upon admission on 2/6/15 or after the MDS assessment was completed. There was a short-term care plan developed on 2/20/15, after Resident 1 sustained a fall with no injury with a goal for the resident to be free from future falls and be free from complications from falls for 30 days. The care plan approaches included to encourage the resident not to get up without assistance. The plan of care was not re-evaluated or revised after 3/20/15. The DON stated a care plan should have been initiated on admission and revised as needed.A review of the facility's policy and procedure titled, "Fall Risk Assessment Form," dated 5/2007, indicated if the total score was 10 or greater, the resident should be considered at high risk for potential fall and a prevention protocol was initiated and documented on the care plan.The facility's undated policy and procedure titled, "Care Plan," indicated the resident care plan must address the needs, strengths, and preferences of the resident as identified on the comprehensive assessment. Care plans should be oriented to prevention of avoidable declines in functioning or functioning levels. Care plans must show evidence of facility's effort to address or manage risk factors and care plans are to be reviewed, once every quarter (every 90 days) and whenever necessary, to assure the continued accuracy of the assessment.According to the undated Falls Prevention Program Interventions Guidelines, a system of identifying at risk residents is established and communicated to all facility staff. This provides an increased awareness and close monitoring by all staff. Confused, wandering, agitated residents are closely observed by all staff when up and about. Such residents are periodically assessed for mobility, gait and changes in physical and mental status. Residents with immobility problems are closely monitored by staff during transfer, while ambulating and during all exercises.A review of the GACH emergency department report, dated 12/23/15, timed at 10:41 a.m., indicated Resident 1 received Morphine (a controlled medication to treat moderate to severe pain) 4 mg.A review of the GACH Surgery and Procedure report dated the same day of the fall, 12/23/15, timed at 10:30 p.m., indicated Resident 1's preoperative and postoperative diagnosis was right hip fracture comminuted (break or splinter of the bone into more than two fragments), unstable displaced right hip intertrochanteric (the upper part of the femur or thigh bone) hip fracture. The resident underwent surgery under general anesthesia and a screw was used to fix the fractured hip (intramedullary hip screw fixation of the right hip and femur). A Procedure Report, dated 12/23/15, timed at 10:40 p.m., indicated Resident 1 experienced uncontrolled post-operative pain requiring an additional procedure, Right Fascia Illiaca (hip and thigh area) Peripheral Nerve Block (a procedure in which an anesthetic agent is injected directly near the nerve to block pain) performed for uncontrolled post-operative pain control.The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed as high risk for falls due to history of falls, physical limitations, unstable balance, medications, diagnoses, and in need of one-person physical assistance for transfer and walking, was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries, including but not limited to:1. Failure to provide the supervision and support of one-person physical assistance during transfer and ambulation as identified in the resident?s comprehensive assessment. 2. Failure to develop and implement interventions to prevent falls, prevent avoidable decline, and address and manage fall risk factors as per facility?s policy and protocols.As a result, on 12/23/15, while left unattended sitting in a wheelchair in the hallway, Resident 1 attempted unassisted transfer and walking and fell on the floor sustaining a fractured right hip. Resident 1 required transfer to a GACH where on same day of the fall, he underwent surgery under general anesthesia. In addition, Resident 1 suffered uncontrolled post-operative pain which resulted in an additional procedure of a right hip and thigh peripheral nerve block.The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 920000017 |
Glenoaks Conv. Hospital |
920012727 |
A |
21-Nov-16 |
GX5V11 |
10980 |
CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 483.25 (c) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that? (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. On 7/21/16, at 9:45 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s transfer to a general acute care hospital (GACH) due to low body temperature, sepsis (a clinical syndrome of life-threatening organ dysfunction, complication of an infection), and pressure sores. 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 that residents admitted to the facility with no pressure sore (a localized injury to the skin and / or underlying tissue, usually over a bony prominence, as a result of pressure), did not develop a pressure sore. The resident was identified as at risk for developing pressure sores, but was not provided with the necessary treatment and services to prevent pressure sores, and promote healing of pressure sore, including: 1. Failure to identify Resident 1?s newly developed pressure sore to the sacral (tailbone) area, skin breakdown to the perineal area (skin around the genitals), and a skin tear to the scrotum (skin covering the testicles). 2. Failure to conduct an ongoing accurate assessment of the resident?s skin condition to promptly identify the development of pressure sores. 3. Failure to implement Resident 1?s skin integrity problem plan of care, and to ensure any red areas or skin breakdown was reported to the physician. 4. Failure to implement the facility?s policy on Change of Condition to ensure proper assessment and promptly notifying the physician of any open or red areas, bruises, lacerations, or skin tears. As a result, on 12/30/15, Resident 1 was transferred to a GACH where he was found with a suspected deep tissue injury (SDTI ? skin injury, 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, a dangerous lesion due to its potential for rapid deterioration) to the resident's sacral area measuring seven centimeters (cm) in length by 10 cm in width. Resident 1 was also found to have a large red perineal excoriation (skin scrape), and a skin tear (break) to the scrotum. A review of the clinical record indicated Resident 1 was admitted to the facility on 12/7/15, with diagnoses including Alzheimer's disease (a type of dementia that causes problems with memory, thinking and behavior) and polyneuropathy (nerve damage affecting several areas such as feet and hands). According to the nursing admission assessment the resident had no skin tears or pressure sores at the time the resident was admitted. A review of the plan of care dated 12/7/15, developed for the resident?s potential impairment of skin integrity related to bowel and bladder incontinence (inability to control urine and bowel movements), edema (swelling), decreased mobility, skin fragility, impaired cognition, and use of diuretics (water pill) indicated goals for the resident to be free from tissue injury and skin breakdown daily. The care plan interventions included reporting to the physician swelling, redness, skin tears, bruises, and discoloration of the skin. A review of Resident 1's Braden Scale ?For Predicting Pressure Sore Risk dated 12/7/15, which included assessment of the resident?s sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The assessment indicated the resident scored 20, representing a low risk for developing a pressure sore. A total score of 12 or less represents a high risk. Another plan of care dated 12/8/15, developed for the resident?s risk of skin breakdown related to resident needing extensive assistance with bed mobility indicated the goal for the resident was to have no skin breakdown. The interventions included monitoring the skin for red areas or skin breakdown and to notify physician if any breakdowns occur. The care plan was in contradiction to the Braden Scale assessment form which indicated Resident 1 had no limitation for mobility and had no apparent problem with moving in bed or chair. A review of Resident 1's initial History and Physical Examination completed and signed by Physician 1 on 12/8/15, indicated the resident had no skin lesions and did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 12/18/15, indicated the resident had the ability to express ideas, needed ?extensive assistance / max physical help,? with bed mobility which included two-person physical assistance for bed mobility and transfers. The MDS indicated under skin conditions, Resident 1 was at risk for developing pressure sores. In addition, the MDS was in contradiction to the Braden Scale assessment form, completed by a licensed registered nurse, which indicated the resident had no limitation in mobility and no apparent problem in moving in bed independently. The weekly Non-Pressure Sore forms from 12/7/15 through 12/30/15, had no documentation the resident had pressures sores or skin breakdown. A review of a Body Check Assessment dated 12/30/15, indicated the resident was assessed with pitting edema (observable swelling of body tissues due to fluid accumulation) to both lower extremities (legs). No other skin condition was assessed at that time. The interdisciplinary progress note dated 12/30/16, timed at 6 a.m., indicated Resident 1 was difficult to arouse with a low blood pressure of 78/50 mmHg (millimeters of mercury ? normal 120/80), pulse rate 112 beats per minute (normal range 60-80), respiratory rate 28 breath per minute (normal range 16-20), body temperature 78.7 degrees Fahrenheit (normal 98.6). The physician was notified and ordered the transfer of Resident 1 to a GACH via paramedics (911). The Initial Physician Pressure Ulcer Progress Notes from the GACH dated 12/30/15, and the Nursing Document form dated 12/30/15, indicated Resident 1 was assessed with a SDTI to the resident's sacrum measuring seven cm in length by 10 width cm. Resident 1 was also assessed as having a large red perineal excoriation (skin scrape), and a skin tear (break) to the scrotum. Resident 1 remained at GACH until 1/15/16 (16 days), when according to the Discharge Summary Notes, the resident expired with a preliminary cause of death being sepsis (a clinical syndrome of life-threatening organ dysfunction caused by a complication of an infection, where there is critical reduction in tissue perfusion; acute failure of multiple organs, including the lungs can occur). On 7/21/16, at 2:45 p.m., during an interview, LVN 1 (who would administer treatment to the pressure sore, and assist in rotating or transferring the resident due to bed mobility issues) stated she cared for Resident 1 the night prior to transferring the resident to the GACH. LVN 1 stated she was not aware of Resident 1 having any treatment orders for open wounds, or that the resident was assessed with any pressure sores. On 8/12/16, at 9:15 a.m., during a telephone interview with LVN 2, who cared for Resident 1 the morning the resident was transferred to the GACH, she stated the resident did not have any pressure sores prior to being transferred. On 8/12/16, at 11 a.m., during an interview, the director of nursing (DON) stated a weekly summary documentation and all body check was conducted and completed for all residents. The DON stated Resident 1 was not assessed with pressure sores. A review of the facility's policy and procedures titled, "Change of Condition Policy," (undated) indicated the following: ?When a resident?s condition change for any reason, this facility will insure proper care and follow-up by using a monitoring system using a NURSING 24 HOUR REPORT FORM.?... ?When a resident?s condition changes, the physician will be called promptly.? Some examples of a change of condition found on the form include open or red areas, bruises, lacerations, or skin tears. 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 that residents admitted to the facility with no pressure sore (a localized injury to the skin and / or underlying tissue, usually over a bony prominence, as a result of pressure) do not develop a pressure sore. The resident was identified as at risk for developing pressure sores, but was not provided with the necessary treatment and services to prevent pressure sores, and promote healing of pressure sores, including: 1. Failure to identify Resident 1?s newly developed pressure sore to the sacral area, skin breakdown to the perineal area, and a skin tear to the scrotum. 2. Failure to conduct an ongoing accurate assessment of the resident?s skin condition to promptly identify the development of pressure sores. 3. Failure to implement Resident 1?s skin integrity problem plan of care, and to ensure any red areas or skin breakdown was reported to the physician. 4. Failure to implement the facility?s policy on Change of Condition to ensure proper assessment and promptly notifying the physician of any open or red areas, bruises, lacerations, or skin tears. As a result, on 12/30/15, Resident 1 was transferred to a GACH where he was found with a SDTI to the resident's sacral area measuring seven cm in length by 10 cm in width. Resident 1 was also found to have a large red perineal excoriation, and a skin tear to the scrotum. Resident 1 remained at GACH until 1/15/16 (16 days), when according to the Discharge Summary Notes the resident expired. According to the Certificate of Death, Resident 1?s immediate cause of death was respiratory failure, an acute failure of a vital organ, which could result from the sepsis. The above violations presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1. |
| 970000085 |
GLENDALE HEALTHCARE CENTER |
920012969 |
A |
24-Mar-17 |
06WL11 |
15543 |
F327
?483.25(j) Hydration
The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
The facility failed to provide sufficient fluids to maintain adequate hydration and health, and to prevent dehydration (a condition when the loss of body fluids, mostly water, exceeds the amount that is taken in), for a resident (RSR 13) by failing to:
1. Ensure RSR 13, who was assessed at risk for dehydration, had poor oral intake, was unable to request fluids due to cognitive impairment, and who received diuretics (medications to help the body get rid of excess fluid), was provided the volume of fluids required daily (1580-1896 cubic centimeters) as assessed by the Registered Dietician (RD).
2. Monitor RSR 13's dehydration-associated indicators, including abnormal laboratory test results and urinary tract infection (UTI), and notify the physician for timely medical intervention as necessary.
As a result, RSR 13 was transferred to the general acute care hospital (GACH) for treatment of dehydration and associated health conditions that included UTI, acute kidney injury, and sepsis (a potentially life-threatening complication of an infection in which the body has a severe response to bacteria or other germs). RSR 13 was hospitalized for five days and was discharged back to the skilled nursing facility (SNF) on XXXXXXX 2016.
According to the admission record, RSR 13 was originally admitted to the facility on XXXXXXX 2013, with diagnoses that included dementia (a loss of intellectual and social abilities severe enough to interfere with daily functioning caused due to the degeneration of a healthy brain tissue), hypertension (high blood pressure), congestive heart failure, and gastro-esophageal reflux disease [stomach contents come back up into your esophagus (the tube that carries food/liquids from your mouth to the stomach) causing heartburn]. RSR 13 was readmitted to the facility on November 8, 2016, with additional diagnoses that included dehydration, sepsis, and acute kidney failure.
The care plan for risk of dehydration (fluid volume deficit) related to diuretics, initiated on September 12, 2014, had a goal to minimize further risks of dehydration as evidenced by good to fair skin turgor (skin?s ability to change shape and return to normal) and moist mucous membranes daily for three months. The interventions included keeping fluids nectar-thick and within easy reach, assist to consume as needed, observe for contributing factors of fluid volume depletion such as poor appetite and intake, offer food substitute if intake is below 50 percent, report when meals were refused, and to refer to the dietitian for evaluation and recommendations.
A review of the Registered Dietitian's (RD) Nutritional Assessment record dated July 15, 2015, indicated RSR 13's daily fluid requirement was 1580 to 1896 cc based on adjusted body weight of 63.2 kilograms (196 pounds). The plan of care was not revised or updated to include the RD?s recommended daily fluid requirement, or how the amount of fluid intake was to be monitored and/or recorded to ensure RSR 13 remained hydrated.
A review of the Minimum Data Set [MDS - an assessment and care screening tool] dated October 2, 2015, indicated RSR 13 had intact cognitive skills, was incontinent (no control) of bowel and bladder, and required supervision for eating. She was 63 inches tall and weighed 196 pounds.
On September 23, 2016, the physician ordered puree controlled carbohydrate (CCHO) diet with nectar thick liquids, including soups with meals, for difficulty swallowing; supervision during intake, slow rate during oral intake, and alternate liquids and solids.
The RD's reassessment record dated September 29, 2016, indicated RSR 13 had decreased intake, and recommended increasing the resident?s daily fluid requirement to 1740 to 2136 cc per day. The RD also recommended to discontinue the controlled carbohydrate (CCHO) mechanically altered pureed diet (for difficulty swallowing), originally ordered April 11, 2016, and change to a regular pureed diet; and to check the resident?s blood sugar levels twice a day (Accucheck), Monday, Wednesday and Friday, for two weeks, to determine if a CCHO diet is needed. The licensed nursing staff did not update the plan of care to include the RD?s increased fluid recommendation. The care plan was not updated to include interventions of how staff were to monitor RSR 13?s fluid intake status. There was no documented evidence provided to indicate RSR 13 was provided 1740 to 2136 cc per day from October 1, 2016, to November 2, 2016.
The MDS dated October 2, 2016, indicated RSR 13?s mental status had changed from intact to severely impaired, and she now required one person assist for eating. The plan of care (POC) was not revised or updated to include interventions to meet the resident's challenges to access food and/or fluids independently until November 14, 2016. The POC also did not include the RD?s recommended daily fluid requirements, or how the amount of fluid intake was to be monitored and/or recorded to ensure RSR 13 remained adequately hydrated.
A review of the October 2016 ?Follow Up Question Report? documentation of RSR 13?s fluid intake with meals, indicated she consumed an average fluid intake of 831 cc, with 25 cc as the lowest and 600 cc as the highest intake per day. There was no other documentation for monitoring RSR 13?s additional fluid intake. According to this information, RSR 13 had an average daily fluid deficit of approximately 909 cc.
A review of RSR 13?s Laboratory test results dated October 5, 2016, revealed the following indicators for dehydration and/or UTI:
1. An elevated BUN [blood urea nitrogen- a test measures the amount of nitrogen waste in your blood] of 44 milligrams per deciliter (mg/dl) (reference range 7-23 mg/dl).
2. An elevated Creatinine [(Cr) an important indicator of renal/kidney health) of 1.5 mg/dl (reference range 0.6-1.4 mg/dl).
3. An increased BUN/Cr ratio of 29 (reference range 5-20 mg/dl).
A BUN/Cr ratio greater than 20 is an indicator for impending dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, and Page 47).
The lab results were faxed to the physician October 5, 2016, at 12:02 p.m. The physician responded on the same date with new orders for a urine specimen. A review of RSR 13?s urine specimen test result reported to the facility on October 9, 2016, indicated nitrite (screening test for significant bacteria in the urine) was positive (reference range is negative) with many bacteria indicating a possible UTI. The results were faxed to the physician October 9, 2016, at 10 p.m.
According to the October 2016 Medication Administration Record (MAR), RSR 13 had a physician order dated October 10, 2016, at 6:43 p.m., for Macrobid (antibiotic to treat infections) 100 mg give one capsule two times a day until October 17, 2016, for UTI. According to the MAR, the first dose of antibiotic was administered on October 11, 2016, at 9 a.m., a delay of two days after the result of the urine specimen.
A review of a Fax Transmittal flagged ?Urgent? and ?For Review? notifying the physician on October 18, 2016, that RSR 13 had low intake of approximately 20 percent of all meals, lost approximately seven pounds, and the family was providing meals but the resident was refusing. The physician responded via the same Fax Transmittal on October 18, 2016, with orders for laboratory tests for complete blood count (CBC), chemistry, urine analysis and urine culture.
A review of the Laboratory test results dated October 19, 2016, indicated the following:
1. An elevated blood sodium of 137 mEq/L (reference range 135-145).
2. An elevated BUN of 63 mg/dl (reference range 7-23).
3. An elevated Creatinine of 2.0 mg/dl (reference range 0.6-1.4).
4. An increased BUN/Cr ratio of 32 (reference range 5-20 mg/dL).
5. Urinalysis test result indicated nitrite was positive for many bacteria, with the presence of white blood cells (WBC) was 2 to 5 (reference range negative), suggestive of UTI.
The test results, except for the urine culture results, were faxed to the physician on October 19, 2016, at 10:25 p.m. The physician responded via fax on October 20, 2016, at 9 a.m., inquiring, ?Where is culture results.?
The urine osmolality 301.8 milliosmole per kilogram [mosm/kg- reference range 275-295]. Urine osmolality is used to measure the number of dissolved particles per unit of water in the urine. Urine osmolality is useful in assessing hydration status (Nursing Care Ready Reference Resident Assessment Protocol Pages 53- 55).
There was another laboratory urine test result dated October 21, 2016, at (Friday) indicating RSR 13's urine specimen was positive for many bacteria and WBCs, indicating a UTI. The results were faxed to the physician on the same date at 6:40 p.m. There was no evidence of a physician response, and no follow-up by a licensed nurse.
The urine culture results were received by the facility October 24, 2016, (Monday) at 9:46 a.m., and the physician responded via fax the same date, at 10:02 a.m., with orders for Rocephin 1 gram I.M. (intramuscular antibiotic) daily for five days.
One of the complications associated with dehydration is urinary tract infections (AJN, American Journal of Nursing: June 2006 - Volume 106 - Issue 6, pages 40-49.
A review of the physician recapitulated orders with the Director of Nursing (DON), for the month of October 2016, indicated RSR 13 was now on three diuretic medications: [Aldactone 25 milligrams (mg - ordered June 2013), Lasix 40 mg (ordered June 2013), and Zaroxolyn 2.5 mg (ordered February 2016)]. The licensed nursing staff also did not update RSR 13?s POC to include interventions related to the increased risk of dehydration when receiving additional diuretics.
During a lunch observation, on November 11, 2016, at 12:10 p.m., RSR 13 was not assisted during her meal, and she was feeding herself. The resident consumed one four ounce glass of milk (120 cc), approximately 10 percent of the four ounces of juice (12 cc) and 75 percent of the eight ounces of water (180 cc). RSR 13 did not eat her entree. RSR 13 then wheeled herself out of the dining room. There were three staff members in the dining room [two Certified Nursing Assistants (CNA) and one Restorative Nursing Assistant (RNA), but none of them were assigned to assist RSR 13 as ordered by the physician to ensure her fluid consumption was adequate. According to the CNA documentation, RSR 13 consumed only 20 percent of her meal on November 11, 2016.
On November 13, 2016, at 5:30 p.m., during an interview with the DON, while reviewing RSR 13?s medical record, the DON stated RSR 13?s intake was not enough, and she was very weak, prior to transfer to the hospital in XXXXXXX 2016. When asked to provide documentation of the monitoring of RSR 13's intake, the DON stated there was no documentation record for RSR 13?s fluid intake. When the DON was asked whether the licensed nursing staff were aware of RSR 13?s daily fluid requirements, she stated she wasn?t sure if they knew or not.
A review of the literature indicated patients with dementia are at high risk for eating and feeding difficulties and inadequate food and fluid intake. Depending on the severity of their cognitive impairment, they may forget to eat, forget they have eaten, fail to recognize food, or eat things that are not food. They may have difficulty with specific tasks (e.g., removing plate covers and wrappings, knowing what the utensils are for and using them, moving food or fluid to their mouth, chewing, and swallowing). They may have difficulty initiating the eating/drinking process, or they may start eating, get distracted, and fail to finish meals (American Journal of Nursing, August 2008, Vol. 108 No 8 pages 51-52).
During the November 13, 2016, interview with the DON at 5:30 p.m., she stated RSR 13 was taking three diuretic medications, which could have contributed to her dehydration, especially since RSR 13 was not drinking or eating enough.
A review of RSR 13?s ?Follow Up Question Report? of fluid intake with meals for November 1 and 2, 2016, indicated she consumed between 25 cc and 240 cc per meal. There was no other documentation for monitoring RSR 13?s additional fluid intake.
A review of a Fax Transmittal flagged ?Urgent? and ?For Review? notifying the physician on November 2, 2016, at 12:51 p.m., that RSR 13 is not drinking enough fluid, or eating per nursing staff and family. The physician responded via the same Fax Transmittal on November 2, 2016, with orders for CBC and chemistry panel.
A review of the last laboratory test results dated November 3, 2016, indicated the following:
1. An elevated blood Sodium 151 mEq/L.
2. An elevated blood BUN 105 mg/dl ?critical high?.
3. An elevated blood Creatinine 3.6 mg/dl.
4. An increased BUN/Cr ratio 29 mg/dL.
5. An increased urine osmolality of 345.5 mosm/kg (this is higher than previous of 301.8 mosm/kg) indicated RSR 13's urine was more concentrated.
RSR 13?s laboratory test results were faxed to the physician the same day at 12:57 p.m. At 1:46 p.m., the physician responded to transfer the resident to the emergency room for evaluation due to consistently abnormal labs and oral antibiotics not effective.
Delayed treatment of dehydration may lead to acute renal failure, which is a sudden decrease in renal function which, if uncorrected, can lead to irreversible tubular necrosis [(kidney failure) American Journal of Nursing, May 1999- Vol. 99-Issue 5 page 66-69].
A review of the facility?s Change of Condition record dated XXXXXXX 2016, indicated RSR 13 was transferred to the GACH due to abnormal laboratory results.
A review of the History and Physical (H&P) from the GACH dated November 3, 2016, indicated RSR 13 was brought to the emergency department with UTI, sepsis, dehydration, and acute kidney injury. The H&P indicated RSR 13 had an elevated BUN level of 106 mg/dl, Creatinine 3.7 mg/dl., and elevated Sodium of 149 mEq/L.
The facility failed to provide sufficient fluids to maintain adequate hydration and health, and to prevent dehydration (a condition when the loss of body fluids, mostly water, exceeds the amount that is taken in), for a resident (RSR 13) by failing to:
1. Ensure RSR 13, who was assessed at risk for dehydration, had poor oral intake, was unable to request fluids due to cognitive impairment, and who received diuretics (medications to help the body get rid of excess fluid), was provided the volume of fluids required daily (1580-1896ccs) as assessed by the Registered Dietician (RD).
2. Monitor RSR 13's dehydration-associated indicators, including abnormal laboratory test results and urinary tract infection (UTI), and notify the physician for timely medical intervention as necessary.
As a result, RSR 13 was transferred to the GACH for treatment of dehydration and associated health conditions that included UTI, acute kidney injury, and sepsis. RSR 13 was hospitalized for five days and was discharged back to the skilled nursing facility on November 8, 2016.
The above violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to
RSR 13. |
| 920000018 |
Griffith Park Healthcare Center |
920013154 |
A |
26-Apr-17 |
90S611 |
10170 |
Right to be Free From Physical Restraints
?483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:
?483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with
?483.12(a)(2).
?42 CFR ?483.12, 483.12(a)(2)
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.
(a) The facility must-
(1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident?s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Free from abuse/involuntary seclusion
?CFR 483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
?483.12(a) The facility must-
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
On January 23, 2017 at 3:10 p.m. during an unannounced complaint investigation to the facility, Resident 1 was observed tied with a bedsheet around his waist into a Geri-chair (geriatric large padded chair that prevents the resident from rising and prevents from self-propelling or wheel self around).
Based on observation, interview, and record review, the facility failed to ensure the resident was treated with respect and dignity including the right to be free from any physical restraint and involuntary seclusion not required to treat the resident?s medical symptoms but for purposes of staff convenience including:
1. Failure to ensure Resident 1?s was not tied with a bedsheet around his waist into a Geri-chair for staff convenience to treat resident?s behavior of getting up unassisted.
2. Failure to ensure Resident 1?s physical movement and/or touching the floor with his feet was not limited by using a Geri-chair, which prevents from rising and impedes propelling self around the facility (room, hallways, dining/recreation room).
3. Failure to ensure Resident 1 was not isolated and secluded in his room, with the door closed, while group activity was ongoing in the activity room.
4. Failure to ensure the facility?s policy on Use of Restraint was implemented when inappropriately utilizing equipment, a Geri-chair and a bedsheet, not permitted to prevent resident mobility.
5. Failure to ensure the facility?s policy on Abuse Preventive Program was implemented by violating the resident?s right to be free from abuse and involuntary seclusion.
As a result, Resident 1 was subject of undignified treatment, involuntary seclusion, unnecessary physical restraint, and isolation which to a reasonable person would cause mental anguish, loss of autonomy, loss of dignity, loss of self-respect, feeling of helplessness and depression. Resident 1 was also placed at risk for injury including strangulation as the bedsheet constituted an accident hazard in the case of the resident, when left isolated and unattended, tried to free him-self and become tangled in the bedsheet.
On January 23, 2017, at 3:10 p.m., during a tour of the facility, accompanied by the Maintenance Supervisor (MS), the door to Resident 1's room was closed. Upon knocking and entering the room, Resident 1 was observed sitting in a Geri-chair with a bedsheet around his waist and the bedsheet was tied at the back of the Geri-chair. Resident 1 was moving his legs up and down as if he was riding a bicycle. Resident 1 had no clothes on and was only wearing an incontinent brief. During the observation, Certified Nursing Assistant 1 (CNA 1) walked into Resident 1's room and upon interview, CNA 1 stated she knew it was wrong to have the resident tied up with a sheet and explained Resident 1 kept getting out of bed. CNA 1 stated she just arrived to work (3 p.m. to 11 p.m.) and someone from the day shift (7 a.m. to 3 p.m.) must have tied Resident 1 to the Geri-chair. An attempt to interview Resident 1 failed as he was not answering the questions coherently and was confused. During the tour, there were activities going on in the activity room.
A review of the admission record indicated, Resident 1 was originally admitted to the facility on November 17, 2016, and readmitted to the facility on January 18, 2017, with diagnoses including pneumonia (lung infection), syncope and collapse (fainting or sudden temporary loss of consciousness), dementia (decline in mental ability that interferes with daily life), Alzheimer's disease (irreversible, progressive brain disorder), and history of falls.
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated November 24, 2016, indicated Resident 1's able to recall things after cueing and was totally dependent on staff for all activities of daily living such as transfers, locomotion, personal hygiene, and bathing. The MDS section for Activity Preferences indicated it was very important to the resident to have reading material, listen to music, and do things with groups of people and go outside to get fresh air.
A review of the Interdisciplinary Team (IDT) Care Conference dated January 11, 2017, indicated Resident 1 had frequent episodes of standing up unassisted, his wheelchair pad alarm kept sounding, and the resident's roommates were complaining about the loud sound of his alarm when he tried to get up unassisted. The note also indicated the CNA could not provide 1:1 (one on one) care to the resident.
According to the physician?s orders dated January 18, 2017, Resident 1 was to have a low bed with bilateral (both sides) quarter side rails up (only the upper part of the bed had rails up), a floor mat on both sides of the bed, and a pad alarm (device to notify staff when the resident attempted unassisted transfers) while in bed. A non-release belt (a belt restraint that cannot be removed by the resident) when up in a wheelchair due to a history of falls, poor trunk control, impaired dynamic sitting balance (the ability to balance while moving or changing between positions), and general muscle weakness. There was no physician?s order for the use of the Geri-chair.
The History and Physical Examination (H&P) completed by Physician 1 and dated January 20, 2017, indicated Resident 1 did not have the capacity to understand and make decisions.
Further record review disclosed no documented evidence the use of the Geri-chair with the bedsheet tied around the resident?s waist was addressed by the IDT. There was no evidence of consent obtained from the resident?s responsible party for the use of the Geri-chair.
According to the facility?s policy and procedure titled, Use of Restraints? dated December 2007, practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including:
i. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility;
ii. Tucking sheet so tightly that a bed-bound resident cannot move;
iii. Placing a resident in a chair that prevents the resident from rising; and
iv. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising.
A review of the facility?s policy and procedure titled, ?Abuse Preventive Program? revised on August 2011, indicated the facility residents has the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.
The facility failed to ensure the resident was treated with respect and dignity including the right to be free from any physical restraint and involuntary seclusion not required to treat the resident?s medical symptoms but for purposes of staff convenience including:
1. Failure to ensure Resident 1?s was not tied with a bedsheet around his waist into a Geri-chair for staff convenience to treat resident?s behavior of getting up unassisted.
2. Failure to ensure Resident 1?s physical movement and/or touching the floor with his feet was not limited by using a Geri-chair, which prevents from rising and impedes propelling self around the facility (room, hallways, dining/recreation room).
3. Failure to ensure Resident 1 was not isolated and secluded in his room, with the door closed, while group activity was ongoing in the activity room.
4. Failure to ensure the facility?s policy on Use of Restraint was implemented when inappropriately utilizing equipment, a Geri-chair and a bedsheet, not permitted to prevent resident mobility.
5. Failure to ensure the facility?s policy on Abuse Preventive Program was implemented by violating the resident?s right to be free from abuse and involuntary seclusion.
As a result, Resident 1 was subject of undignified treatment, involuntary seclusion, unnecessary physical restraint, and isolation which to a reasonable person would cause mental anguish, loss of autonomy, loss of dignity, loss of self-respect, feeling of helplessness and depression. Resident 1 was also placed at risk for injury including strangulation as the bedsheet constituted an accident hazard in the case of the resident, when left isolated and unattended, tried to free him-self and become tangled in the bedsheet.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 940000078 |
GREENFIELD CARE CENTER OF SOUTH GATE |
940010598 |
B |
03-Apr-14 |
MEYO11 |
6125 |
? 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. NOTE: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference. Section 1276, Health and Safety Code. The facility failed to report to the Department an incident that threatened the welfare, safety or health of Patient 14 by failing to: 1. Report a fall incident that resulted in a hip fracture and surgery. 2. Implement the facility?s policy and procedure on unusual occurrences. A review of the Resident Admission Record indicated that Patient 14 was an eighty year old female, admitted to the facility on 1/16/14 with diagnoses that included cerebrovascular disease (stroke) with left side hemiplegia (paralysis affecting only one side of the body), history of fall, and osteoporosis (fragile bones due to thinning of bone tissue and loss of bone density). The Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/28/14, indicated that Patient 14 scored 8 out of 15 on the ?Brief Interview for Mental Status? (BIMS, a test for the patient's ability to repeat three words, recall, and orientation to year, month, and day). The MDS also indicated that the patient required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, toilet use, bathing, personal hygiene, and dressing. Patient 14 used a wheelchair for mobility and her balance was not steady moving from seating to standing position or from surface to surface transfer; and only able to stabilize with staff assistance.The fall risk assessment completed on 1/17/14 indicated that Patient 14 was at high risk for fall. The care plan developed on 1/16/14 for Patient 14 included the provision of safe and hazard free environment, call light within patient?s reach and to encourage/remind the patient to call for help/assistance.A further review of Patient 14?s care plans indicated that Patient 14 had a fall incident on 1/23/14. The care plans indicated to provide motion alarm at bed and wheelchair due to patient trying to get up unassisted and to provide frequent checks.A review of the occurrence report completed on 1/24/14 indicated that on 1/23/14 at 11 a.m., a laundry staff member informed the licensed nurse of patient sliding down her wheelchair inside her room. The licensed nurse found Patient 14 on the floor lying on her left side and was complaining of pain to her left hand and left shoulder. Patient 14 was transferred back to bed with the help of three staff members. The report indicated Patient 14 lost her balance while trying to reach down to her shoe while on her wheelchair.A review of the care plan developed on 2/1/14 indicated that Patient 14 had another fall incident. A review of the occurrence report completed on 2/4/14 indicated that on 2/1/14 at 12:45 p.m., a nursing assistant heard the patient?s motion alarm beeping and went to see the patient. Patient 14 was found on the floor, lying on her left side inside her room, and was moaning in pain, pointing to her left hip. Patient 14 was transferred back to bed with the help of eight staff members. The report indicated that Patient 14 got up from her wheelchair unassisted and lost her balance. Patient 14 sustained a fracture and was transferred to the acute-care hospital on the same day for further evaluation and treatment.A review of the acute hospital x-ray report for Patient 14 dated 2/1/14, indicated a comminuted (the bone was broken into several pieces) intertrochanteric (the breaks of the femur [thigh bone] were located between the greater and the lesser trochanters [hip socket]) fracture of the left femur.Further review of the acute hospital record indicated that Patient 14 underwent open reduction and internal fixation (a type of surgery used to fix hip fractures) of the left hip.On 3/9/14 at 6:45 p.m., during an interview with the director of nursing (DON), when asked about the reason why the incident was not reported to the Department, the DON stated she was told, as long as the facility knew the cause of the fall, they were not obligated to report to the Department. A review of the facility?s policy and procedure on unusual occurrences, with a revised date of 07/2012, indicated that the facility must report unusual occurrences to the Department within 24 hours of its occurrence. The unusual occurrences listed below are not intended to be all inclusive list, but are examples of the types of events that should be reported. ?9. Other occurrences which threaten the welfare, safety, or health of residents.? The policy and procedure indicated that the administrator, DON or designee will report any unusual occurrences within 24 hours. A report will be initiated by calling the Department of Public Health and Services by phone or by fax. The verbal report will be accompanied by written report to the same agency.The facility failed to report to the Department an incident that threatened the welfare, safety or health of Patient 14 by failing to:1. Report a fall incident that resulted to a hip fracture and surgery. 2. Implement the facility?s policy and procedure on unusual occurrences.The above violation either jointly, separately, or in combination had a direct or immediate relationship to patient health, safety, or security. |
| 940000078 |
GREENFIELD CARE CENTER OF SOUTH GATE |
940012435 |
A |
2-Aug-16 |
99O511 |
17201 |
?483.10(a) Exercise of Rights ?483.10(a) (1) The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. ?483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. ?483.75(i) Medical Director (1) The facility must designate a physician to serve as medical director. (2) The medical director is responsible for ? (i) Implementation of resident care policies; and (ii) The coordination of medical care in the facility. On July 28, 2015, at 1:30 p.m., an unannounced visit was made to the facility to investigate an allegation that the facility failed to act upon Resident 1's complaints of abdominal pain, vomiting, and lack of appetite for approximately two weeks. Based on observation, interviews, and record review, the facility failed to ensure that Resident 1 who had a history of gastric bypass (surgical procedure during which the stomach is re-routed, so a person does not absorb as much food) was provided with necessary care and services, including but not limited to: (a) Failure to assess and monitor Resident 1's progressive complaints of lack of appetite, abdominal pain, nausea and vomiting, and lack of relief with the interventions provided. (b) Failure to notify the physician and analyze Resident 1?s abnormal blood chemistry test results (Tests that are routinely ordered to determine a person's general health status), in a timely manner. (c) Failure to coordinate Resident 1?care with the medical director to provide further clinical guidance and oversight of her care when she continued to have abdominal pain, loss of appetite , vomiting and her repeated requests to be transferred to the GACH. (d) Failure to ensure Resident 1 exercised her right to participate in her care, and honor her wishes as indicated in her POLST (Physician Orders for Life-Sustaining Treatment). The above failures resulted in Resident 1 calling 911 (Emergency number) without the staff's knowledge on July 14, 2015, at 12:20 a.m., and was transferred to the general acute care hospital (GACH), where Resident 1 was found to have abnormal blood chemistry levels, and a severe low blood count. The resident underwent emergency surgery that lasted for six hours, for bowel obstruction (when the small or large bowel becomes blocked, and prevents food, fluid, and gas to move through the intestines in a normal manner). A review of the closed record indicated Resident 1 was initially admitted to the facility on April 24, 2015, and re-admitted on July 2, 2015, with diagnoses that included history of gastric bypass, septicemia (infection of the blood stream), hypothyroidism (condition where the thyroid gland does not produce enough of certain important hormones), and vitamin deficiency. A review of the Admission Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated May 6, 2015, indicated Resident 1 was alert and able to make her needs known, and was independent in her activities of daily living (bed mobility, transfer, toileting, personal hygiene and eating). A review of the Resident 1?s POLST dated June 24, 2015, signed by the primary care physician on July 3, 2015, indicated the resident preferences were to receive ?Full Treatment,? (When comfort cannot be achieved in the current setting, the patient (resident), including someone with ?Comfort-Focused Treatment,? should be transferred to a setting able to provide comfort. Resident 1 had the following physician's order for hypothyroidism: 1. April 24, 2015, Synthroid 75 micrograms (mcg) by mouth (orally), once a day. 2. June 21, 2015, Armour Thyroid tablet 30 mg orally once a day. 3. July 8, 2015, Armour Thyroid tablet was increase to 60 mg orally once a day. A review of the physician's orders, dated June 25, 2015, included calcium 500 milligrams (mg) with vitamin D orally three times daily for vitamin deficiency; and ferrous sulfate (iron) delayed release 325 mg orally daily for diagnosis of anemia (a decrease in the amount of red blood cells, or hemoglobin in the blood). A review of Resident 1's blood chemistry laboratory test results, dated May 18, 2015, indicated the following: Sodium level (Helps maintain the water and electrolyte balance of the body, and is also important in how nerves and muscles work) was 137 milli-equivalents per milliliter (mEq/ml) (Normal range: 136-145 mEq/ml.) A repeat level was obtained on July 6, 2015 which indicated that the sodium level had dropped to 132 mEq/ml. Calcium level (A mineral that helps to make and keep bones and teeth strong, plays an important part in functioning of muscles and blood vessels, secretes hormones and enzymes, and sends messages through the nervous system) was 7.0 milligrams per deciliter (mg/dL) (Normal range: 8.6-10.3 mg/dL). A repeat level was obtained on July 6, 2015 which indicated that the Calcium level had dropped to 6.4 mg/dL. Albumin level (is the body's major plasma (The colorless liquid part of blood) protein) measured 2.8 grams per deciliter (gm/dL) (Normal range: 3.5-5.7gm/dL). A repeat result was obtained on July 6, 2015 which indicated that the Albumin level had dropped to 1.8 gm/dL. Thyroid Stimulating Hormone (TSH, a high levels of TSH in the blood stream indicate the thyroid gland is underperforming, and is a common indication of hypothyroidism [the thyroid gland does not produce enough of certain important hormones]) was measured at 7.27 uIU per milliliter (ml) (Normal range: 0.34-5.60 uIU/ml). A repeat result was obtained on July 6, 2015 which indicated that the Thyroid Stimulating Hormone level had increased to 15.71 uIU/ml. T4, Total dL (The main hormone produced by the thyroid gland that plays a role in several body functions, including growth and metabolism) dated July 6, 2015 indicated 1.8 micrograms per deciliter (mcg/dL) (Normal range: 6.0-12.0 mcg/dL). A review of the Physician Progress Notes, dated May 5, 2015, May 12, 2015, May 21, 2015, and May 29, 2015, indicated Resident 1 had diagnoses of hypothyroidism, anemia, osteoarthritis (a type of joint disease that results from breakdown of joint cartilage and underlying bone), history of cerebral vascular accident (CVA-sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired), and history of chronic pain. The May 21, 2015, physician's progress note did not indicate /note the results of the May 18, 2015 laboratory results. A review of the Physician Progress Note, dated July 11, 2015, indicated Resident 1 was noted with multiple somatic (intense thoughts, feelings, and behaviors related to the symptoms that interfere with daily life) complaints. The progress note indicated to repeat thyroid levels in three weeks, and to reassign the resident's care to the medical director. A review of the Vitals Report document indicated that for the period between July 9, 2015 and July 13, 2015, Resident 1's meal intake percentage indicated the following: July 9, 2015: breakfast 0-25%, lunch 0%, dinner 51-75% July 10, 2015: 51-75% breakfast & lunch, dinner 26-50% July 11, 2015: breakfast & lunch 76-100%, dinner 26-50% July 12, 2015: breakfast and lunch 1-25%, dinner76-100% July 13, 2015: breakfast and lunch 0%, dinner 76-100% A review the Nursing Resident Progress Notes, dated July 12, 2015, at 11:02 a.m., indicated Resident 1 had an episode of vomiting. The resident verbalized to the licensed nurse that she felt nauseous and bloated, and had not had a bowel movement for three days. An assessment by the licensed nurse indicated that bowel sounds were present, and there was no abdominal tenderness. An entry dated July 12, 2015 at 2:13 p.m., indicated the resident had a bowel movement after an enema (An enema is procedure used for clearing the bowel and colon of fecal matter) was administered. The Nursing Resident Progress Notes dated July 13, 2015, indicated the following entry: At 9 a.m., the Nursing Progress Note indicated Resident 1 complained of nausea, refused her breakfast tray, and verbalized that she wanted to be transferred to the hospital due to lack of appetite. The notes further indicated that the physician was notified, and ordered not to transfer the resident, and to monitor for nausea and lack of appetite. At 9:30 a.m., the Nursing Progress Note indicated that Resident 1 had vomited a moderate amount of yellowish-gray fluid. The nurse informed Resident 1 that she would notify the physician, and encouraged the resident to eat. The resident refused to eat. At 12:30 p.m., the Nursing Progress Note indicated the resident refused her lunch tray, and informed the director of nursing (DON) that she was going to call the paramedics. The DON explained to the resident that they were unable to transfer her because they did not have a physician order, and that they would continue to monitor her for lack of appetite and vomiting. The note further indicated that the resident was upset. At 4:06 p.m., the Nursing Progress Note indicated the resident complained of upper abdominal pain, on the pain scale of seven out of 10 (Ten being a worst pain a person can experience), that the resident's vital signs were within normal limits, and had active bowel sounds in all four abdominal quadrants. The notes further indicated that at approximately 4:05 p.m., the physician was updated with the resident's condition with no new orders received, and to continue to monitor. At 11:30 p.m., the Nursing Progress Note indicated that the resident complained of abdominal pain, five out of 10 pain level, and had informed the night shift licensed nurse that she received pain medication at 11 p.m. The Nursing Resident Progress Notes, dated July 14, 2015, at 12:20 a.m., indicated the resident had called 911 (Emergency number) without the staff's knowledge, and that at 12:27 a.m., the resident was transferred by paramedics to the GACH. A review of the GACH emergency department (ED) MD History and Physical (H&P), dated July 14, 2015, at 3:20 a.m., indicated Resident 1's primary diagnosis was gastro-intestinal bleed, abdominal pain, and anemia. The resident was presented with several weeks of decreased appetite, vomiting, and severe and constant non-radiating pain in the upper epigastric (upper abdomen) area that became worse with eating and moving. The resident reported two episodes of vomiting for that day. The second episode was described as black in color. The current symptoms were severe. The H&P also indicated the resident had been evaluated for this complaint in the past. A physician note, dated July 14, 2015, and timed at 9:30 a.m., indicated a rectal exam that revealed occult positive (presence of blood in stool that cannot be seen). A review of the GACH emergency department (ED) nursing assessment note, dated July 14, 2015, at 3:26 a.m., indicated Resident 1 complained of weakness, lack of appetite, and episodes of vomiting. The resident also complained of abdominal pain of "10," on a one to 10 pain scale. A review of the laboratory results obtained in the Emergency Department (ED) indicated that the resident tested positive for blood in the stool. Resident 1's hemoglobin level (a protein in the blood that carries oxygen from the lungs to the rest of the body) was 6.4 grams per deciliter (gm/dL) (Normal range: 12.0-16.0 gm/dL), and hematocrit level (the percentage of red blood cells in the body was 20.4% (Normal range: 37.0-47.0%). The resident was also diagnosed with urinary sepsis (a serious infection that can result in septic shock and premature death if treatment is delayed or absent). The resident was transferred to the Intensive Care Unit (ICU), and then to the Operating Room (OR). A review of the Operative Note, dated July 15, 2015, indicated Resident 1 underwent exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease) with extensive lysis of adhesions (fibrous bands that form between tissues and organs- the tissues and organs are stuck together, and commonly develop as a result of previous surgeries in the same area). The note indicated there were multiple adhesions throughout the entire bowel, and that the surgery lasted a total of six hours. The record also indicated the resident required a total of eight blood transfusions during her hospital stay. A review of the GACH Discharge Summary, dated August 11, 2015, (29 day stay in the GACH) indicated that postoperatively, Resident 1 developed sepsis and respiratory failure, (when too little oxygen passes from your lungs to your blood), and required a breathing tube and ventilator (breathing machine). The summary also indicated the resident's discharge diagnoses included septicemia (infection of the bloodstream) by a multi-drug resistant organism, urinary tract infection, and generalized weakness due to prolonged bed stay. On August 25, 2015, at 10:20 a.m., a telephone interview was conducted with Resident 1, who stated she was still in the hospital. The resident indicated that when she was at the facility prior to being transferred to the hospital, she had been having a problem with her appetite, and was having episodes of vomiting and diarrhea. Resident 1 informed the nurses, who notified the physician, but the physician would only tell the nurses to observe the resident. The resident further stated that after several weeks had passed, she requested to be transferred to the hospital, but the physician refused. When she was transferred to the hospital, her blood count was very low, and she required emergency surgery for intestinal blockage. Resident 1 stated she had a problem with malabsorption (inability to absorb nutrients, vitamins, and minerals from the intestinal tract into the bloodstream), due to a history of gastric bypass (surgery during which the digestive system is re-routed, so not as much food is absorbed), and that her blood levels required close monitoring. On July 28, 2015, at 1:45 p.m., during an interview, LVN 1 stated that on July 14, 2015, Resident 1 had complained of lack of appetite, did not eat anything, and had one episode of vomiting. LVN 1 also stated the resident requested to be transferred to the hospital and when she notified the physician, the physician ordered to monitor the resident. On July 18, 2016, at 4:48 p.m., a telephone interview was conducted with the DON, she stated that she should have listened to the resident and followed her request to be transferred to the hospital. The DON stated that her decision would have been in conflict with the primary care physician?s order to continue to monitor the resident. She admitted that she should have called the medical director. According to the January 2015, revised facility?s ?Duties and Responsibilities of the Medical Director,? indicated: ?Coordinate medical care in the facility to insure the adequacy and appropriateness of the medical services provided, be familiar with policies and programs of public health agencies that may affect resident care programs?? The facility further indicated that:? Coordinate medical care, example advise the facility when physicians? or other practitioners? performance is inadequate or their behavior is contrary to established facility?s rules and regulations.? The facility failed to ensure that Resident 1 who had a history of gastric bypass was provided with necessary care and services, including but not limited to: (a) Failure to assess and monitor Resident 1's progressive complaints of lack of appetite, abdominal pain, nausea and vomiting, and lack of relief with the interventions provided. (b) Failure to notify the physician and analyze Resident 1?s the abnormal blood chemistry test results (Tests that are routinely ordered to determine a person's general health status), in a timely manner. (c) Failure to coordinate Resident 1?care with the medical director to provide further clinical guidance and oversight of her care when she continued to have abdominal pain, loss of appetite, vomiting and repeated requests to be transferred to the GACH. (d) Failure to ensure Resident 1 exercised her right to participate in her care, and honor her wishes as indicated in her POLST (Physician Orders for Life-Sustaining Treatment). The above failure resulted in Resident 1 calling 911 without the staff?s knowledge on July 14, 2015, at 12:20 a.m., and was transferred to the GACH, where Resident 1 was found to have abnormal blood chemistry levels, and a severe low blood count. The resident underwent emergency surgery that lasted for six hours, for bowel obstruction. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000078 |
GREENFIELD CARE CENTER OF SOUTH GATE |
940012718 |
B |
10-Nov-16 |
V67811 |
4028 |
CFR 483.15(h)(2) -QUALITY OF LIFE F 253 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This violation was found during an unannounced investigation of a complaint regarding a leaking roof in a room for three residents. Based on observation, record review and interview, the facility failed to provide necessary services to maintain a sanitary, orderly, and comfortable interior. This failure subjected the residents in the room with the leaking ceiling, to undue hazards, stress and anxiety for two of three residents in that room (Residents 1 and 2). Findings: During a complaint investigation on 5/3/16, Resident 3 reported that the ceiling in the room which he shares with two other residents was leaking. He stated that he sees and hears it rain over beds B and C when it rains. Resident 3 was in in bed A. Review of the Admission Sheet for Resident 1 (bed C) indicated he was admitted to the facility on 6/5/14, with diagnoses that included osteoporosis, anxiety disorder, major depressive disorder insomnia, and neuropathy. Review of the Minimum Data Set (MDS, a clinical assessment tool) dated 2/11/16, indicated Resident 1 was cognitively intact and required limited assistance with one person in most activities of daily living (ADL). Review of the Admission Sheet for Resident 2 (bed B) indicated he was admitted to the facility on 1/8/16, with diagnoses that included generalized weakness, hypertension and chronic obstructive pulmonary disease (COPD, a lung condition that block airflow to the lungs making it difficult to breathe). His MDS dated 2/11/16, assessed him to require limited to extensive assistance with one person in most ADLs. In an interview on 5/3/16, Resident 1 stated water seeps through the ceiling over his bed when it rains especially "during the recent rain last week". He also stated that he is very "uncomfortable" when it's raining but that he didn't like to be displaced to another room. He further stated he complained about the leaking ceiling "since last year but the facility had done nothing to fix it". Observation of the room revealed four patches on the celling by the residents in bed B and C, two of which had brown circles which indicated water was seeping from the ceiling. One patch with a brown circle measuring 6 ft. x 8 in. was above Resident 1's bed (bed C) and another patch measuring 4 ft. x 8 in. was above Resident 2's bed (bed B). Resident 2 is non- interviewable. During an interview on 5/3/16, the administrator stated that they were working on repairing the ceiling in the room where the leak is located. When asked what "working on it" meant, he stated that he has reported the leak to Corporate. In an interview with the Maintenance supervisor on 5/4/16, he stated that he had tried to fix the ceiling twice since the ceiling first started to leak sometime in November 2015, but that it continued to leak. When asked how he accommodated the residents when the ceiling leaks water, he stated he moved the residents' beds away from the leak(s) or placed them in another room(s). A review of the facility's invoices dated 10/31/15 and 1/11/16, indicated that the facility contacted a construction company to repair/fix the leaking roof. However, as of 5/4/16, the roof repair still had not been completed. Further interview with the maintenance supervisor on 9/7/16, indicated that the roof repair was finally completed during the first week of June 2016, seven to eight months later after the roof was first reported to the facility staff as leaking. An invoice signed by the owner of the roof repair company indicated the roof repair was completed on 7/19/16. Failure of the facility to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior subjected the residents to undue hazards, stress, and anxiety for two of three residents in the room with the leaking ceiling (Residents 1 and 2). |
| 950000009 |
GLENDORA GRAND, INC. |
950009868 |
B |
01-May-13 |
DCBS11 |
3661 |
F225 The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 12/20/11 at 3:05 p.m., an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged resident abuse which resulted in a resident sustaining an injury of unknown origin to the facial/nasal areas.Based on interview and record review, the facility failed to develop and implement policies and procedures for investigating and immediately reporting to the Department, injuries of unknown source. A review of Resident A's clinical records revealed that she was an 89 year-old female readmitted to the facility on 12/9/11, with diagnoses that included seizure disorder and dementia. The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/29/11 indicated that the resident had memory problems and required extensive assistance with daily activities such as transfers, dressing, and toilet use. During an interview with the Administrator on 12/20/11, at 3:05 p.m., he stated that the facility had not reported to the Department the investigation of Resident A's injuries of unknown source of the facial/nasal area, which was first discovered by the facility's staff on 12/17/12.According to a licensed nurse's notes dated 12/17/11, at 8 a.m., Resident A was noted with a skin tear and a swollen nose, and discolorations on the left lower jaw, right upper thigh and right upper arm. It was further noted that the resident did not know how she sustained the injuries. The resident was, then, transferred to the acute hospital for further evaluation. The resident was still at the acute hospital during this onsite visit. The Administrator stated that they were still in the middle of their investigation, but acknowledged the facility?s failure to not immediately report the injury of unknown source to the Department.According to the acute hospital record dated 12/18/11, the resident had an abrasion to the face and a nasal fracture. A review of the facility?s undated policy and procedures, titled ?Abuse & Neglect Prohibition,? revealed that it did not contain procedures for investigating and immediately reporting to the Department injuries of unknown source.This violation had a direct relationship to the health, safety or security of residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950010116 |
B |
22-Aug-13 |
D5TB11 |
7461 |
F 323 CFR 483.25 (h) Accidents 1) The facility must ensure that the resident environment remains as free from accident hazards as is possible. 2) Each resident receives adequate supervision.On October 26, 2012, at 3:40 p.m., an unannounced visit was made to the skilled nursing facility (SNF) regarding an entity reported incident of a fire that occurred in Resident A?s bathroom caused by smoking.Based on record review, observation and interview, the facility failed to ensure Resident A received adequate supervision by failing to: 1. Ensure Resident A?s who was assessed as an unsafe smoker, did not have smoking materials within his possession in accordance with the facility?s smoking policy. 2. Ensure Resident A was supervised at all times when smoking.On October 25, 2012, at approximately 11:45 p.m., Resident A, while smoking unsupervised in a bathroom, accidentally started a fire in the facility.A review of the Narrative Fire Incident Reports (NFIRS) dated October 26, 2012, at 12:16 a.m. indicated the local firemen responded to a fire that occurred at the skilled nursing facility (SNF) caused by a cigarette in a trash can and spread from the trash can to the bathroom door. The report estimated the amount of damage to the facility was $200.00.A review of Resident A?s admission information record indicated, Resident A was admitted to the facility on October 16, 2012, with diagnoses including: Parkinson?s disease (A progressive nervous disorder that affects movements), schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems), bipolar (a mental condition in which people go back and forth between periods of a very good or irritable mood and depression) and chronic obstructive pulmonary disease (COPD- refers to a group of lung diseases that make it increasingly difficult to breathe). A review of the most recent Minimum Data Set (MDS- a standardized assessment and care screening tool) dated October 26, 2012, indicated the resident was independent in cognitive (mental) skills for daily decision making, had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and required supervision to limited nursing assistance to perform activities of daily living including personal hygiene and grooming.A review of the Resident Smoking Assessment Form dated October 16, 2012, indicated Resident A was an unsafe smoker and must be supervised at all times when smoking.On October 30, 2012, at 2:10 p.m., during a telephone interview with CN 1 (Charge Nurse 1) who works during the 7 a.m. to 3 p.m. shift, he stated he observed Resident A (at unspecified times) smoking unsupervised in non-designated smoking areas but he redirected the resident to the patio which was the designated smoking area. CN 1 stated the resident was not capable of keeping smoking materials in his possessions because the resident had impaired cognition (mental) status. On October 30, 2012, at 3:10 p.m., CNA 2 (Certified Nursing Assistant) who works during the 11 p.m. to 7 a.m. shift, was interviewed and stated she had observed Resident A (at unspecified times) to have cigarettes and a lighter in his pocket. CNA 2 stated she did not confiscate the cigarettes and lighter from the resident nor did she report to this to the charge nurse because she thought the resident was allowed to keep smoking articles with him.CN 1 and CNA 2 were aware Resident A smoked unsupervised and retained smoking articles but did not confiscate the smoking articles even though the resident had been determined to be an unsafe (non-responsible) smoker as identified on the Resident Smoking Assessment Form dated October 16, 2012.In a telephone interview with Resident A conducted on November 05, 2012, at 11:20 a.m., he stated on the night of the fire, he must have fallen asleep while in the bathroom and dropped the cigarette on the floor. In a telephone interview with RN Supervisor 2 conducted on November 06, 2012, at 2:15 p.m., she stated on October 25, 2012, at approximately 11:45 p.m., CNA 1 reported to have smelled smoke outside Room 105. Immediately RN Supervisor 2 and CN 2 conducted an inspection and observed smoke coming out of Room 111. Thereafter, Residents B and C who reside in Room 111, reported Resident A, was smoking in the bathroom. On November 06, 2012, at 2:30 p.m., in an interview with CN 2, she stated on the date of the fire she observed smoke coming out of the bathroom (Room 111) and half of the bathroom door frame was on fire. CN 2 stated a fire department staff found Resident A on the bathroom floor and also found a charred disposable diaper and a charred sheet on the bathroom floor. According to CN 2, Resident A refused to have a body check after he was found. However, later that morning, the resident was sent out to the acute hospital via paramedics as ordered by the physician for further evaluation for possible smoke inhalation and exhibitions of aggressive behavior. CN 2 stated Resident A?s smoking activities should have been closely monitored (supervised) due to poor safety awareness.There was no documented evidence on the licensed nurses notes or progress notes of October 16, to 25, 2012, to indicate the staff provided ongoing monitoring of Resident A to ensure the resident smoked only while supervised. Additionally, there was no evidence the staff provided supervision of Resident A at all times when smoking, to minimize the chance of starting an accidental fire. According to the acute hospital urgent care nursing record dated October 26, 2012, at 4:35 a.m., the resident was received via ambulance for possible smoke inhalation, and was in no acute distress. The resident?s admitting diagnosis was chronic ulcer of an unspecified site. On the same day a chest x-ray was taken for possible smoke inhalation. The result showed that the lungs were clear. During the resident?s hospital stay, he received intravenous fluids for hydration, both intravenous and oral antibiotics and a series of laboratory tests. The resident was discharged to another skilled nursing facility (SNF) on October 30, 2012, in stable condition. Resident A was hospitalized from October 26, 2012, to October 30, 2012, a total of five days. A review of the facility?s policy titled ?Smoking Policy? revised April 2006, indicated any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel maybe alerted to the smoking restrictions. Any resident who has been classified as non-responsible shall not be permitted to smoke without the direct supervision of a representative staff member and direct supervision must be provided throughout the entire smoking period. Residents classified as non-responsible shall not be permitted to retain any types of smoking articles on his person. The facility failed to ensure Resident A?s received adequate supervision by failing to:1. Ensure Resident A?s who was assessed as an unsafe smoker, did not have smoking materials within his possession in accordance with the facility?s smoking policy. 2. Ensure Resident A was supervised at all times when smoking.As a result on October 25, 2012, at approximately 11:45 p.m., Resident A while smoking unsupervised in the bathroom, accidentally started a fire in the facility. These violations had a direct relationship to the health, safety and security of the residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950011518 |
AA |
19-Jun-15 |
KWS411 |
7707 |
F323-Accidents The facility must ensure that the resident environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. On 5/28/14 at 2:15 PM, an unannounced visit was made to the facility to investigate a self-reported incident regarding Resident 1, who was found unresponsive on the floor, in her room.Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents by failing to:1. Ensure Resident 1, who had difficulty in swallowing and a history of choking, received adequate supervision during meals as indicated in the plan of care to prevent a repeat occurrence of choking. Consequently Resident 1 choked on some food particles and subsequently expired. During a review of the clinical record for Resident 1, the admission record (face sheet) indicated the resident was originally admitted to the facility on 5/11/12, and readmitted to the facility, on 9/13/13, with diagnoses that included dementia, bipolar disorder, and schizophrenia.The most recent comprehensive Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 5/12/14, indicated Resident 1 had the ability to make herself understood and to understand others. According to the MDS, Resident 1 required supervision from staff for most of her activities of daily living, including eating. The MDS indicated she was receiving a mechanically altered diet. A review of Resident 1's medical record, with RN 1, indicated Resident 1 has had a history of choking on food materials. An entry in the Nurse's Notes , dated 5/13/12, at 2:20 PM, indicated at approximately 1:20 PM, Resident 1 was found lying in bed, with her mouth full of food, and with harsh breath sounds. Resident 1 was also noted to have cyanotic lips and fingertips. The nurse?s notes further indicated the Heimlich maneuver was initiated, and suctioning was done, which improved the resident's condition. Resident 1 was then transferred to an acute hospital for further evaluation and was returned to the facility on 5/14/12. A review of an entry in the "Dysphagia (difficulty in swallowing) documentation report," with RN 1, indicated that on 5/18/12, Resident 1 had a speech/swallow evaluation by a therapist, who recommended that Resident 1 undergo swallow/diet management and safety training. The evaluation report indicated Resident 1 appeared to be tolerating a mechanically soft (MS) diet, with poor safety and risk for choking.A review of an entry in the "dysphagia documentation report" with RN 1, dated 5/21/12, indicated Resident 1 was on maximum assist (staff assistance in cutting, meal set-up, feeding) with meals for safety, due to being easily distracted, and with a risk for choking. Another entry in the "dysphagia documentation report" dated 5/29/12, indicated the resident had poor safety awareness, required maximum cues to slow down and take small bites, and cues to increase chewing. The report further indicated to continue 1:1 monitoring for cues and supervision. A review of an entry in the ?dysphagia documentation report, " with RN 1, dated 5/31/12, indicated Resident 1 was discharged from speech/swallow rehabilitation therapy but would still be on maximum assistance for safety compliance because of poor safety awareness and an increased risk for choking. A review of an entry in the Nurses Notes, with RN 1, dated 3/20/13, at 1:30 PM, indicated Resident 1 had another episode of choking. The entry indicated at approximately 1 PM, on 3/20/13, Resident 1 was noted by staff standing in front of her closet door and then she fell down on her back. Resident 1 appeared to be cyanotic and was unable to respond to tactile (touch) or verbal stimuli. The Heimlich maneuver was performed immediately and some liquid and soft food came out from the resident?s mouth. After a few minutes Resident 1 responded well and was refusing care.A care plan developed in April 2014, and re-evaluated in May 2014, indicated Resident 1 was at risk for further choking and/or aspiration secondary to actual episodes of choking, history of choking, taking large bites of food, refusing staff to assist with feeding, taking food from other residents who were on different therapeutic diets, and taking and grabbing food from the food trays and carts. The care plan approaches included to monitor Resident 1 during meals, to observe for any difficulty in swallowing, supervise food trays and carts during meals, and to monitor for access to solid foods. The physician?s orders dated 2/5/14, indicated that Resident 1 was on a fortified puree diet with non-fat milk and may deviate from this diet on special occasions and/or when the resident so desired.A review of an entry in the nurse's notes by Licensed Vocational Nurse 1 (LVN 1), dated 5/25/14, at 3 PM, indicated at approximately 12:22 PM, on 5/25/14, Resident 1 was found by her Certified Nurse Assistant 1 (CNA 1) in her room, on the floor, and gasping for air. Knowing that Resident 1 had a high risk for choking, CNA 1 yelled for help and initiated the Heimlich maneuver. LVN 1 immediately arrived and continued the Heimlich maneuver. Resident 1 was noted regurgitating puree food during the Heimlich maneuver. Emergency 911 was called and after two minutes of the Heimlich maneuver, the resident was still unresponsive. Cardiopulmonary resuscitation (CPR) was initiated and continued until emergency personnel arrived. The fire department arrived and Resident 1 was attended to by three Emergency medical technicians, (EMT) for another 10 ten minutes. Resident 1 was unresponsive to CPR. At around 12:56 PM, Resident 1 was still without a pulse, and was pronounced dead by the EMT. During an interview with Registered Nurse 1 (RN 1), on 5/28/14, at 2 PM, she stated on 5/25/14, during lunch time, Resident 1 choked on a hot dog she took from her roommate's tray. She said Resident 1 was found in her room, on the floor, unresponsive, by CNA 1, who had been assigned to her. RN 1 said they tried the Heimlich maneuver on the resident, while waiting for the paramedics, but were unsuccessful. She further stated Resident 1 and her roommate usually ate in their room and Resident 1 required supervision during meals because she had difficulty in swallowing and a history of choking. RN 1 stated she did not know why Resident 1 was not supervised at that time.During an interview with CNA 1, on 5/28/14, at 2:45 PM, he stated after he delivered the food tray for Resident 1 and her roommate, he opened a carton of milk for her and left the room to deliver a food tray for a resident in another room. CNA 1 stated that he left Resident 1?s room only for a short time but was not sure specifically how long he was out of the room. CNA 1 stated that when he came back to Resident 1's room she was already on the floor and unresponsive. He stated that he knew Resident 1 needed supervision while eating because she had a risk for choking. He further stated Resident 1?s food tray should have been delivered last so Resident 1 could be supervised while eating.The coroner autopsy report, dated 6/3/14, indicated Resident 1's cause of death was choking due to an obstructive food bolus.The facility?s failure to provide adequate supervision to Resident 1, during meals as indicated in the plan of care to prevent a reoccurrence of choking resulted in Resident 1 choking on some food particles and subsequently expired.This violation presented an imminent danger of death or serious harm to the patient and was a direct cause of death of the patient. |
| 950000009 |
GLENDORA GRAND, INC. |
950012125 |
B |
18-Mar-16 |
GG5Z11 |
7886 |
Based on observation, interview, and record review, the facility failed to report an allegation of employee to resident abuse immediately or within 24 hours in accordance with the facility's policy and procedure. Resident 1 was allegedly hit by a facility staff and sustained multiple injuries on the face.Findings: On May 21, 2015, at 2:40 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Employee to Resident Abuse involving Resident 1. A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility on November 7, 2014, and was readmitted on May 5, 2015, with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), psychosis (a mental disorder characterized by a disconnection from reality), and hypertension (high blood pressure).The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated May 17, 2015, indicated Resident 1 was able to complete the brief mental status interview, able to make himself understood and usually understood others, and required limited assistance with most activities of daily living. The MDS indicated the resident is occasionally incontinent of bowel and bladder.During a telephone interview on May 21, 2015, at 12:37 a.m., the resident's Family Member A stated that she received a call from a facility staff who informed her that Resident 1 had fallen and was being transferred to the hospital. Family Member A stated that she could not believe the extent of the resident's injuries when she saw him at the hospital. According to the Family Member A, the Resident 1's left eye was completely closed and swollen, his right eye was partially closed and swollen, and he had a cut above his right eyebrow. The family member stated that when she asked the resident what happened, the resident replied "he hit me" and when she asked who hit him, Resident 1 replied "some big Mexican guy." A review of the facility Nurse's note dated May 15, 2015, at 8:50 p.m., indicated at around 7:20 p.m., a staff member CNA 1called for help at room 35. The resident was found on the floor on a side lying position. The note indicated per staff member, "When we're (CNA 1 and CNA 2) just buttoning his pants, he briefly ran away and slipped, lost his balance." "He hit his right eyebrow on the edge of the bed and landed down on his face on the floor." According to the note, Resident 1 was assessed (by the Registered Nurse Supervisor) with 1 centimeter (cm) right eyebrow cut and left under eye swelling with purplish discoloration and had to be transferred to the acute care hospital. According to the Emergency Physician Record from the acute care hospital dated May 15, 2015, at 9:55 p.m., the resident fell out of his bed at the nursing facility and sustained two linear superficial lacerations on the right eyebrow, hematoma under the left eye, acute bilateral nasal bone fractures, and left orbital wall fracture. A review of a Nurse's note from the acute care hospital dated May 15, 2015, at 11:36 p.m., indicated the resident's right eyebrow laceration was cleaned and dressed, an ice pack was applied to the left eye area; and the resident has been examined by the physician and indicated that the resident's injuries were consistent with the fall on the face and will be discharged back to the nursing facility.During an interview on May 21, 2015, at 2:40 p.m., the administrator and the director of nursing (DON) stated that they started an investigation immediately after the fall incident and did not suspect any abuse based on the statements of the two certified nursing assistants (CNAs). The administrator further stated that they first heard of the alleged abuse on May 16, 2015, when the Glendora Police Department came to the facility to investigate an alleged assault towards the resident.May 21, 2015, at 3 p.m., Resident 1 was observed with swelling and discoloration on the left eye and a healing abrasion on the right side of the face. When asked how he was doing, the resident stated "so far so good." When asked about what happened to his eye, the resident mumbled and kept repeating "I'm okay." When asked about what happened to his face, Resident 1 stated "Oh nothing bad."During another interview on May 22, 2015, at 11:40 a.m., the administrator stated that the resident's family member came to the facility on May 18, 2015, and claimed that the resident was hit by a facility staff and did not fall. The administrator stated that the alleged abuse was not reported to the Department immediately because the facility staff knew exactly what happened and that the resident's injuries were sustained from a fall and not from an abuse. During a telephone interview with CNA 1 on June 25, 2015, at 10:15 a.m., and with CNA 2 on June 25, 2015, at 11 a.m., both facility staff stated that they had changed the resident's diaper in bed, put on his pants, and stood him up by the head of the bed to zip and button his pants when the resident suddenly ran towards the foot of the bed then slipped and fell, hitting his right eyebrow on the edge of the bed's foot board then landing on the floor on his left side. CNA 1 and CNA 2 stated they called Licensed Vocational Nurse (LVN) 1 right away.During a telephone interview on June 25, 2015, at 9:05 a.m., LVN 1 stated that the CNA called for help and informed him that the resident had fallen. LVN 1 stated he went in the room and found the resident on the floor face down, bleeding. According to LVN 1, the resident's face was clear and intact when he saw him an hour before the incident happened. On June 25, 2015, at 9:40 a.m., during a telephone interview, the registered nurse (RN) supervisor stated that she was called into the room to assess the resident after the fall incident. The RN supervisor stated that the resident sustained a laceration on the right side of his face and swelling and discoloration on the left side of his face. First aid was provided and the physician was notified, who then ordered to transfer the resident to the acute care hospital. A review of a police report dated May 17, 2015, indicated a report was received regarding a possible assault towards Resident 1. The report indicated that according to the reporting party, the resident stated that he had been hit. The report further indicated the resident sustained minor facial injuries from a fall and there was no suspicion of foul play noted in the resident's hospital records. According to the report, the police department was unable to determine if a crime had actually occurred. A review of the facility's undated policy and procedure titled "Elder Abuse - Policy and Procedure" indicated the facility will report all allegations and substantiated occurrences of abuse, neglect and misappropriation of property to the state agency and law enforcement officials as designated by state law. If the suspected abuse does not result in serious bodily injury, the mandated reporter must report the incident by telephone within 24 hours to local law enforcement agency and provide a written report to the local ombudsman, the L&C Program and the local law enforcement agency within 24 hours. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five working days of the reported incident.The facility?s failure to implement their Abuse Policy and Procedure placed Resident 1 at risk for potential abuse which had a direct relationship to the Health and Safety of all residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950012127 |
B |
18-Mar-16 |
MU0511 |
7169 |
F225 The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law: or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property: and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State Law through established Procedures. (including to the State survey and certification agency). The facility must have evidence that all alleged violation are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigation must be reported to the Administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Based on interview and record review, the facility failed to implement its policies and procedures on abuse by failing to thoroughly investigate and report to the Department verbal threats made by Resident 1 toward Resident 2 and Resident 3.On 9/24/14 at 2:43 p.m., and 9/25/14 at 12:45 p.m., unannounced visits were made to the facility to investigate a complaint regarding an incident of alleged verbal threats by Resident 1 toward Resident 2. During an interview on 9/24/14, at 3:03 p.m. Resident 4 stated that Resident 1 made a verbal threat to Resident 2 that Resident 1 would get friends (from outside) to beat up Resident 2. Resident 4 stated that he was afraid that Resident 1?s friends would come to the facility and beat up residents. During an interview on 9/24/14, at 3:10 p.m. Resident 2 stated that Resident 1 made verbal threats to him and another Resident (Resident 3) that Resident 1 would call his outside friends to beat up on them. Resident 2 stated that it all started about two weeks ago at bedtime when Resident 1 had the radio very loud. They (Resident 1 and Resident 2) were by the nurse?s station and the Licensed Vocational Nurse (LVN 1) went to Resident 1?s room and told him to lower the radio because some people cannot sleep. Resident 1 then came out of the room in his wheelchair and assumed Resident 2 and Resident 3 complained to the nurse about the loud radio. Resident 2 stated this was when Resident 1 verbally threatened them of calling his friends from outside to beat up on them. Resident 2 stated that he was afraid that Resident 1 would really call his friends to beat up on them. During an interview on 9/24/14, at 3:20 p.m. Resident 3 stated that Resident 1 did make verbal threats against them (Resident 2 and Resident 3) and that Resident 1 will have his friends come to the facility to beat up on them. Resident 3 added that LVN 1 witnessed the incident. During an interview on 9/24/14 at 4:05 p.m. Resident 1 denied the above allegations. He denied making verbal threats to anybody in the facility. During a telephone interview on 9/24/14 at 4:05 p.m. LVN 1 stated Resident 1 did make verbal threats to Resident 2 and Resident 3 and that Resident 1 stated he would call his outside friends if any problem occurred with Resident 2 and Resident 3. LVN 1 stated that she reported the incident to the RN Supervisor during the evening shift. During an interview on 9/24/14 at 4:19 p.m. the RN Supervisor stated she did remember LVN 1 calling her and that she came to the nursing unit to investigate the incident. However, the RN Supervisor did not remember being told about Resident 1?s verbal threats to Resident 2 and Resident 3. She stated that she made a report and made the Administrator and DON aware of the incident, without the information about the verbal threats.During an interview on 9/24/14, at 4:40 p.m. both the Director of Nursing and a Social Services staff stated that they were not aware of Resident 1?s verbal threats to Resident 2 and Resident 3 about calling his friends to beat up on them. Both the DON and SS 1 stated Resident 1?s threats were serious and that they would do further investigations. SS 1 stated the severity of Resident 1?s verbal threats made by this a reportable case to the Department. Both stated this incident was not reported to the Department because of their lack of knowledge about the verbal threats. During an interview on 9/25/14 at 12:45 p.m. the Administrator stated he was not aware of Resident 1?s verbal threats to Resident 2 and Resident 3, and that they would do further investigations. The facility?s undated policy and procedure, titled Elder Abuse, indicated, ?Any allegation of abuse, neglect or of any form of behavior that could be construed as a form of abuse or alleged violation and/or report of misappropriation of property received from any source inside or outside of the facility shall be immediately and thoroughly investigated. The results of all investigation will be reported to the Administrator or a designated representative or to other officials (including the State Survey and Certification Agency) in accordance with State law within 24 hours of the incident. The facility will make every attempt to prevent further potential abuse while the investigation is in progress. After thorough investigation, if the alleged violation is verified, appropriate corrective action will be taken.All information revealed during the investigation will be held in confidence and released only as allowed or required by law. Where there is a probability of a criminal act, the incident may be investigated by a law enforcement agency. 1. The facility will conduct an investigation of any alleged abuse/ neglect or misappropriation of Resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state as per state regulation. 4. The facility will investigate all patterns, trends or incidents that have suggest the possible presence of abuse, neglect, injury of unknown source of misappropriation of property, identified through analysis conducted by the facility supervisors, with intervention, reporting or policy/procedure modification conducted as appropriate.? The facility failed to implement its policies and procedure on abuse by failing to thoroughly investigate and report to the Department verbal threats made by Resident 1 toward Resident 2 and Resident 3. The facility?s failure to implement their abuse policy and procedure placed all the Residents at risk for potential abuse.This violation had a direct relationship to the health, safety or security of Residents. |
| 950000001 |
GLADSTONE CARE AND REHABILITATION CENTER |
950012695 |
A |
28-Oct-16 |
7QQF11 |
6493 |
Free of accidents hazards/supervision/devices. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 5/3/13 at 2:30 p.m., an unannounced visit was conducted to investigate an Entity Reported Incident that Resident A fell from her bed and sustained a fractured left hip on 4/23/13. Resident A had surgery (open reduction and internal fixation of the left hip fracture) on 4/26/13 and was hospitalized until 4/29/13. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance device to prevent falls for Resident A who had three fall incidents by failing to: 1. Implement its policy and procedures to revise Resident A's Care Plan to prevent further falls. 2. Implement the physician's order to monitor the placement of Resident A's bed alarm every shift. As a result, Resident A fell the third time from her bed, and had a fractured left hip. A review of the Admission Face Sheet indicated Resident A was a 72-year old female who was admitted to the facility on 12/7/12, with diagnoses that included hypertension (high blood pressure) and cerebrovascular accident (stroke) with left sided hemiplegia (weakness or paralysis of one side of the body). A review of the initial and quarterly Fall Risk Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of fall) dated 12/7/12 and 3/18/13, indicated Resident A scored 9. The Fall Risk Assessment indicated a total score of 10 or above represented a high risk for fall. A review of the quarterly Minimum Data Set (MDS-a care planning tool) dated 3/18/13, indicated Resident A had short term memory recall ability, used a wheelchair for locomotion on and off the unit and required extensive assistance in transfer (staff provide weight bearing support) with one physical support. On 5/3/13 at 2:50 p.m., Resident A was observed lying in bed on a bed alarm pad (a monitoring device that makes a loud sound when the resident tries to get up and pressure is released from the pad) while in bed. Resident A had left sided weakness. Her left hand and left arm were contracted. The resident's two daughters, who were visiting at that time, both stated that prior to Resident A?s falls, she had a bed alarm (another alarm device secured to the bed with an attached magnetic pull activation cord that is clipped to the resident?s clothing. It makes a loud sound when the pull activation cord pin is dislodged/disconnected from the alarm unit) while in bed, but the alarm cord was always seen hanging on Resident A?s left bed rail. Resident A stated she did not like the bed alarm. She unclipped the bed alarm pull cord before she got out of bed unassisted on 4/23/13, and fell. During an interview on 5/3/13 at 3:46 p.m., Certified Nursing Assistant (CNA 1) stated she went to Resident A's room to collect the breakfast tray on 4/23/13, when she found Resident A lying on the floor near the foot of her bed. The bed alarm cord was hanging on the resident's left bed rail. CNA 1 stated Resident A was known to remove her bed alarm. On 5/3/13 at 4:15 p.m., the medical record of Resident A was reviewed with the Director of Nursing (DON). The Licensed Nurses Progress Notes indicated Resident A fell from her bed on 1/9/13, 3/11/13, and 4/23/13. The Licensed Nurses Progress Notes indicated the fall incidents were unwitnessed. On 1/9/13, the resident had a skin tear to her left upper arm and skin discoloration to her left upper leg. On 3/11/13, she did not sustain any injury. An X-Ray result dated 4/25/13 indicated intertrochanteric fracture (broken thigh bone) of the left hip, after her fall on 4/23/13. Resident A was transferred to the hospital on 4/25/13. According to the operative report from the acute hospital, Resident A had surgery (open reduction and internal fixation of the left hip fracture) on 4/26/13 and was hospitalized until 4/29/13. The re-admission assessment at the facility dated 4/29/13 indicated Resident A had discoloration over three incision sites with staples and left inner thigh hematoma with swelling. The initial Care Plan for falls dated 12/7/12 and 12/10/12 indicated Resident A was at risk for falls due to generalized weakness, unsteady gait and episodes of removing her bed alarm. The Care Plan goal was for Resident A not to have falls and/or injuries every day. The Care Plan interventions included reminding the resident to call staff for assistance in transfer and visual checks (unspecified frequency). On 12/10/12, the physician ordered the use of a bed alarm and to monitor its placement every shift. The monitoring document in the Treatment Record for the bed alarm placement was not initialed by the licensed staff for the 7:00 a.m. - 3:00 p.m. shift on 4/8/13, 4/9/13, 4/16/13 and 4/23/13. The DON stated licensed staff's initials would indicate the bed alarm placement was monitored. Resident A's record indicated the initial Care Plan for falls was not revised on 1/9/13, and 3/11/13, to prevent further falls from her bed. The DON stated Resident A had a bed alarm which she thought was enough to prevent the resident falling from her bed. The DON stated she knew that Resident A was removing her bed alarm, but was not able to show alternatives or additions to the bed alarm until after the resident fell on 4/23/13 and sustained a fractured left hip. A review of the facility's undated policy and procedure titled ?Falls" indicated the Care Plan is to be reviewed, revised and updated after each fall incident of a resident. The facility failed to provide adequate supervision and assistance device to prevent falls for Resident A who had three fall incidents by failing to: 1. Implement its policy and procedures to revise Resident A's Care Plan to prevent further falls. 2. Implement the physician's order to monitor the placement of Resident A's bed alarm every shift. As a result of the fall, Resident A had a fractured left hip after her third fall from her bed. Resident A had surgery (open reduction and internal fixation of the left hip fracture) on 4/26/13 and was hospitalized until 4/29/13. 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. |
| 950000009 |
GLENDORA GRAND, INC. |
950012772 |
B |
23-Nov-16 |
3X2712 |
12137 |
483.25(h) The facility must ensure that- 1) The resident environment remains as free from accident hazards as is possible; and 2) Each resident receives adequate supervision and assistance devices to prevent accidents. On July 5, 2016, the facility?s recertification survey was initiated. The facility failed to ensure the resident environment was free from accident hazards by failing to: 1. Ensure residents were assessed and deemed safe for outings by their attending physician. 2. Adequately supervise and monitor residents with special needs, when they were taken on an all-day outing to the park two miles away from the facility. Of the 55 residents who were out on an outing to the park, 31 residents (Residents 11, 22, 35, 36, 38, 38, 41 thru 50, 52 thru 61, 70, 74, and 78 thru 81) were from the secured (locked) unit of the facility, and required close supervision due to wandering behavior and psychotic disorders (dysregulation of thought processes). On July 7, 2016 at 8:05 a.m., facility staff were observed gathering residents for an outing. Thirteen residents were observed sitting in a large van getting ready for an outing at the park. In a concurrent interview, Activity Staff (AS) 1 was asked for the names of the residents in the van but was unable to name them. AS 1 stated she met with the licensed vocational nurse (LVN) supervisor to arrange medications, the dietary supervisor to arrange meals, the director of nursing, and the administrator on July 6, 2016 at 4 p.m., to coordinate the park outing for July 7, 2016. A review of the roster for the residents who were attending the park outing, revealed there were 31 residents (11, 22, 35, 36, 38, 41 thru 50, 52 thru 61, 70, 74, and 78-81) from the secured unit, who required close supervision due to wandering behavior and psychotic disorders (dysregulation of thought processes). A review of the Face Sheets and Medication Administration Record (MAR) for the 31 residents indicated all 31 residents had mental health diagnoses and were receiving psychotropic (medications used in treating several mental disorders) medications. For example: 1. Resident 35 was readmitted to the facility on June 3, 2016, with diagnoses that included but not limited to Alzheimer's disease (memory loss) and Schizoaffective disorder (mental disorder characterized by abnormal thought processes and deregulated emotions). Resident 35's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Seroquel (medication used to treat mental disorders) for verbally abusive toward staff and Depakote for striking out. 2. Resident 36 was readmitted to the facility on October 8, 2015, with diagnoses that included but not limited to bipolar and psychotic disorder. Resident 36's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Seroquel for delusional of being picked up every day at certain time and Lithium Carbonate (used to treat mania and bipolar disorder) for fluctuating mood of happiness and anger. 3. Resident 38 was readmitted to the facility on June 29, 2016, with diagnoses that included but not limited to abnormalities of gait and mobility and psychosis. Resident 38's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Depakote for slapping others for no reason and Lithium Carbonate for delusions (misconceptions) that several females stole her ex-husband. 4. Resident 41 was admitted to the facility on May 22, 2016, with diagnoses that included but not limited to schizophrenia and bipolar disorder. Resident 41's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Zyprexa for paranoia that others are after her. 5. Resident 42 was readmitted to the facility on May 27, 2016, with diagnoses that included but not limited to difficulty walking and schizophrenia. Resident 42?s Medication Administration Record (MAR), dated July 2016, indicated a physician order for Abilify (used to treat schizophrenia) for talking to self and Buspar (used to treat anxiety) for yelling for no apparent reason. 6. Resident 43 was readmitted to the facility on July 1, 2016, with diagnoses that included but not limited to dementia and schizoaffective disorder. Resident 43's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Nuedexta (used to treat involuntary outbursts of crying or laughing in people with certain neurological disorders) for mood liability and Depakote for persistent anger with others. 7. Resident 44 was readmitted to the facility on May 28, 2016, with diagnoses that included but not limited to schizophrenia and anxiety. Resident 44's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Risperdal for delusional thoughts. 8. Resident 45 was readmitted to the facility on April 1, 2016, with diagnoses that included but not limited to difficulty walking and schizophrenia. Resident 45?s Medication Administration Record (MAR), dated July 2016, indicated a physician order for Lithium for throwing objects at staff and others and Zyprexa for responding to auditory hallucination. 9. Resident 46 was readmitted to the facility on February 9, 2016, with diagnoses that included but not limited to psychosis and schizoaffective disorder. Resident 46?s Medication Administration Record (MAR), dated July 2016, indicated a physician order for Stelazine (used to treat schizophrenia) for delusions of staff attempting to kill her and Depakote for striking out for no reason. 10. Resident 47 was readmitted to the facility on May 31, 2016, with diagnoses that included but not limited to abnormalities of gait and mobility and schizoaffective disorder. Resident 47's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Depakote for yelling for no apparent reason and Risperdal for rummaging through others belongings. 11. Resident 48 was readmitted to the facility on May 19, 2016, with diagnoses that included abnormalities of gait (manner of walking) and mobility (ability to move freely) and psychosis (severe mental disorder which thought and emotions are impaired). Resident 48's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Depakote for striking out and Abilify for verbally abusive to staff and throwing objects. 12. Resident 69 was recently readmitted to the facility on June 21, 2016, with diagnoses that included but not limited to difficulty in walking, encephalopathy (abnormal brain function) and muscle weakness. Resident 69's Medication Administration Record (MAR), dated July 2016, indicated a physician's order for Zyprexa (medication used to treat mental disorders) for having thoughts that others would hurt him and Seroquel (medication used to treat mental disorder) for assaultive behavior towards staff and peers. 13. Resident 56 was admitted to the facility on February 28, 2014 and readmitted on April 7, 2016. The resident's diagnosis included cancer of the skin and nose. A review of physician's orders dated April 7, 2016, included: Haldol (antipsychotic) 5 milligrams (mg) three times a day for schizophrenia manifested by auditory hallucinations, Seroquel (antipsychotic) 600 mg by mouth at hour of sleep for psychosis manifested by hypersexual activity, Depakote (mood stabilizer) 500 mg by mouth three times a day for schizophrenia manifested by yelling for no apparent reason. Resident 56 did not have a physician's order to go out on pass. 14. Resident 38 was admitted to the facility on April 30, 2014 and readmitted June 29, 2016. The resident's diagnoses included seizures. A review of physician's orders dated June 29, 2016, included Lithium Carbonate (for manic-depressive disorder) 300 milligrams (mg) twice a day for psychosis; Trazadone (antidepressant) 100 mg by mouth every day, at hour of sleep, for depression manifested by trying to hurt herself, and Haldol (antipsychotic medication) 10 mg twice a day for schizophrenia manifested by verbally abusive behavior. Resident 38 did not have a physician's order to go out on outings. 15. Resident 77 was admitted to the facility on November 30, 2010. The resident's diagnosis included dermatitis (allergic skin condition) and seizures. The physician's orders dated May 9, 2016 included Olanzapine (antipathetic medication) 10 mg by mouth daily and at hour of sleep for schizophrenia manifested by striking out at others. Resident 77 did not have a physician's order to go on outings. On July 7, 2016 at 3:15 p.m., a total of 55 residents were observed sitting in their wheelchairs or walking around the park. Resident 69 was sitting in his wheelchair, propelling himself along the walkway close to the parking lot. Resident 62 was sitting in his wheelchair, blocking the pathway. Resident 69 yelled at Resident 62 to move. When Resident 62 did not move his wheelchair out of the pathway, Resident 69 kicked the left wheel of Resident 62's wheelchair multiple times. When Staff 1 asked Resident 69 to stop kicking Resident 62's wheelchair, Resident 69 started to chase Staff 1 while yelling that he is calling law enforcement. During a concurrent observation, Resident 34 was sitting in his wheelchair smoking a cigarette over a dry grass area. According to the National Fire Protection Association's study entitled "Brush, Grass, and Forest Fires" published in November 2013, "smoking materials were the heat source in almost half (47%) of the brush or brush and grass mixture fires" during the years of 2007-2011. During an interview with LVN 14, on July 7, 2016, at 3:20 p.m., he stated he was one of the two charge nurses who accompanied the residents. LVN 14 was asked how he would account for these 55 residents and stated he was taking a head count of each resident. LVN 14 showed a hand written roster of residents who attended the outing. The roster did not contain an account of the head counts; or the frequency that staff were doing it, to ensure the residents were supervised of their whereabouts and safety. During an interview with the Medical Director, on July 8, 2016, at 2:36 p.m., he stated residents must have an order prior to attending an outing because residents needed to be assessed based on their functional status, especially for resident with dementia (disconnection of reality) and due to the risk of getting lost, and their medications. During an interview with the DON, on July 13, 2016, at 1:30 p.m., she stated of the 55 residents who attended the park outing; only seven (7) had orders from their physicians to attend the outing. There were 48 residents who attended the activity without physician's approval. A review of the facility?s "Off-Premise Activities" revised August 2006, indicated off-premise activities are monitored for safety. Residents are considered appropriate for off-premise activities based on physician's approval and resident's request to participate in the outing. An appropriately qualified and authorized individual will accompany the activity director/coordinator on field trips to help oversee the residents and tend to any medical or behavioral problems that might arise. The facility failed to ensure the resident environment was free from accident hazards by failing to: 3. Ensure residents were assessed and deemed safe for outings by their attending physicians. 4. Adequately supervise and monitor residents with special needs, when they were taken on an all-day outing to the park two miles away from the facility. Of the 55 residents who were out on an outing to the park, 31 residents (Residents 11, 22, 35, 36, 38, 38, 41 thru 50, 52 thru 61, 70, 74, and 78 thru 81) were from the secured (locked) unit of the facility, and required close supervision due to wandering behavior and psychotic disorders (dysregulation of thought processes). The deficient practices had a direct relationship to the health, safety, and security of all the residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950012831 |
A |
22-Dec-16 |
3X2711 |
15781 |
F309 Quality of care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well -being, in accordance with the comprehensive assessment and plan of care. On July 5, 2016, the facility?s recertification survey was initiated. The facility failed to provide the necessary care and services to attain and maintain the highest practicable physical and mental well-being of residents by failing to: 1. Adequately monitor residents with special needs to prevent serious medical conditions, when they were taken on an outing. 2. Ensure the residents who went on the outing were assessed and had physician?s orders that allowed them to go on outings, taking into consideration their functional ability and the medications that they are receiving. 3. Ensure the residents were offered sunscreen or sunblock, resulting in skin redness, pain and discomfort. It was sunny and the outside temperature was 86 degrees Fahrenheit, resulting in sunburn (skin redness) pain, and discomfort. On July 7, 2016 at 8:05 a.m., the facility staff were observed gathering residents for an outing. A review of the roster for the residents who were attending the park outing, revealed there were 55 residents going on the outing. Out of the 55, there were 31 residents (11, 22, 35, 36, 38, 41 thru 50, 52 thru 61, 70, 74, and 78-81) from the secured unit, who required close supervision due to wandering behavior and psychotic disorders (dysregulation of thought processes). A review of the Face Sheets and Medication Administration Record (MAR) for the 31 residents indicated all 31 residents had psychiatric diagnoses and were receiving psychotropic (medications used in treating several mental disorders) medications. For example: 1. Resident 11 was recently readmitted to the facility on xxxxxxx, with diagnoses that included schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), bipolar disorder (mental disorder with periods of depression and periods of elevated mood) and encephalopathy (abnormal brain function). Resident 11's Medication Administration Record (MAR), dated July 2016, indicated a physician's order for Depakote (medication used to treat mental disorders) for striking out. One of the precautions to take when on Depakote is to avoid exposure to sunlight or tanning beds. 2. Resident 35 was readmitted to the facility on xxxxxxx, with diagnoses that included but not limited to Alzheimer's disease (memory loss), and Schizoaffective disorder (mental disorder characterized by abnormal thought processes and deregulated emotions). Resident 35's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Seroquel (medication used to treat mental disorders) for being verbally abusive toward staff and Depakote for striking out. 3. Resident 36 was readmitted to the facility on xxxxxxx, with diagnoses that included but not limited to bipolar and psychotic disorder. Resident 36's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Seroquel for delusions of being picked up every day at a certain time, and Lithium Carbonate (used to treat mania and bipolar disorder) for fluctuating mood of happiness and anger. 4. Resident 38 was readmitted to the facility on xxxxxxx, with diagnoses that included but not limited to abnormalities of gait and mobility and psychosis. Resident 38's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Depakote for slapping others for no reason and Lithium Carbonate for delusions (misconceptions) that several females stole her ex-husband. 5. Resident 41 was admitted to the facility on xxxxxxx, with diagnoses that included but not limited to schizophrenia and bipolar disorder. Resident 41's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Zyprexa for paranoia that others are after her. 6. Resident 42 was readmitted to the facility on xxxxxxx, with diagnoses that included but not limited to difficulty walking and schizophrenia. Resident 42's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Abilify (used to treat schizophrenia) for talking to self and Buspar (used to treat anxiety) for yelling for no apparent reason. 7. Resident 43 was readmitted to the facility on xxxxxxx, with diagnoses that included but not limited to dementia and schizoaffective disorder. Resident 43's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Nuedexta (used to treat involuntary outbursts of crying or laughing in people with certain neurological disorders) for mood liability and Depakote for persistent anger with others. 8. Resident 44 was readmitted to the facility on May 28, 2016, with diagnoses that included but not limited to schizophrenia and anxiety. Resident 44's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Risperdal for delusional thoughts. 9. Resident 45 was readmitted to the facility on April 1, 2016, with diagnoses that included but not limited to difficulty walking and schizophrenia. Resident 45's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Lithium for throwing objects at staff and others and Zyprexa for responding to auditory hallucination. 10. Resident 46 was readmitted to the facility on February 9, 2016, with diagnoses that included but not limited to psychosis and schizoaffective disorder. Resident 46's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Stelazine (used to treat schizophrenia) for delusions of staff attempting to kill her and Depakote for striking out for no reason. 11. Resident 47 was readmitted to the facility on May 31, 2016, with diagnoses that included but not limited to abnormalities of gait and mobility and schizoaffective disorder. Resident 47's Medication Administration Record (MAR), dated July 2016, indicated a physician?s order for Depakote for yelling for no apparent reason and Risperdal for rummaging through others belongings. 12. Resident 48 was readmitted to the facility on May 19, 2016, with diagnoses that included abnormalities of gait (manner of walking) and mobility (ability to move freely) and psychosis (severe mental disorder which thought and emotions are impaired). Resident 48's Medication Administration Record (MAR), dated July 2016, indicated a physician order for Depakote for striking out and Abilify for verbally abusive to staff and throwing objects. 13. Resident 69 was recently readmitted to the facility on June 21, 2016, with diagnoses that included but not limited to difficulty in walking, encephalopathy (abnormal brain function) and muscle weakness. Resident 69's Medication Administration Record (MAR), dated July 2016, indicated a physician's order for Zyprexa (medication used to treat mental disorders) for having thoughts that others would hurt him and Seroquel (medication used to treat mental disorder) for assaultive behavior towards staff and peers. 14. Resident 56 was admitted to the facility on February 28, 2014 and readmitted on April 7, 2016. The resident's diagnosis included cancer of the skin and nose. A review of the physician's orders dated April 7, 2016, included: Haldol (antipsychotic) 5 milligrams (mg) three times a day for schizophrenia manifested by auditory hallucinations, Seroquel (antipsychotic) 600 mg by mouth at hour of sleep for psychosis manifested by hypersexual activity, Depakote (mood stabilizer) 500 mg by mouth three times a day for schizophrenia manifested by yelling for no apparent reason. Resident 56 did not have a physician's order to go out on pass. 15. Resident 77 was admitted to the facility on November 30, 2010. The resident's diagnosis included dermatitis (allergic skin condition) and seizures. The physician's orders dated May 9, 2016 included Olanzapine (antipathetic medication) 10 mg by mouth daily and at hour of sleep for schizophrenia manifested by striking out at others. Resident 77 did not have a physician's order to go on outings. According to the Iowa Geriatric Education Center, nearly all psychiatric medications increase the body's sensitivity to the heat or sun. Photosensitivity is the result of drugs combining with proteins in the skin to form substances which react with direct light. Being in the sun for as little as 30 to 60 minutes can cause a variety of allergic skin rashes. Other signs of sensitivity are severe sunburn, nausea and vomiting, flushed or pale skin, and confusion and fainting. According to the All Facilities Letter from the California Department of Public Health dated June 7, 2016, (), the facilities were to implement recommended precautionary measures to keep individuals safe and comfortable during extremely hot weather because elderly and other health-compromised individuals are more susceptible to extremes in temperature and possible dehydration. The L&C Program recommends facilities review " Fast Facts: Preventing Summer Heat Injuries " and implement measures to keep residents and clients comfortable during extremely hot weather, including the following: úKeep residents well hydrated with particular attention to dependent residents. úMinimize physical activities during the hottest parts of the day úStay indoors and out of the sun during the hottest parts of the day úKeep a hydration station readily available to residents, family, and staff úBe alert to adverse changes in patient and resident conditions that may be heat related úDevelop and implement a system to monitor hydration status and be prepared to take appropriate interventions. úPay special attention to patients with medications that make the patient susceptible to high temperatures, e.g. psychotropic medications. On July 7, 2016 at 3:15 p.m., a total of 55 residents were observed sitting in their wheelchairs or walking around the park. None of them were observed to have any form of sunscreen or sunblock. There were three tarps providing shade, but residents were walking around the park. It was sunny and the outside temperature was 86 degrees Fahrenheit. During an interview with LVN 14, on July 7, 2016, at 3:20 p.m., he stated he was one of the two charge nurses who accompanied the residents. LVN 14 was asked how he was monitoring the needs of the 55 residents. He stated he was taking a head count of each resident. LVN 14 showed a hand written roster of residents who attended the outing. A review of the roster did not contain the timing of the head counts, or the frequency of monitoring, to ensure the residents? condition were monitored. Residents were observed at the park on July 7, 2016 from about 10 am until about 4:30 pm. On July 7, 2016 at 4:40 p.m. following the outing, Resident 56 was observed in the dining room of the center building. The resident?s face and scalp were a bright red color. During a concurrent interview, Resident 56 stated he had attended the outing. He stated it was "too hot". The resident stated his nose and scalp were hurting. When asked if he was offered any sunblock, he replied ?no?. When asked how he spent the day. He stated, "I smoked cigarettes." When asked if he had enough water to drink during the outing, he stated, he ?mostly drank soda?. On July 7, 2016 at 4:50 p.m., Resident 38 was observed in the dining room of the center building. The resident's cheeks were bright red. An attempt to interview was made. However the resident did not respond. On July 7, 2016 at 5 pm, Resident 77 was observed sitting in a wheelchair in his room. The resident was wearing pants and a long sleeve shirt. Resident 77 was asked if he had enjoyed the outing at the park. The resident stated, "It was a little too hot." When asked if he had been wearing the same clothes at the park, he stated "Ya". At 5:30 p.m., the 55 residents were assessed by the charge nurses for signs and symptoms of adverse (harmful) reactions related to the off-site event participation. A total of 41 residents (Resident 6, 8, 11, 22, 32, 34-36, 38-43, 46 thru 60, 62, 65, 66, 70, 71, 76 thru 78, and 80) had acquired skin redness or sunburn, pain, and discomfort. The charge nurse was observed conducting body assessments. The charge nurse applied Aloe Vera (gel substance from a cactus-like plant used to relieve burns.) The charge nurse documented the following on 7/8/16: For Resident 21: ?Body assessment done, redness on face and bilateral forearms, Aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP (complete metabolic panel)(blood sample to test health status) panel was done due to complaints of nausea, vomiting, and diarrhea.? For Resident 33: ?Body assessment done, redness on cheek, Aloe Vera applied, no complaints of pain or discomfort, fluids encouraged. Resident complained of diarrhea while on outing on July 7, 2016, and was placed on 72-hour monitoring and no further episodes since returning from outing. CMP panel was done due to complaints of diarrhea.? For Resident 64: ?Body assessment done, redness on face and bilateral forearms, Aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged.? During an interview with the Medical Director, on July 8, 2016, at 2:36 p.m., he stated residents must have an order prior to attending an outing because the residents needed to be assessed related to the time of the event, functional status of the residents, especially for dementia (disconnection of reality) due to risk of getting lost, and side effects of their medications. During an interview and review of the clinical records with the DON, on July 13, 2016, at 1:30 p.m., she stated of the 55 residents who attended the park outing; only seven (7) had orders from their physicians to attend the outing. There were 48 residents who attended the activity without physician's approval. Review of the facility?s "Off-Premise Activities" revised August 2006, indicated off-premise activities are monitored for safety. Residents are considered appropriate for off-premise activities based on physician's approval and resident's request to participate in the outing. An appropriately qualified and authorized individual will accompany the activity director/coordinator on field trips to help oversee the residents and tend to any medical or behavioral problems that might arise. The facility failed to provide the necessary care and services to attain and maintain the highest practicable physical and mental well-being of residents by failing to: 1. Adequately monitor residents with special needs to prevent serious medical conditions, when they were taken on an outing. 2. Ensure the residents who went on the outing were assessed and had physician?s orders that allowed them to go on outings, taking into consideration their functional ability and the medications that they are receiving. 3. Ensure the residents were offered sunscreen or sunblock, resulting in skin redness, pain and discomfort. It was sunny and the outside temperature was 86 degrees Fahrenheit, resulting in sunburn (skin redness) pain, and discomfort. These violations either jointly, separately, or in any combination presented either an immediate danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 950000009 |
GLENDORA GRAND, INC. |
950012889 |
B |
18-Jan-17 |
3X2711 |
10430 |
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. F441 483.65 Infection Control, Prevent Spread The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. During the recertification survey that started on July 5, 2016, an outbreak of scabies infestation was identified. The facility failed to provide necessary care and services for Resident 55 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. According to the facility's undated policy and procedure, "Scabies Prevention and Control Programs," indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, "Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. The policy and procedure was lacking the following: investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. (According to Prevention and Control of Scabies in California long-term care facilities, March 2008, Long-term care facilities should have a scabies prevention program.) This program should include an assessment of the skin, hair and nail beds of all new admissions as soon as possible following arrival. Pruritus, rashes and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. A skin assessment should be repeated at least every 4 weeks and any signs or symptoms suggestive of infestation should be documented and communicated to the infection control practitioner. When scabies is suspected, an immediate search for additional cases should be initiated. [According to CDC (Centers for Disease Control): "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash."] Resident 55 was admitted to the facility on XXXXXXX and readmitted on XXXXXXX A review of Resident 55's medical record revealed the resident was being treated for scattered rashes since November 2014. The physician?s orders dated November 30, 2014 and December 21, 2014, indicated to apply Triamcinolone (used to treat itching, redness, dryness, crusting, scaling, inflammation) 0.1% cream for scattered body skin rashes. Review of the "Non-Pressure Sore Skin Problem Report" dated November 8, 15, 22, 29, 2014, indicated the resident had a scattered red generalized body rashes. On December 6, 13, 20, 21, 27, 2014, the Non Pressure Skin Problem Report indicated skin rashes had a slow response to treatment, and to continue treatment. In addition on January 3, 10, 17, 2015, the same treatment for the scattered body rashes continued thru June 12, 2015. Review of a "Non-Pressure Sore Skin Problem Report", dated June through August 2015 indicated Resident 55 had scattered body rashes. A physician's order dated July 25, 2015, indicated to apply Lidex Cream (used for itching and inflammation of certain skin conditions) 0.05% ointment to scattered body rash daily. The skin rashes resolved in August 2015, then returned May 2016. A physician's order on May 3, 2016, indicated to mix 10 milliliters (ml) of tree oil with 100 ml of water and apply to generalized body rashes daily. Another physician's order on July 11, 2016, indicated to apply Triamcinolone 0.1 % cream to generalized body skin rashes. During an interview on July 12, 2016 at p.m., the Director of Nursing (DON), stated Residents 55's skin condition was provided with multiple treatments which were ineffective treatments. The DON stated there had not been any scabies outbreaks among the residents or staff. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rashes, recognition and management of skin rashes when rashes do not improve after multiple treatment attempts. The DSD stated that skin rashes were not included in the surveillance of infection. The DSD was not able to present evidence of surveillance and tracking mechanism. The DON was not able to present evidence that the Public Health Nurse was notified/consulted of a possible scabies outbreak until the findings were brought to the facility?s attention on July 11, 2016 at 4 p.m. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview, the PHN stated as per direction by the District Medical Director of Public Health, the stations affected by the residents with clinical presentation of scabies will be closed for admission effective July 12, 2016. The facility would be on surveillance for six weeks due to a scabies outbreak in the facility. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of Elimite cream. According to http://www.cdc.gov, Elimite (Permethrin) is the drug of choice for the treatment of Scabies. Permethrin kills the Scabies mite and eggs, and is safe and effective when used as directed. The facility failed to provide necessary care and services for Resident 55 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. These violations had a direct relationship to the health, safety, or security of the residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950012890 |
B |
18-Jan-17 |
3X2711 |
11125 |
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. F441 483.65 Infection Control, Prevent Spread The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. During the recertification survey that started on July 5. 2016. an outbreak of scabies infestation was identified. The facility failed to provide necessary care and services for Resident 85 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. According to the facility's undated policy and procedure, "Scabies Prevention and Control Programs," indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, "Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. The policy and procedure was lacking the following: investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. (According to Prevention and Control of Scabies in California long-term care facilities, March 2008, Long-term care facilities should have a scabies prevention program.) This program should include an assessment of the skin, hair and nail beds of all new admissions as soon as possible following arrival. Pruritus, rashes and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. A skin assessment should be repeated at least every 4 weeks and any signs or symptoms suggestive of infestation should be documented and communicated to the infection control practitioner. When scabies is suspected, an immediate search for additional cases should be initiated. [According to CDC (Centers for Disease Control): "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash."] Resident 85 was originally admitted to the facility on XXXXXXX and re-admitted on XXXXXXX, and January 1, 2016 with the diagnoses that included difficulty walking, Alzheimer?s disease (memory loss), senile dementia (decline in mental ability), lack of coordination, and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The MDS dated May 27, 2016 indicated RSR 85 spoke clearly, usually makes self-understood, and usually understands others. RSR 85 requires extensive assistance with transfer, dressing, and toilet use. The body assessment dated January 1, 2016, indicated Resident 85 had generalized body skin rashes and itching. The physician ordered to mix 10 ml of Tea Tree oil with 100 ml of water and apply to generalized body skin rashes daily x 21 days and re-assess. Consequent body assessments on 1/29/2016, 2/6/2016, 2/13/2016, 2/21/2016, 2/28/2016, 3/5/2016, 3/11/2016, 3/19/2016, 3/25/2016, 4/3/2016, 4/10/2016, 4/16/2016, and 4/23/2016, indicated Resident 85 had scattered body rashes with raised papules, and dry skin. On April 28, 2016, Resident 85?s physician ordered to mix 10 ml of Tea tree oil to 100 ml of water and apply to body rashes daily x 2 weeks for dermatitis, re-ordered it on May 14, 2016 daily for 7 more days, on May 20, 2016 for 7 more days. On May 28, 2016 ordered to mix 10ml of tea tree oil with 100ml of waters to generalized body rashes daily x 14 days and re-ordered it on June 13, 2016 for another 21 days. The body assessment dated July 2, 2016 and July 9, 2016 indicated Resident 85 had scattered rashes, few scabs visible on bilateral upper arms, pink and faded on chest and abdomen. During an observation on July 11, 2016, at 11:07 a.m., with TN 2 in Station 2, Resident 85?s hands, feet, back, and stomach had multiple scattered raised red papules. TN 2 stated Resident 85 still had skin rashes. During an interview at 11:10 a.m., Resident 85 stated, "I feel itchy, and it feels like bugs living in my arms?. During an interview July 11, 2016 at 2 pm, the DON stated that staff members had not notified her of Residents 85's skin condition and the multiple ineffective treatments. The DON stated there were no skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. There was no evidence staff recognized that the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse, was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rashes, recognition and management of skin rashes when rashes do not improve after multiple treatment attempts. The DSD stated that skin rashes were not included in the surveillance of infection. The DSD was not able to present evidence of surveillance and tracking mechanism. The DON was not able to present evidence that the Public Health Nurse was notified/consulted of a possible scabies outbreak until the findings were brought to the facility?s attention on July 11, 2016 at 4 p.m. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview, the PHN stated as per direction by the District Medical Director of Public Health, the stations affected by the residents with clinical presentation of scabies will be closed for admission effective July 12, 2016. The facility would be on surveillance for six weeks due to a scabies outbreak in the facility. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of Elimite cream. According to http://www.cdc.gov, Elimite (Permethrin) is the drug of choice for the treatment of Scabies. Permethrin kills the Scabies mite and eggs, and is safe and effective when used as directed. The facility failed to provide necessary care and services for Resident 85 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. These violations had a direct relationship to the health, safety, or security of the residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950012891 |
B |
18-Jan-17 |
3X2711 |
13364 |
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. F441 483.65 Infection Control, Prevent Spread The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. During the recertification survey that started on July 5, 2016, an outbreak of scabies infestation was identified. The facility failed to provide necessary care and services for Resident 34 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. According to the facility's undated policy and procedure, "Scabies Prevention and Control Programs," indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, "Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. The policy and procedure was lacking the following: investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. (According to Prevention and Control of Scabies in California long-term care facilities, March 2008, Long-term care facilities should have a scabies prevention program.) This program should include an assessment of the skin, hair and nail beds of all new admissions as soon as possible following arrival. Pruritus, rashes and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. A skin assessment should be repeated at least every 4 weeks and any signs or symptoms suggestive of infestation should be documented and communicated to the infection control practitioner. When scabies is suspected, an immediate search for additional cases should be initiated. [According to CDC (Centers for Disease Control): "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash."] Resident 34 was originally admitted to the facility on XXXXXXX. The diagnoses included chronic obstructive pulmonary disease (COPD-a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), cerebrovascular accident (CVA- or stroke) with left- sided weakness and hypertension (high blood pressure). Resident 34?s Minimum Data Set (MDS), a standardized assessment and care screening tool dated June 7, 2016, indicated Resident 34 had the ability to understand others, make self-understood, and required extensive assistance from one person with most activities of daily living (ADLs) that included bed mobility, dressing, toilet use, and personal hygiene. A review of the facility?s ?Non- Pressure Sore Skin Problem Report" dated March 18, 2016, indicated Resident 34 had generalized skin rashes, described as red raised rashes with evidence of itching. The preventive measures indicated to keep the area clean, dry, and to apply Triamcinolone 0.1 percent (%) cream (treatment for a variety of skin conditions) to generalized body rashes every day for 21 days. The weekly progress report dated April 2, 2016 indicated skin rashes were noted on Resident 34?s upper back. The nurse?s notes dated April 9, 2016, indicated red and pink rashes on the right upper back and shoulders, with pink scattered areas to the lower back. On April 10, 2016, the Dermatologist (medical expert that deals with skin problems) saw Resident 34 at the facility and diagnosed the skin condition as dermatitis (inflammation of the skin) and psoriasis (a persistent, long lasting disease that causes the skin cells to build up rapidly on the surface of the skin. The treatment order was to apply Spectazole (anti-fungal cream) every day for one month to the arms and Triamcinolone 0.1 % every day for two weeks. The weekly nurses notes dated April 15, 2016 to April 22, 2016, indicated, Resident 34 still had red rashes to ?side ?of body with itching. Spectazole cream was continued to be applied for the skin rashes. On June 10, 2016, the nurse?s notes indicated Resident 34?s body rashes were still noted as pink elevated rashes with scratching, old scars present from rashes. On June 10, 2016, the Dermatologist ordered to mix 10 milliliter (ml) of Tea Tree Oil to 100 ml of water and apply to body rashes every day for two weeks. According to ?Nursing 2011 Drug Handbook?, Tea tree oil is 100 % pure essential oil, used as lotion for dermatoses (non-inflammatory disorder of the skin). Caution not to apply oil to wounds or to skin that?s dry or cracked. On June 18, 2016, Resident 34?s body assessment indicated there were scattered body rashes/patches. The nurse?s notes identified right and left arm abrasions (scraped area) with treatment of triple antibiotic for 14 days. On June 21, 2016, the physician ordered Calmoseptine (used to prevent and treat minor skin irritations) ointment to perineum (space between the anus genital areas) for 14 days. A review of the "Non-pressure Skin Problem Report" from July 2, 2016 to July 9, 2016, indicated presence of rashes with scabs to legs, redness to perineum area, self-inflicted scratches to left side of face and redness to face. Resident 34 was receiving triple antibiotic for the abrasion on the face, Calmoseptine ointment to the perineal area and Triamcinolone 0.1 % to rashes on both legs. On July 7, 2016, at 3:30 p.m., the Treatment Nurse (TN 1) performed Resident 34?s skin/body assessment after a sun exposure while out on a group facility activities at the park. During this time, Resident 34 was observed to have both arms with reddish dots and skin rashes to the front upper body parts, between the fingers of the right hand, right armpit and both legs. The right arm had open lesions (skin tears or wound) and dry scabs (crusts that form over a cut or wound during healing). On July 7, 2016, a 3:40 p.m., during an interview with Resident 34, with an interpreter, he stated, "I scratch all the time, day and night. Current treatment was not helping, the cream they apply don't work. I'm tired of it." At 3:45 p.m., TN 1 stated Resident 34 was already being seen regularly by a Dermatologist for his skin condition. On July 8, 2016, at 10 a.m., during an observation with Certified Nurse Assistant (CNA) 1, Resident 34?s upper back, trunk, and legs were covered with raised red papules (pimple-like rashes). At 10:15 a.m., during an interview, CNA 1 stated she had observed Resident 34 with skin rashes all the time. CNA 1 stated she applied A &D ointment (skin protectant) to dry areas of the skin. On July 8, 2016, at 10:30 a.m., during an interview with Licensed Vocational Nurse (LVN) 3, she stated Resident 34 had been receiving Tea tree oil prescribed by the Dermatologist for the skin rashes, but was not working. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse, was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rashes, recognition and management of skin rashes when rashes do not improve after multiple treatment attempts. The DSD stated that skin rashes were not included in the surveillance of infection. The DSD was not able to present evidence of surveillance and tracking mechanism. The DON was not able to present evidence that the Public Health Nurse notified/consulted of a possible scabies outbreak until the findings were brought to the facility?s attention on July 11, 2016 at 4 p.m. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview, the PHN stated as per direction by the District Medical Director of Public Health, the stations affected by the residents with clinical presentation of scabies will be closed for admission effective July 12, 2016. The facility would be on surveillance for six weeks due to a scabies outbreak in the facility. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of Elimite cream. According to http://www.cdc.gov, Elimite (Permethrin) is the drug of choice for the treatment of Scabies. Permethrin kills the Scabies mite and eggs, and is safe and effective when used as directed. The facility failed to provide necessary care and services for Resident 34 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. These violations had a direct relationship to the health, safety, or security of the residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950012892 |
B |
18-Jan-17 |
3X2711 |
10183 |
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. F441 483.65 Infection Control, Prevent Spread The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. During the recertification survey that started on July 5, 2016, an outbreak of scabies infestation was identified. The facility failed to provide necessary care and services for Residents 68 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. According to the facility's undated policy and procedure, "Scabies Prevention and Control Programs," indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, "Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. The policy and procedure was lacking the following: investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. (According to Prevention and Control of Scabies in California long-term care facilities, March 2008, Long-term care facilities should have a scabies prevention program.) This program should include an assessment of the skin, hair and nail beds of all new admissions as soon as possible following arrival. Pruritus, rashes and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. A skin assessment should be repeated at least every 4 weeks and any signs or symptoms suggestive of infestation should be documented and communicated to the infection control practitioner. When scabies is suspected, an immediate search for additional cases should be initiated. [According to CDC (Centers for Disease Control): "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash."] Resident 68 was originally admitted to the facility on XXXXXXX, with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus (higher sugar level in the blood), and hypertension (high blood sugar). The MDS dated June 4, 2016, indicated Resident 68 able to make self-understood, had episodes of confusion and required extensive assistance with transfers, dressing, toilet use and personal hygiene. A review of Resident 68's clinical record indicated a physician?s order on April 29, 2016, to apply Hydrocortisone 1% cream to generalized body rashes every day for 14 days. On June 2, 2016, Dermatology Consult notes indicated Resident 68's skin rashes had been unresponsive to multiple therapies. The plan of treatment was to continue Lidex 0.05% cream and to start treatment for Tea Tree Oil every day for 2 weeks. On June 23, 2016, an order to continue to apply Lidex 0.05% cream every day to the scattered body rash for 30 days. On July 11, 2016, at 12:00p.m., during an observation with TN 1, Resident 68?s arms and back were covered with multiple scattered raised red papules. During an interview at this time, Resident 68 stated she was itchy and had bugs in her skin. TN 1 stated the resident had a history of scabies. During an interview with the DON on July 11, 2016, at 2p.m. she stated staff members had not notified her of Resident 68?s skin condition and the multiple unsuccessful treatments. There was no evidence staff recognized that the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rashes, recognition and management of skin rashes when rashes do not improve after multiple treatment attempts. The DSD stated that skin rashes were not included in the surveillance of infection. The DSD was not able to present evidence of surveillance and tracking mechanism. The DON was not able to present evidence that the Public Health Nurse was notified/consulted of a possible scabies outbreak until the findings were brought to the facility?s attention on July 11, 2016 at 4 p.m. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview, the PHN stated as per direction by the District Medical Director of Public Health, the stations affected by the residents with clinical presentation of scabies will be closed for admission effective July 12, 2016. The facility would be on surveillance for six weeks due to a scabies outbreak in the facility. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of Elimite cream. According to http://www.cdc.gov, Elimite (Permethrin) is the drug of choice for the treatment of Scabies. Permethrin kills the Scabies mite and eggs, and is safe and effective when used as directed. The facility failed to provide necessary care and services for Residents 68 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. These violations had a direct relationship to the health, safety, or security of the resident. |
| 950000009 |
GLENDORA GRAND, INC. |
950012893 |
B |
18-Jan-17 |
3X2711 |
12127 |
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. F441 483.65 Infection Control, Prevent Spread The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. During the recertification survey that started on July 5, 2016, an outbreak of scabies infestation was identified. The facility failed to provide necessary care and services for Resident 83 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. According to the facility's undated policy and procedure, "Scabies Prevention and Control Programs," indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, "Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. The policy and procedure was lacking the following: investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. (According to Prevention and Control of Scabies in California long-term care facilities, March 2008, Long-term care facilities should have a scabies prevention program.) This program should include an assessment of the skin, hair and nail beds of all new admissions as soon as possible following arrival. Pruritus, rashes and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. A skin assessment should be repeated at least every 4 weeks and any signs or symptoms suggestive of infestation should be documented and communicated to the infection control practitioner. When scabies is suspected, an immediate search for additional cases should be initiated. [According to CDC (Centers for Disease Control): "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash."] Resident 83 was originally admitted to the facility on XXXXXXX, with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus (high sugar level in the blood), and heart disease. The MDS dated April 5, 2016; indicated Resident 83 usually understood others, able to make self-understood and required extensive assistance with one person during transfers, dressing, toilet use and personal hygiene. A review of the facility?s "Non- Pressure Sore Skin Problem Report? dated January 1, 2016; indicated Resident 83 had generalized skin rashes on the body. The skin rashes were described as red and brown scabs with itching and treated with Lidex (for dermatitis-condition of the skin which it becomes red and swollen) 0.05 % cream. On February 24, 2016, the Dermatologist ordered Tea Tree Oil 10 ml. mixed with 100 ml of water to be applied to the generalized body rashes every day for two weeks. On March 10, 2016, the Dermatologist again ordered to apply Tea Tree Oil 10 ml mixed with 100 ml of water to the generalized body rashes. On March 31, 2016, an order was obtained for Benadryl 50 mg by mouth every 6 hours for itching for 30 days. On April 1, 2016, a physician's order of Hydrocortisone (treat variety of skin condition) cream was obtained to be applied to the generalized skin rashes to the body times 14 days. On April 2, 2016, the nurse's notes indicated Resident 83 was given Benadryl 50 milligrams for complaints of body itching. The notes indicated there were multiple skin scratches on arms, legs and back. On April 18, 2016, there was another order to apply Hydrocortisone 1 % cream to generalized body and extremities scattered body skin rashes every day for another 30 days. On May 1, 2016, an order indicated to discontinue the previous order for Hydrocortisone cream and again started treatment with Tea Tree Oil 10 ml with 100 ml water to be applied to the generalized body rash every day for 14 days. On May 15, 2016, physician's consultation follow-up notes indicated Resident 83 was evaluated for the progress of the skin rashes which were not responding to the multiple therapies. Again, Tea tree oil was ordered daily for one month for the skin rashes. On May 17, 2016, there was an order to apply Amalactin cream (treatment applied to mild to severe forms of dry, scaly skin). On June 30, 2016, there was an order again to apply Hydrocortisone 1 % cream twice daily for 21 days for scattered body rash and Benadryl 25 mg by mouth every 6 hours as needed for itching for 21 days. On July 11, 2016, at 1 p.m. during an observation with Certified Nurse Assistant (CNA) 1, Resident 83?s front and back, upper trunk, legs and neck were covered with multiple scattered raised red skin rashes. Resident 83 informed CNA 1 (in Spanish) his left ear was very itchy. During an interview at 1:05 p.m., CNA 1 stated Resident 83 had been having skin rashes all over his body for over a year. During an interview on July 11, 2016, at 2 p.m., the DON stated Resident 83's skin condition had gone to multiple unsuccessful skin treatments. The DON stated there were no skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. There was no evidence staff recognized that the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies. The DON was not able to present evidence that the Public Health Nurse was notified/consulted of a possible outbreak. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rashes, recognition and management of skin rashes when rashes do not improve after multiple treatment attempts. The DSD stated that skin rashes were not included in the surveillance of infection. The DSD was not able to present evidence of a surveillance and tracking mechanism. The DON was not able to present evidence that the Public Health Nurse notified/consulted of a possible scabies outbreak until the findings were brought to the facility?s attention on July 11, 2016 at 4 p.m. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview, the PHN stated as per direction by the District Medical Director of Public Health, the stations affected by the residents with clinical presentation of scabies will be closed for admission effective July 12, 2016. The facility would be on surveillance for six weeks due to a scabies outbreak in the facility. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of Elimite cream. According to http://www.cdc.gov, Elimite (Permethrin) is the drug of choice for the treatment of Scabies. Permethrin kills the Scabies mite and eggs, and is safe and effective when used as directed. The facility failed to provide necessary care and services for Resident 83 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. These violations had a direct relationship to the health, safety, or security of the residents. |
| 950000009 |
GLENDORA GRAND, INC. |
950012894 |
B |
18-Jan-17 |
3X2711 |
10275 |
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. F441 483.65 Infection Control, Prevent Spread The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. During the recertification survey that started on July 5, 2016, an outbreak of scabies infestation was identified. The facility failed to provide necessary care and services for Resident 84 by failing to: 1. Recognize the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies, and consult with the District Public Health Nurse for a possible outbreak. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop and implement policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. According to the facility's undated policy and procedure, "Scabies Prevention and Control Programs," indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, "Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. The policy and procedure was lacking the following: investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. (According to Prevention and Control of Scabies in California long-term care facilities, March 2008, Long-term care facilities should have a scabies prevention program.) This program should include an assessment of the skin, hair and nail beds of all new admissions as soon as possible following arrival. Pruritus, rashes and skin lesions should be documented and brought to the attention of the nursing supervisor and the attending physician. A skin assessment should be repeated at least every 4 weeks and any signs or symptoms suggestive of infestation should be documented and communicated to the infection control practitioner. When scabies is suspected, an immediate search for additional cases should be initiated. [According to CDC (Centers for Disease Control): "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash."] Resident 84 was originally admitted to the facility on XXXXXXX,2015 and re-admitted on XXXXXXX 2016 with diagnoses that included Alzheimer's disease (memory loss) and Schizophrenia (mental disorder). The MDS dated April 10, 2016, indicated Resident 84 usually understood others, able to make self-understood and required limited assistance with transfers, dressing and toilet use. There was a physician?s order dated February 4, 2016, to apply triamcinolone 0.1% cream twice a day for 21 days to skin rashes; daily showers with Hibiclens (skin cleanser) every day for 7 days. On February 23, 2016, the physician ordered to apply Tea tree oil to the generalized skin rashes every day for 10 days. On March 7, 2016, the physician ordered to apply Tea tree oil to the generalized rash every day for 30 days. On March 19, 2016, the physician ordered to apply warm compresses to rashes on the face and arms for 5 minutes every four hours for 7 days. On April 21, 2016, the physician re-ordered to apply Tea tree oil to the generalized rash every day for two weeks. On April 24, 2016, the physician ordered to apply warm compress to side of the head and ear for 5 minutes every four hours for 7 days. On June 2, 2016, the physician re-ordered Triamcinolone 0.1 % cream to body once a day for 2 weeks and Tea tree oil to the body rashes every day for two weeks. On July 11, 2016, at 11:00 a.m., during an observation with the TN 1, Resident 84's hands and feet had multiple scattered rashes, raised red papules. Resident 84 stated at that time that he was very itchy. During an interview with the DON on July 11, 2016, at 2 p.m., she stated Resident 84 had a skin condition and was treated with multiple unsuccessful treatments. The DON was not able to present evidence that the Public Health Nurse was notified/consulted of a possible outbreak of scabies. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rashes, recognition and management of skin rashes when rashes do not improve after multiple treatment attempts. The DSD stated that skin rashes were not included in the surveillance of infection. The DSD was not able to present evidence of a surveillance and tracking mechanism. The DON was not able to present evidence that the Public Health Nurse notified/consulted of a possible scabies outbreak until the findings were brought to the facility?s attention on July 11, 2016 at 4 p.m. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview, the PHN stated as per direction by the District Medical Director of Public Health, the stations affected by the residents with clinical presentation of scabies will be closed for admission effective July 12, 2016. The facility would be on surveillance for six weeks due to a scabies outbreak in the facility. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of Elimite cream. According to http://www.cdc.gov, Elimite (Permethrin) is the drug of choice for the treatment of Scabies. Permethrin kills the Scabies mite and eggs, and is safe and effective when used as directed. The facility failed to provide necessary care and services for Resident 84 by failing to: 1. Identify the clinical signs and symptoms of the skin condition, such as itching, scratching, and raised red papules (pimple-like rashes) all over the residents? body, as suspicious for scabies. 2. Identify and provide appropriate treatment to the skin rashes after the multiple treatments have failed. 3. Develop policies and procedures that included investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and prophylaxis (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies, in accordance with Prevention and Control of Scabies in California long-term care facilities, March 2008 guidelines. These violations had a direct relationship to the health, safety, or security of the residents. |
| 970000171 |
GOLDEN CROSS HEALTH CARE |
950013182 |
A |
4-May-17 |
LEUB11 |
13741 |
F- 323
?483.25(d) (1) (2) Accidents.
The facility must ensure that:
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 1/23/17, at 1:00 p.m. an unannounced visit was made to the facility to investigate an entity reported incident regarding a resident (Resident 1) being found outside the facility and complained of pain to the right shoulder.
Based on observation, interview and record review, the facility failed to:
1. Ensure the facility's Wander Guard alert system was maintained and functioned properly. This tracking device is designed to prevent persons at risk from leaving the facility The system tracks the person using a wrist or ankle band and automatically alarms if the person moves outside a defined area without being accompanied by an authorized person.
2. Ensure residents were not allowed to leave the facility without proper supervision/authorization. These deficient practices resulted in the elopement (left the facility without authorization and/or supervision) of Residents 1 and 2 from the facility and Resident 1 sustaining a fractured right arm.
A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on XXXXXXX 16 with diagnoses that included: Alzheimer's disease (chronic disease characterized by memory loss, behavioral issues and disorientation) and muscle weakness (lack of muscle strength).
A review of Resident 1's History and Physical dated 1/9/17 indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment tool, dated 12/21/16 indicated Resident 1 had a brief interview for mental status (BIMS) score of 8 (8-12 indicates moderately impaired cognition), required supervision with bed mobility, transfer, dressing, eating, personal hygiene and bathing.
A review of Resident 1's Wandering Risk Scale dated 6/7/2016 indicated Resident 1 had a wandering risk scale score of 12. A score of 11 and above indicates a high risk to wander.
A review of Resident 1's physician's Order Summary Report for January 2017 indicated the following order dated 6/7/2016: May use Wander Guard due to wandering (aimless or random movement by a person with a mental disorder or cognitive impairment) behavior.
A review of Resident 1's Social Service Assessment dated 6/7/16 indicated Resident 1 may have a potential to elope, and had a WanderGuard in place.
A review of Resident 1's Activity Participation Note dated 1/2/17 indicated Resident 1 enjoyed drawing and crocheting, had been making a blanket as a crochet project. The Activity Participation Note also indicated Resident 1 needed to be monitored closely as the resident has episodes of confusion where she will pack her belongings saying she is going to another country while heading for the door.
A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility of XXXXXXX12 with diagnoses that included: Parkinson's disease (chronic disease of nervous system characterized by shaking, rigidity and difficulty walking), muscle weakness and dementia (chronic brain disease characterized by decrease in ability to think).
A review of Resident 2's MDS dated 10/2/16 indicated Resident 2 had severely impaired cognitive skills for daily decision making, required extensive assistance with bed mobility and transfer, required total dependence with one-person physical assist with locomotion off unit, required wheelchair as mobility device.
A review of Resident 2's care plan Limited Physical Mobility r/t (related to) weakness, dated 10/11/13 indicated Resident 2 will remain free of complications related to immobility, interventions included Resident 2 required extensive to total assistance by one staff for locomotion using recliner wheelchair.
During a concurrent observation and interview with Resident 1 on 1/23/17 at 1:30 pm, Resident 1 was observed sitting on a chair in the hallway. Resident 1 was observed with a sling applied on the right upper extremity. Resident 1 was also observed with a WanderGuard on the left wrist. Resident 1 stated that she fell at home when she was watering the plants in her backyard. Resident 1 further stated that she could not crochet anymore because of the injury.
A review of the facility's video surveillance was conducted with the Administrator on 1/23/17 at 2:00 pm. The video dated 1/4/17, showed the following:
1. At 3:07 pm-Resident 1 was observed standing beside Resident 2 who was sitting on a reclined wheelchair beside the south nursing station. Licensed Vocational Nurse (LVN) 1 was seen going to a medication cart in front of south nursing station near both Residents 1 and 2.
2. At 3:08 pm-LVN 1 looked at both Residents 1 and 2. LVN 2 went to LVN 1 and started to do a medication count. Resident 1 was seen pushing Resident 2 in the wheelchair.
3. At 3:10 pm-Residents 1 and 2 were seen leaving the building from the south exit door. The video had no sound track and it could not be determined if the WanderGuard alarm system had been activated. No staff was visible in the video at the time the residents were leaving the facility or after the residents had left the facility.
4. At 3:12 pm-Video surveillance outside the building showed Resident 1 was pushing Resident 2 towards a driveway with a wall on the left side and the facility building on the right side. The driveway sloped down to an entrance that had a closed gate. On the other side of the gate was a busy four lane street. Resident 1 was observed falling onto the ground towards the end of the downhill slope and letting go of Resident 2's wheelchair.
5. At 3:13 pm-The video showed Resident 2's wheelchair, hit the wall along the driveway, which slowed the wheelchair and eventually the wheelchair stopped at the bottom of the driveway.
6. At 3:14 pm, the video showed two cars entered the driveway stopping in front of Residents 1 and 2. Two facility staff were observed running downhill and assisted Residents 1 and 2.
7. At 3:16 pm, both residents were brought back into the facility.
During a concurrent observation and interview with the maintenance supervisor on 3/16/2017 at 1:00 pm, the maintenance supervisor stated that the slope of the downhill driveway is about 45 degree angle. The maintenance supervisor measured and stated that the downhill driveway was 61 feet.
A review of Resident 1's Licensed Personnel Progress Notes dated 1/4/17 indicated Resident 1 was found outside the building. Resident 1 lost her balance and slipped while outside the facility. Resident 1 had abrasions on both knees and could not lift her right arm. Resident 1's right arm was immobilized with a sling, attending physician was notified and ordered STAT (immediately) X-ray (photograph in order to see the bone), responsible party notified.
A review of a document from the general acute care hospital (GACH) titled Physician H & P (History and Physical) dated 1/5/17 indicated a medical impression of displaced fracture (broken bone that is not lined up straight), of the upper end of the right humerus (long bone in the upper arm).
A review of a document from the GACH titled Consultation Report dated 1/5/17 indicated Resident 1 had a diagnosis of acute fracture, right humeral neck with displacement and treatment of sling (bandage to support an injured arm) for 6 weeks followed by physiotherapy treatment (corrects impairments and promotes mobility by using mechanical force and movement).
A review of a record titled "Final X-Ray Report" dated 1/4/17 indicated Resident 1 had acute displaced fracture of the neck of the right humerus.
During an interview with CNA 1 on 1/23/17 at 2:50 pm, CNA 1 stated that Resident 1 had episodes of trying to open the exit door and saying she wanted to go to another country.
During an interview with LVN 1 on 1/23/17 at 3:25 pm, LVN 1 stated that she saw Residents 1 and 2 by the hallway on 1/4/17 during change of shift but did not notice both residents had left the hallway and was not aware they had left the building. LVN 1 also stated that she was counting narcotic medications with LVN 2 and did not hear any WanderGuard alarm while they were counting the narcotic medications. LVN 1 also stated that the WanderGuard alarm could be heard from where she was standing while she was doing the narcotic count with LVN 2. LVN 1 also stated that she never checked if the WanderGuard was working. LVN 1 also stated that a resident is not allowed to push another resident on a wheelchair, and she did not notice Resident 2 had pushed Resident 1 out of the exit door.
During an interview with LVN 2 on 1/23/17 at 3:30 pm, LVN 2 stated that she did not notice Resident 1 and 2 leave the facility on 1/4/17. LVN 2 stated that she did not hear any door alarm while she was counting narcotic medications with LVN 1. LVN 2 stated that both she and LVN 1 were only aware that Residents 1 and 2 were outside the building when a former employee called the facility and told them. LVN 2 stated that the former employee happened to drop by the facility and saw Residents 1 and 2 outside the building in the driveway. LVN 2 stated that the WanderGuard was checked before by using a WanderGuard testing device and the testing device would alarm if WanderGuard was working. LVN 2 stated she could not remember when the WanderGuard testing device was last used.
During an interview with CNA 3 on 1/23/17 at 3:45 pm, CNA 3 stated that CNAs were the ones in-charge of checking if the WanderGuards were working or not. CNA 3 also stated that the facility used a Wander Guard testing device before to check the WanderGuards. CNA 3 stated that it had been a long time when she last used the testing device to check the WanderGuard. CNA 3 stated that she checks if the WanderGuard is working when the residents with the WanderGuards go near the exit door.
During an interview with the Director of Nursing (DON) on 1/23/17 at 4:00 pm, the DON stated that the WanderGuard testing device was not accurate and that the facility was not using it anymore. The DON stated that the WanderGuard was being checked in the morning shift by the Restorative Nurse Assistants (RNAs) every day. The DON stated that the RNAs do not document that they checked the WanderGuards. The DON further stated that the RNAs bring the residents with WanderGuards near the exit door to check if the WanderGuard was working. The DON also stated that it was the responsibility of CNAs during evening shift and night shift to monitor if WanderGuards were working. The DON stated that the WanderGuard batteries were changed on an as needed basis and that facility does not have a log of when the batteries had been changed for the WanderGuards currently in use.
During an interview with Restorative Nursing Assistant (RNA) 1 on 1/25/17 at 3:00 pm, RNA 1 stated that he checks the WanderGuard daily by bringing residents with WanderGuard near the door, and if the door alarms, the WanderGuard was working. RNA 1 stated that the facility does not document the checking of the WanderGuards. RNA 1 stated that a WanderGuard lasts for about 90 days per manufacturer's recommendation. RNA 1 also stated that facility does not change WanderGuards every 90 days; Wander Guards are only replaced if they are not working. RNA further stated that the facility does not maintain a record of the non-functioning WanderGuards that had been replaced.
A review of Resident 1's care plan for Elopement dated 9/23/16 indicated Resident 1 was at risk for elopement as evidenced by: Verbalization of wanting to go to another country and keeps on getting out of the building, wandering at the parking lot without notifying staff. Interventions include the use of an audible monitoring system to alert staff of exit-seeking behaviors and to check for proper functioning of the audible alarm system every shift and as needed.
A review of the facility's policy and procedure titled "Wandering, Unsafe Resident" dated 8/2014 indicated that the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.
Review of facility's policy and procedure titled "WanderGuard" dated 1/1/11 indicated that it is the policy of the facility to preserve and maintain resident's safety, by instituting measures to monitor and prevent resident from opportunities of wandering away from the facility. Licensed nurse shall be responsible for care and use of WanderGuard, following manufacturer's recommendation.
Review of manufacturer's insert guide for the WanderGuard indicated to test each signaling device before using, thereafter, test the device daily and record the results in the resident's records. The WanderGuard insert guide indicated that once a WanderGuard is activated for use, it was good for approximately 90 days of use.
Therefore, the facility failed to:
1. Ensure the facility's WanderGuard alert system was maintained and functioned properly.
2. Ensure residents were not allowed to leave the facility without proper supervision/authorization.
These deficient practices resulted in the elopement (left the facility without authorization and/or supervision) of Residents 1 and 2 from the facility and Resident 1 sustaining a fractured right arm.
These violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 950000058 |
GREEN ACRES HEALTHCARE CENTER |
950013316 |
B |
26-Jun-17 |
B3L111 |
4818 |
F225 - Abuse
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
This violation was identified during an unannounced annual recertification survey of the facility on 5/27/2017.
Based on interview and record review, the facility failed to immediately report (within 24 hours) two alleged abuse incidents and injury of unknown origin for three residents (Resident 14 and 10) and one randomly selected resident (RSR 22).
1. Resident 14 reported to staff he was touched inappropriately on 3/22/17 by another resident.
2. RSR 22 reported to staff he was touched inappropriately on 3/22/17 by another resident.
3. Resident 10 had an injury of unknown origin which resulted in a right wrist fracture. Resident 10 has severe cognitive impairment and was the only source provided to obtain the cause of the injury.
During an interview with the Administrator on 5/27/17 at 11:49 a.m., he was asked about the facility?s procedures for handling alleged violations of abuse. The following three incidents were reviewed:
1. The Investigation of Incident/Accident Known/Unknown Origin Form dated 3/22/17, indicated an incident on 3/22/17 at 1:00 p.m., when Resident 14 reported to staff he was touched inappropriately by another resident.
A review of Resident 14?s admission Face Sheet (document with resident information), indicated Resident 14 was admitted to the facility on XXXXXXX14. The resident?s diagnoses included Schizophrenia (a severe brain disorder in which people interpret reality abnormally) and depression (mood disorder).
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/9/17, indicated Resident 14 had no cognitive impairment.
2. The Investigation of Incident/Accident Known/Unknown Origin Form dated 3/22/17, indicated an incident on 3/22/17 at 1:00 p.m., when RSR 22 reported to staff he was touched inappropriately by another resident.
A review of RSR 22?s admission Face Sheet (document with resident information), indicated RSR 22 was admitted to the facility on XXXXXXX14. The resident?s diagnoses included paranoid schizophrenia and intellectual disabilities.
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/26/17, indicated RSR 22 had no cognitive impairment.
3. The Investigation of Incident/Accident Known/Unknown Origin Form dated 4/4/17, indicated an incident on 4/4/17 at 6:00 a.m., when Resident 10 was found with a right wrist fracture. The origin of the fracture was unknown because no one witnessed the injury or possible cause. The evidence provided to determine the cause was an interview with Resident 10.
During this interview the administrator was asked if any of these incidents were reported to the state agency and he stated that they were not reported because he and the director of nursing determined the incidents were not reportable. When asked how they determined these incidents were not reportable, he stated the DON made the determination. The DON was not available for interview. When asked about the fracture with unknown origin, he stated he was not sure if the fracture was considered a major injury.
A review of Resident 10?s admission Face Sheet (document with resident information), indicated Resident 10 was admitted to the facility on XXXXXXX15 and readmitted on XXXXXXX16. The resident?s diagnoses included psychosis and Alzheimer?s disease.
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/28/17, indicated Resident 10 had severe cognitive impairment.
A Review of an undated facility?s policy and procedure titled, ?Abuse and Mistreatment of Residents? indicated the facility is required to report to the Department of Health Services any incident of unknown origin. The policy further indicated that when an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility?s administrator, or his/her designee, will notify the following persons or agencies of such incident within twenty-four (24) hours as deemed appropriate based on the initial investigation:
a. Licensing and Certification Program;
b. The local Ombudsman;
c. Local law Enforcement.
The facility failed to immediately report (within 24 hours) Resident 10, 14 and RSR 22?s incidents to the State survey and certification agency.
This violation had a direct relationship to Resident 14, 10 and RSR22?s health, safety, or security. |
| 960000945 |
GOLDEN STATE CARE CENTER |
960008982 |
B |
08-Feb-12 |
O8S511 |
4214 |
Golden State Care Center ? B Citation 76525(a)(7) 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: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. On April 1, 2011 at 1:30 p.m. an onsite investigation was conducted regarding an entity reported incident that occurred on March 31, 2011, while Client 1 was being helped on the bus when she became resistive and lightly hit the forearm of the bus driver who was putting on her seatbelt. The bus driver became agitated and said ?If she does that shit one more time, she is off this fucking bus?. Direct Care Staff (DCS) A, who was helping Client 1 told the driver he can?t talk like that. Client 1 again lightly hit the bus driver?s forearm. This time the bus driver got Client 1 out of her seat, twisted her right arm behind her back and pushed her off the bus. DCS A told the driver he could not touch the client like that. Client 1 landed on the parking pavement on her left knee. Based on interview, observation and record review, the facility failed to: 1. Ensure Client 1 was free from physical and mental abuse by the school bus driver. On April 1, 2011 at 1:35 p.m. during an interview, the administrator stated he spoke to the school bus company supervisor about the incident and the supervisor told him that the bus driver that was involved was suspended pending the outcome of the investigation. The administrator informed the supervisor that the involved bus driver would no longer be allowed to transport any of the facility?s clients. The administrator also stated he reported the incident to the ombudsman and the local police department. He added that this was a first time incident between the bus driver and Client 1. On April 1, 2011 at 1:45 p.m. during an interview, DCS A stated on March 31, 2011 at 7:20 a.m., she was helping client 1 on the bus. While the bus driver was putting Client 1?s seatbelt, Client 1 lightly hit the bus driver?s forearm and the bus driver said ?If she does that again, she?ll be out of this bus?. But Client 1 again lightly hit the bus driver?s forearm and this time the bus driver twisted her right arm behind her back and grabbed her strap and lifted her out of her seat and pushed her out of the bus. DCS A tried to help Client 1 but she was behind the bus driver and could not reach her. Client 1 fell on the ground on her knees. She further stated she did not see any injuries on Client 1 after she fell. On April 1, 2011 at 2:00 p.m. the evaluator observed Client 1 lying in bed. She was non-verbal and there were no body injuries noted. On April 1, 2011 at 2:10 p.m. during an interview, the facility QMRP stated Client 1 had no history of hitting people. A review of Client 1?s face sheet revealed the client was admitted to the facility on February 16, 2010 with diagnoses that included severe mental retardation, mild cerebral palsy, autism, traumatic cataract, reactive detachment of infancy, parent/child problems. A review of the interdisciplinary progress notes dated March 31, 2011 indicated Client 1 was immediately assessed by the charge nurse after the incident and no injuries were noted. Client 1 was assessed as being ?alert and responsive and respirations were even and unlabored. No change in LOC. No discolorations. No bumps on parts of the body. No open skin, redness or swelling on the left and right upper and lower extremities. No signs of pain or discomfort noted.? A review of the facility?s policy and procedure on Client Abuse indicated the policy of the facility was to ensure that all clients were protected from abuse and the policy applied to all residents, facility staff, consultants or volunteers, staff of other agencies serving the individual. The facility failed to ensure Client 1 was free from physical abuse by the school bus driver. The above violation had a direct relationship to the health and safety or security of Client 1. |
| 960002098 |
G E PEDIATRIC CARE |
960009472 |
B |
06-Sep-12 |
UYGJ11 |
6116 |
4502. Persons with developmental disabilities have the same legal rightsand responsibilities guaranteed all other individuals by United States 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, denied 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. On April 26, 2012, at 2:45 p.m., an unannounced visit was made to the facility to investigate a reported incident involving Client 1 who was fed formula and the temperature was too hot resulting in a second degree burn to his lower lip, chin and left cheek area.Based on observation, interview and record review, the facility failed to: 1. Warm Client 1?s formula according to the facility?s policy.Client 1 received formula that was heated in a microwave oven and the temperature was very hot and not tested prior to giving it to Client 1resulting in him getting burned. A review of Client 1?s health record indicated he was a one year old male admitted to the facility on June 21, 2011. His diagnoses included severe brain injury related to non-accidental trauma, bilateral retinal hemorrhages (bleeding into the innermost coat lining of the eyeball), and seizure disorder (a disruption of the brains electrical activity manifested by a change in the level of consciousness and jerky movements of the body) and global developmental delay (overall delay in a child?s development in more than two areas). Client 1 totally depended upon direct care staff (DCS) for all activities of daily living.On April 26, 2012 at 2:50 p.m., a review of the facility?s special incident report (SIR) dated April 21, 2012 indicated Client 1 spit out his milk and it spilled down to his left chin area during his 7 a.m. feeding. DCS 1 then noted he had redness to the left lower lip and chin area. First aid measure was given by DCS 1. DCS 1 placed ice in a towel and applied it to the area and the licensed vocational nurse (LVN) was called. LVN 1 informed the RN Supervisor and facility?s physician. Client 1 was transported to an acute care hospital for further evaluation in the emergency department. During a phone interview with DCS 1, on May 15, 2012 at 3:20 p.m., she stated she poured the formula into a glass cup and placed it in the microwave for 35 seconds, then into the baby?s bottle. She further stated she did not check the temperature of the formula by dripping some onto the inside of her wrist before giving the formula to the client. She stated after he spit the formula out, she placed ice on the area (left lower lip and chin) because it became reddened.On April 27, 2012, during observations of six pictures received from LVN 1, three pictures taken on April 21, 2012, the day of the incident and three pictures taken on April 24, 2012. On the day of the incident, the pictures reveal redness to the left lip and lower chin area. On April 24, 2012, three days later the pictures revealed scabbing and crusting of the area.During an interview with the Qualified Mental Retardation Professional (QMRP), on June 7, 2012, at 1:50 p.m., she stated DCS 1 was interviewed on April 21, 2012 at 3:00 p.m. and she retained a written statement from her regarding the incident with Client 1 on April 21, 2012. The QMRP statedDCS 1 she heated the bottle in the microwave and she should have checked the temperature of the formula on her wrist but the bottle felt ok. When the client spit out the milk and it leaked down to his chin, there was some redness noted on his chin.On July 18, 2012, at 12:10 a.m., a review of Client 1?s emergency department visit on April 21, 2012, the nursing flow sheet indicated at 11:30 a.m., Client 1 had a burn approximately 4 centimeters by 2-3 centimeters, shiny in appearance with yellow healing tissue, red/pink in color, and a blister present on left chin. Further review revealed the chief complaint was burn to side of mouth, after receiving hot milk at 7 a.m. The objective findings indicated Client 1 suffered a second degree partial thickness burn to side of mouth. Client 1 received 70 mg. of Motrin (pain medication) and was to follow up with primary care physician in one day.On April 26, 2012 at 3:15 p.m., a review of a consultation visit with a pediatric doctor dated April 23, 2012 indicated the following: reason for consultation was a burn in the mouth and on the face that was healing.On April 27, 2012, a review of the facility?s policy titled Bottle Feeding and section II read as follows: formula or milk may be warmed using a bottle warmer or by placing the bottle in a warm-not hot or boiling-water, or by running it under the tap. Never use a microwave to heat formula or milk or baby bottles. Microwave oven heats unevenly, it can create hot pockets, leading to burns. Always check the formula or milk temperature by testing the fluid on the inner wrist before feeding. A record review of a form titled Employee Termination dated April 23, 2012, indicated DCS1 failed to adhere to the feeding policy, procedure and standards of care. Especially failing to check for infant?s formula temperature prior to feeding child and resulted in a burn to the left side of lower lip and cheek area. DCS 1 stated she did not check the fluid using the inside of her wrist as trained but first judged the temperature by touching the outside of the bottle, was the reason for termination.The facility staff failed to follow their policy for warming formula/milk for Client 1. This failure resulted in Client 1 sustaining second degree burns to the left side of his mouth and left chin. The above violation had a direct and immediate relationship to the health, safety, or security of the patient. |
| 960002312 |
GRAND AVENUE HOME |
960009641 |
B |
04-Dec-12 |
LPZ811 |
8130 |
4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals b6y United States 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, denied 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. On May 29, 2012, at 7:50 a.m., an unannounced visit was made to the facility to investigate an entity reported incident involving Client 1 falling, while seated in her wheelchair. Client 1 fell through the kitchen door, down two stairs, onto the concrete floor in the garage and sustained a fractured nose and broken tooth.Based on observation, interview and record review, the facility staff failed to:1. Provide adequate supervision for Client 1 based on her physical limitations while waiting for day program transportation.On May 3, 2012, about 8:15 a.m., Client 1 was in her wheelchair in the living room, waiting for transportation to her day program. Direct care staff (DCS1) went into the laundry area which was in the garage. Client 1 propelled her wheelchair following DCS 1 to the kitchen which has a door leading to the garage.DCS 1 pushed Client 1 back into the living room. As DCS 1 went back into the garage the second time, leaving the door open, Client 1 again propelled her wheelchair to the door in the kitchen that leads to the garage and fell down two steps onto the concrete floor in the garage on her face. Client 1 was transported to a local emergency department for evaluation.Client 1 was diagnosed with a broken nose and lost a tooth due to the lack of supervision. On May 29, 2012, a review of Client 1?s health record revealed she was admitted to the facility on September 21, 1999, with diagnoses that included profound mental retardation, cerebral palsy, bilateral flat feet, severe visual impairment, and osteoporosis.Client 1is nonverbal, she is ambulatory using walls and furniture for support and dependent upon staff for activities of daily living.Further review of a form completed by DCS 1 titled, ?Staff Report?, dated May 3, 2012, at 8:30 a.m., noting, ?I was in the laundry room washing the cushion covers in the sink because one of the clients had a toileting accident on them. I stepped out of the laundry room but realized I forgot the actual couch cushions, because I was going to scrub them. I had stepped back into the laundry room (in the garage) to grab the cushions which were leaning against the cabinet near the door. As I turned around, Client 1 rolled over the steps and hit her face on the concrete floor. It was a split second before I could catch her. She cracked her nose and lost a tooth.? During an interview, on May 29, 2012, at 1:45 p.m., DCS 2 stated, Client 2 had soiled the couch and she took him to the bathroom to give him a shower. DCS 1 took the cushions into the garage to be washed. DCS 2 stated DCS1 came to the shower to tell her Client 1 had fallen down the steps and was bleeding. She said when they went into the garage, Client 1 was still in her wheelchair, on her left side and she was bleeding from her nose.They called the Registered Nurse (RN) right away because there was blood coming from her mouth and nose which had a dent on it and it did not look normal. DCS 2 stated, Client 1 was screaming/crying because they tried to stick toilet paper in her nose to stop the bleeding (as instructed by the RN). The client?s mouth and lip were also swollen. During an interview with DCS 1, on August 2, 2012 at 9:45 a.m., she stated, Client 1 was already in her wheelchair in the living room on the morning of May 3, 2012 about 8:15 a.m. and waiting for transportation to her day program . Client 2 had an accident, which he soiled the cushions on the couch and DCS 2 took him to the bathroom for a shower. She, DCS 1, took the couch cushions to the laundry area (garage) to wash them. She put the cushion covers in the sink to wash them and was going to take the cushions outside when she saw Client 1 in her wheelchair, in the kitchen in front of the refrigerator. DCS 1stated she placed the cushions against the white cabinet in the garage and pushed Client1 back into the living room. She went back into the garage, was standing on the bottom step and the door was open because she was going to get the cushions and take them outside. Client 1 propelled herself back to the kitchen area.She heard a noise and before she knew it, the client fell through the door, down the steps and into the garage on her face.During another interview with DCS 1, on August 2, 2012, at 10:00 a.m., she stated, after Client 1 followed her into the kitchen the first time, she should have made sure the door was closed when she went back to the garage/ laundry room, or she should have stayed with Client1 in the living room. On May 29, 2012, a review of the emergency discharge instructions indicated the following: Client 1 sustained a nasal fracture and acute dental trauma. Client 1 was to follow up with a dentist today or tomorrow and see an ENT (ear, nose and throat) doctor next week. A review of the x-ray report, dated May 3, 2012 at 2:34 p.m. indicated the following: patient fell and hit her nose; which resulted in a fracture of the anterior nasal spine. A review of an ENT consult dated May 9, 2012 indicated Client 1 sustained a nasal fracture due to facial trauma. Another report dated May 10, 2012 indicated the client had a nasal fracture with reduction (right side of nose reduced, no packing placed). A review of the Qualified Mental Retardation Professional (QMRP) note dated May 4, 2012, revealed a review of the dental visit dated May 10, 2012 indicated the following the patient fell on May 3, 2012, tooth #9 was lost and tooth #8 was loose and possibly fractured. The plan was to consider general anesthesia for evaluation and possible extraction. On May 29, 2012, a review of Client 1?s health record revealed an order for the use of a wheelchair dated November 18, 2003. The order noted the client may use a wheelchair with seat belt for transportation due to poor safety awareness.Continued review of Client 1?s semi-annual physical therapy (PT) evaluation dated January 10, 2012 indicated Client 1 ambulates with self-initiated balance assist within the home, using walls or furniture for support. She reaches out to others for hand-held balance assist to ambulate on uneven surfaces; gait pattern is stiff, wide-based, waddling with exaggerated lumbar lordosis (forward curvature of lower back). The evaluation indicated Client 1 to use manual wheelchair for day program and outings due to limited ambulation endurance. The annual PT evaluation was dated July 24, 2012, indicated Client 1is able to propel a wheelchair on level surfaces, and requires close supervision for safety when in the wheelchair.A review of the facility?s nursing semi- annual assessment dated January 12, 2012, revealed Client 1 had severe visual impairment, (myopia which is the inability to see objects far away). On May 29, 2012, a copy of the job description for DCS was submitted by the QMRP. The section titled Responsibilities, indicated ?housekeeping is done after clients leave for day program and DCS are to follow all safety policies/procedures, maintain a safe environment in the home and never leave clients unsupervised.?The facility staff failed to provide adequate supervision for Client 1 based on her limited physical disabilities. This failure resulted in Client 1 sustaining a fractured nose, a lost and an extraction of a tooth. The above violation had a direct and immediate relationship to the health, safety or security of the client. |
| 960001715 |
GOLDEN CARE HOME |
960009964 |
B |
24-Jun-13 |
O0G311 |
3814 |
? 76865. Developmental Program Services-Health, Hygiene and Grooming (m) The facility shall not admit or retain clients with decubitus ulcers.On March 27, 2013 at 6:20 a.m., during a recertification survey, an unannounced visit was made to the facility.Based on observation, interview and record review, the facility?s administration failed to: 1. Ensure Client 2 was not re-admitted to the facility with a decubitus ulcer. 2. Ensure direct care staff did not perform dressing changes without an approved program plan. These failures had the potential to result in the client not receiving adequate care and treatments and increased the risk for wound infection. The clinical record for Client 2 was reviewed on April 2, 2013. The face sheet indicated the client was admitted to the facility June 7, 1994, with diagnoses that included moderate mental retardation (developmentally functions at one third of chronological age and can learn elementary health and safety habits) and seizure disorder. A review of physician?s notes dated December 11, 2012, indicated the client had pneumonia and was discharged from the hospital December 6, 2012. Client 2 had an abscess on her left leg that was erythematous with yellow discharge and a brown black covering. The physician ordered oral Bactrim DS (treats infections caused by bacteria) twice a day (bid) for fourteen days and bacitracin ointment to affected area twice a day.A review of the nursing progress notes dated December 6, 2012, indicated the facility?s nurse assessed the client at the hospital and the client returned home to the facility December 6, 2012. According to the nurse?s assessment, the client was readmitted to the facility with a stage III ulcer on the right inner aspect of her lower leg. A review of the nursing patient care plan dated December 6, 2012, indicated the client had a stage III ulcer on her right inner aspect of her lower leg. The ulcer measured 2 x 4 centimeter (cm) and was being treated with normal saline and 1% silver sulfa diazide cream (a topical antimicrobial) per the physician's order. The monthly nursing assessment dated January 31, 2013, indicated the client had a pressure area on her right leg 2 x 3 inches, and red with granulation.During an interview with the RN on April 2, 2013 at 3:45 p.m., she stated she knew the client had a pressure sore prior to the client's re-admission. She stated she accepted the client. She stated she did not re-call contacting the department about the client's pressure ulcer. The RN/ administrator stated she was not aware the facility could not accept a client with a pressure sore.During an interview with the house leader (Staff A, unlicensed staff) on April 2, 2013 at 4:20 p.m., she stated she would put solution on the client's leg, an antibiotic cream and change the gauze for the client's ulcer everyday twice a day for approximately a month. She stated only she and the RN would change the client's dressings.A review of the facility?s approved program plan did not address caring for a client with a decubitus ulcer. There was no supportive documentation provided by the facility?s administrative staff that the facility had an approved plan for a licensed nurse to complete wound care in this intermediate care facility for developmentally disabled ?habilitative facility.The facility?s administration failed to ensure Client 2 was not re-admitted to the facility with a decubitus ulcer and ensure direct care staff did not perform dressing changes without a written approved program plan. These failures had the potential to result in the client not receiving adequate care and treatments and increased the risk for wound infection. The violation had a direct relationship to health, safety, or security of Client 2. |
| 960000949 |
GLENRIDGE CENTER, #140 |
960009965 |
B |
24-Jun-13 |
E3YU11 |
3368 |
Title 22- 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: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. An unannounced visit was made to the facility on January 28, 2013, to conduct a recertification survey.Based on observation, interview and record review, the facility staff failed to protect Client 8?s right to privacy by failing to: 1. Close the privacy curtain during Client 8?s morning care. Client 8?s nude body was exposed to anyone who walked pass the room.On January 28, 2013 at 6:45 a.m., during an observation of Client 8's room, Staff A was observed providingmorning care for Client 8 while the client was lying completely nude in his bed. The door to Client 8's room was open and the curtain was not pulled. The evaluator was able to see Client 8's entire nude body. There were two other clients and another staff member in the room. Anyone, passing the main corridor had visual access to Client 8?s nude body walking pass. On January 28, 2013, review of Client 8's Admission Face Sheet revealed the client was admitted to the facility on October 20, 2010, with diagnoses that included mild mental retardation, severe contractures of the right leg, cerebral palsy (A group of disorders that can involve brain and nervous system functions), and osteopenia (weak bones). Client 8 was totally dependent on staff for activities of daily living. Client 8 was verbal, able to understand others and the client was wheelchair bound.During an interview with Staff A on January 28, 2013 at 6:50 a.m., Staff A stated, he should have ensured the privacy of the client by pulling the privacy curtain while providing morning care for Client 8.During an interview with Client 8 on January 29, 2013 at 11 a.m., Client 8 stated his privacy curtain was not closed and he was totally nude. Client 8 further stated his privacy was being violated and Staff A should have closed his privacy curtain so his nude body was not exposed to others. Client 8 stated it makes him feel sad when his nude body is exposed. During an interview with the director of nursing (DON) on January 28, 2013, at 9:30 a.m., she stated, staff is trained to close the privacy curtain when providing personal care to the clients. The DON also stated Staff A should have closed Client 8?s privacy curtain.On January 28, 2013, a review of the facility in-service records revealed Staff A received in-service training regarding "Privacy" on March 9, 2012.A review of an undated facility?s policy titled, "Policy and Procedure for Resident Privacy" indicated all clients will be provided privacy at all times by closing doors and pulling privacy curtain during care. The facility staff failed to protect Client 8?s right to privacy by failing to close the privacy curtain during Client 8?s morning care. Client 8?s nude body was exposed to anyone who walked pass the room. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or emotional trauma to the client. |
| 960001148 |
GRANADA DIVISION |
960013049 |
A |
24-Mar-17 |
7ZUJ11 |
8665 |
Title 22: 76918 Clients Rights
(a) Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code.
4502(h) Welfare and Institutions Code
Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds.
It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:
(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
On January 6, 2017 at 7:00 a.m., an unannounced visit was made to the facility to conduct an investigation of an Entity Reported Incident (ERI) regarding Client 1 being found on the shower floor by the staff.
The facility staff failed to:
Ensure Client 1 was supervised during morning care. Client 1 was left alone and unsecured in the shower chair. Client 1 fell out of the shower chair suffering a laceration to the left side of her head/face requiring stitches on December 27, 2016 at 9:10 a.m.
During a review of the clinical record for Client 1 on January 6, 2017, the face sheet indicated the client was admitted to the facility with diagnoses of borderline intellectual disability (developmentally functions below chronological age. Is slow in all areas, but can acquire practical and vocational skills), Sialidosis Type I (an extreme rare genetic metabolic disorder, the enzyme called sialidase is deficient and associated with progressive myoclonus which is sudden , involuntary jerking of a muscle or group of muscles) and depression. Client 1 was wheelchair bound and verbal.
The ERI dated December 27, 2016 indicated Client 1 fell out of the shower chair hit her head on the shower floor, causing a laceration to the left side of the head/face and copious amount of blood was identified at the scene.
The Change of Condition/Incident Report dated December 27, 2016, indicated Client 1 was found on shower floor, client fell out of the shower chair, left side of head bleeding. In the comments section it indicated the following: ?never leave client unattended while in the shower.? The licensed vocational nurse (LVN 1) signed the change of condition report as a witness to the incident.
The physician's notes dated December 7, 2016, indicated Client 1 had moderate tremors.
The physician's orders dated January 1-31, 2017, indicated orders for Benztropine 1 mg three times a day for tremors, baclofen 10 mg every day for spasticity, clonazepam 2 mg, Vimpat 200 mg, and Levetiracetam 750 mg two times a day for seizure control. Continual review of the physician?s order indicated that Client 1 required assistance with activities of daily living (ADL) which include showering, bathing, and dressing. The initial date for this order was August 4, 2009.
A review of the Psychological Assessment dated October 26, 2012, indicated Client 1 was oriented to person, place, and time. There was no evidence of thought disorder.
A review of the Annual Occupational Therapist (OT) Evaluation, dated November 2, 2014, indicated Client 1 needed assistance to dress self and had difficulty reaching and grasping objects.
During an interview and a written statement provided by LVN 1, on January 6, 2017 at 7:10 a.m., she stated on the morning of December 27, 2016, she arrived to the facility to administer medication to Client 1. LVN 1 stated while standing at the medication cupboard, she heard a loud crashing sound and yelling coming from the bathroom. LVN 1 stated when she entered the bathroom she found Client 1 on the shower floor with the water running on her body, and blood oozing from her head. LVN 1 stated she immediately called for Staff A to call 911. LVN 1 stated the client was unattended in the shower and per the company's policy and procedure, the staff should not allow a client to remain unattended in the shower. LVN 1 stated the problem was there was only 1 DCS present with 6 clients and the 1 staff was in the kitchen preparing food and monitoring another client who was eating who had a choking disorder.
During an interview and a written statement provided by Direct Care Staff (Staff A), on January 6, 2017 at 9:10 a.m., she stated on the morning of December 27, 2016, she arrived to work at 6:00 a.m., and was told by the night shift staff that the person scheduled to work with her called off sick and that she would be alone with 6 clients. Staff A stated she immediately notified the qualified intellectual disability professional (QIDP), who directed her to leave the clients in the bed and ask LVN 1 when she arrived to the facility to administer medication, to assist her with the clients who attend day program only and leave the other clients in the bed. She stated despite the directions of the QIDP, she placed Client 1 in the shower because she was soiled with urine. Staff A stated she placed the client under the running shower water, and left because she needed to monitor a client who was eating breakfast and who required monitoring due to a risk of choking. Staff A stated as soon as LVN 1 arrived to the facility, the LVN ran to the kitchen screaming for help because she found Client 1 on the floor and there was blood everywhere. Staff A stated when she arrived in the bathroom she found Client 1 on the shower room floor bleeding from the left side of her head. Staff A stated she called 911, who escorted Client 1 to the emergency room of a General Acute Care Hospital (GACH) for treatment.
During an interview with Client 1, on January 6, 2017 at 9:28 a.m., she stated Staff A placed her in the shower chair, unsecured by safety straps and left her unattended in the shower with the water running, while she took care of the other clients. Client 1 stated Staff A was the only staff present in the facility taking care of all 6 clients. Client 1 stated she does not have a problem with the staff remaining in the bathroom while she was showering.
During an interview and a written report (Investigative Report dated December 27, 2016) provided by the QIDP, she indicated on January 6, 2017 at 9:50 a.m., she stated on the morning of December 27, 2016 after 7:00 a.m., (an hour after her shift started) she received a call from Staff A who informed her that she was the only staff with 6 clients. The QIDP stated she directed Staff A to leave the clients in the bed for the safety of the clients until help arrived. The QIDP stated Staff A did not listen to her directions but instead put the client in the shower and left her unsupervised. The QIDP stated Staff A violated the policy and procedure regarding leaving the client unattended. The QIDP stated Staff A should have left Client 1 in bed, and waited until another staff arrived to provide care to the clients. Staff A should not have left the client unattended in the shower.
The facility?s undated policy and procedure titled ?New Employee Orientation Do?s and Don?ts,? indicated Do Not leave any resident unsupervised at any time or anywhere.
A review of the emergency room documentation of the General Acute Care Hospital dated December 27, 2016, indicated Client 1 was seen for face laceration (a cut through the skin which requires stitches or surgical tape) due to a traumatic head injury. The course of treatment included sutures which were to be removed in one week.
A review of the documentation titled "The Becoming Independent Assessment" (documentation which details the client?s strengths and weaknesses) dated October 9, 2016, indicated Client 1 was dependent on staff during showers and baths and must be assisted with showers and the client was totally dependent on staff for all of her needs.
The facility failed to ensure Client 1 was supervised during morning care. Client 1 was left alone and unsecured in the shower chair. Client 1 fell out of the shower chair suffering a laceration to the left side of her head/face requiring stiches on December 27, 2016 at 9:10 a.m.
The above violations jointly, or either separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 960000945 |
GOLDEN STATE CARE CENTER |
960013093 |
A |
4-Apr-17 |
Y9XN11 |
11138 |
Title 22: 76918 Clients Rights
(a) Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code.
4502(h) Welfare and Institutions Code
Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds.
It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:
(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
On January 20, 2017, an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI) and a complaint regarding Client 1 experiencing a choking episode at his day program on January 12, 2017. Client 1 was given the wrong diet, which was prepared and sent by the facility to the day program.
The facility staff failed to:
1. Inform the day program staff that Client 1 had a change in diet from a mechanical soft diet to a puree diet.
2. Send the appropriate diet to Client 1?s day program.
This failure resulted in Client 1 choking and aspirating at his day program, becoming unresponsive, requiring life saving measures, being transferred to a general acute care hospital and finally requiring surgery to provide a gastrointestinal tube (GT- a surgically place opening in the stomach, utilizing a tube for administration of nutrition and medication).
Client 1's clinical record was reviewed January 20, 2017. The face sheet indicated he was admitted to the facility with diagnoses of profound intellectual disability (cognitive ability markedly below average level, incapable of self-care), cerebral palsy, (a group of disorders that affect a person's ability to move and maintain balance and posture related to the brains ability to control the body), and history of seizure (a brain disorder involving repeated, spontaneous movements). A review of the Comprehensive Functional Assessment (CFA) dated April 5, 2016, indicated Client 1 was dependent on staff for activities of daily living (which included feeding, bathing/showering and toileting).
During an interview and review of a document titled "Facility/Program Special Incident Report" dated January 12, 2017 at 12:05 p.m., (on hand as a reference) was conducted on January 20, 2017 at 10:02 a.m., with the day program staff (Staff E). Staff E stated on January 12, 2017 around 11:30 a.m., he began to feed Client 1 his lunch which consisted of white bread and soft meat in the middle. Staff E stated he had worked with Client 1 which included feeding him for more than 3 years. Staff E stated he proceeded to feed Client 1 when suddenly Client 1 began to choke and he immediately began the Heimlich Maneuver (a first aid procedure for dislodging an obstruction from a person?s windpipe) so he could dislodge the food the client was choking on. Staff E stated after seeing the food come out of Client 1's mouth, the client became unresponsive so he and some other staff began cardiopulmonary resuscitation (CPR, an emergency procedure that combines chest compression often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest). Staff E stated he and the other staff continued CPR until the emergency responders arrived. Staff E stated the facility staff did not visit the day program to inform him of the diet change from mechanical soft diet to a puree diet or provide feeding directions for the day program staff to follow until after the choking event had taken place.
During an interview with the day program assistant (Staff L), on January 20, 2017 at 11:01 a.m., she stated the facility?s staff did not inform the day program staff of Client 1?s diet change from mechanical soft to puree. She stated the facility staff which included qualified intellectual disabilities professional (QIDP 1), the administrator, or any certified nursing attendants (CNA) did not visit the day program to inform the day program staff of the diet change until after the choking event had taken place.
During an interview with QIDP 1, on January 20, 2017 at 6:55 a.m., she stated the client was choking a lot when the staff fed him, and the occupational therapist (OT) thought it would be best to change the client's diet on October 13, 2016 from mechanical soft to puree. QIDP 1 stated on January 12, 2017, the facility received a phone call from the day program staff who informed them that Client 1 choked while he was being fed by the day program staff. QIDP 1 stated when Client 1 choked; the day program staff informed her Client 1 was still receiving a mechanical soft diet. QIDP 1 stated when Client 1 choked she had not informed the day program staff of the change in diet. QIDP 1 further stated she had not provided training to the direct care staff, nor the dietary staff.
During an interview with certified nurse assistant (CNA A), on January 20, 2017 at 7:36 a.m., she stated she was responsible for feeding Client 1 and when she fed the client she had to feed him slow because he would cough if she did not. She stated she started giving Client 1 a pureed diet in the middle of October 2016 because he kept coughing. CNA A stated the nurses informed her of the change in diet and the dietary department changed the meal card but was not sure of the day she was informed.
During an interview with Staff R (the dietary supervisor), on January 20, 2017 at 7:15 a.m., he stated he made a mistake and takes full responsibility for the incident. Staff R stated he was aware of Client 1's diet change from a mechanical soft diet to a pureed diet since October 13, 2016 but he did not change the label in the lunch pail. Staff R stated he did not in-service the dietary staff regarding the changes, and as a result the dietary staff prepared a mechanical soft diet for Client 1 every day until the choking incident occurred, January 12, 2017.
During an interview with Staff J (the director of staff development), on January 20, 2017 at 8:01 a.m., he stated the CNAs had not been in-serviced regarding the change of Client 1's diet on October 12, 2016, from a mechanical soft diet to a puree diet.
During an interview with the registered nurse (RN), on January 20, 2017, at 8:30 a.m., he stated the CNAs had not been in-serviced regarding the change of Client 1's diet on October 12, 2016, from a mechanical soft to a puree diet. The RN stated the CNAs were following the physician's order because the diet card was changed in the facility. The RN stated the card was changed in the facility but not in the lunch pail.
The Occupational Therapy (OT) feeding evaluation dated October 13, 2016 was reviewed and indicated, ?It is recommended that diet be changed to puree with nectar thick liquids. Such a diet will increase safety and be more comfortable and easier for Client 1 to consume."
The physician telephone order dated October 12, 2016 was reviewed and indicated a puree large portion diet three times a day. The order was again clarified on October 13, 2016 to a puree large portion diet three times a day with nectar thickened liquids.
The Dietary order dated October 13, 2016 was reviewed and indicated by the dietary supervisor, a change in diet from mechanical soft to puree large portion.
According to the initial General Acute Care Hospital (GACH) Admission and History and Physical Exam Records dated XXXXXXX 2017, indicated Client 1 was admitted from the day program and Client 1's sister stated the client had been having a problem swallowing over the past 3 weeks and his diet had been changed from a soft mechanical diet to a puree diet. Client 1's sister reported the client was at his day program, choked and turned blue. The Heimlich maneuver and CPR were performed until emergency medical services (EMS) arrived. Client 1 was found to be in impending respiratory failure in the emergency room and was intubated (the process of inserting a tube, called an endotracheal tube (ETT), through the mouth and then into the airway). Large bolus of bread measuring 3 cm in diameter was recovered from Client 1's airway. Following intubation the client was found to have a large amount of blood from the ETT. A chest x-ray demonstrated infiltrates in the left lung (pulmonary infiltrate is a substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma (tissue of an organ as distinguished from the connective and supporting tissue of the lungs). Client 1 was then placed on mechanical ventilation (a machine called a ventilator which can mechanically assist or replace spontaneous breathing) due to pulmonary hemorrhage (any form of bleeding into the lung) and sedated due to agitation. Client 1 was transferred to the second GACH 3 days later.
According to the second GACH documentation submitted and titled "Pulmonary Consultation" dated January 15, 2017, indicated Client 1 was transferred to the their facility after aspirating (food and or liquid enter the lungs accidentally) on a food bolus. The record indicated Client 1 was being fed at the day program when he choked on his meal and turned blue. The Heimlich maneuver was applied and resuscitation was started. Client 1 was transferred to GACH 1 where he was intubated, with ventilator support. After intubation, Client 1 had a bloody nose and bloody secretions from the endotracheal tube. Client 1 required the use of a bronchoscope (special procedure for viewing the smaller tubes of the lungs) was done; Client 1 had a left bronchial obstruction due to a bolus of bread which required suctioning out. Client 1's overall prognosis was measured as grave.
A review of the "Operative Report" dated January 19, 2017, indicated Client 1 had surgery to place a size 20 gauge gastrostomy tube (GT, a surgically placed opening in the stomach for administering food and medication).
The facility failed to:
1. Inform the day program staff that Client 1 had a change in diet from mechanical soft to puree diet.
2. Send the appropriate diet to Client1?s day program.
This failure resulted in client choking and aspirating at his day program, becoming unresponsive, requiring life saving measures, being transferred to an acute hospital and finally requiring surgery to provide a GT for administration of nutrition and medication.
The above violations jointly, or either separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 630011333 |
GATEWAY HOMES TO INDEPENDENCE |
980013077 |
B |
23-Mar-17 |
0Z5K11 |
7477 |
T22 DIV CH3 ART5-72523(c)(3) Patient Care Policies and Procedures
(c) Each facility shall establish and implement policies and procedures, including but not limited to:
(3) Infection control policies and procedures
An unannounced visit was made to the facility on 1/26/17 to investigate a complaint regarding infection control.
Based on record reviews and interviews, the facility failed to establish and implement an infection control program that prevents the spread of infection for one of six sampled patients (Patient 1). Patient 1 experienced itching for approximately three months without an accurate diagnosis, without the facility implementing the plan of care to document skin assessments, and without the facility establishing and following its policy and procedure for scabies prevention and control.
As a result, Patient 1 was transferred to the general acute care facility (GACH), and was diagnosed with scabies (a parasitic infestation of the skin caused by the human itch mite, can live up to 4-6 weeks on the body, a highly contagious skin disease). These deficient practices resulted in the potential spread of the scabies infection to other patients, staff, and visitors.
A review of the clinical record indicated Patient 1 was admitted, on 3/22/12, with diagnoses which included respiratory failure (results from inadequate gas exchange by the respiratory system, oxygen, carbon dioxide or both cannot be kept at normal levels) and hypoxia (low oxygen in the tissues, a dangerous condition where your brain, liver, and other organs can be damaged just minutes after symptoms start).
A review of Patient 1's initial plan of care, dated 10/27/16 to 12/25/16, indicated 24 hour nursing care was needed to perform skin assessments for signs and symptoms of skin breakdown, rash, and reddened areas, and to apply topical creams as ordered. The plan of care, dated 12/26/16 to 2/23/17, indicated the same nursing care intervention to perform skin assessments for signs and symptoms of skin breakdown, rash, and reddened areas, and to apply topical creams as ordered.
A review of the physician's orders, dated 12/26/16, indicated the following:
1. A and D ointment to apply to affected areas as needed.
2. Hydrocortisone 1 percent to apply to affected areas as needed.
3. Lidex (a steroid medication to treat many skin disorders, and relieves pain, itching and swelling of the skin) to apply to skin lesions twice daily.
A review of the physician's order, dated 1/19/17, indicated to transfer Patient 1 to an acute hospital for further evaluation, treatment for abdominal pain, and increased gastric tube feeding (feeding tube placed through the abdominal wall into the stomach) residual (amount of stomach contents following administration of the tube feeding).
A review of the GACH Dermatology Inpatient Progress Note, dated 1/23/17, indicated Patient 1 had a scabies prep result with positive visualization of scabies mite and eggs. The initial treatment provided to Patient 1 was to give Permethrin 5 percent (medication to treat scabies) and Ivermectin (medication to treat scabies) 0.2 milligrams and to repeat treatment.
On 1/27/17, at 1 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), she stated Patient 1 was observed with dry red pimple-like patches at the abdominal area, on her upper extremities, and whitish-reddish dry scaly rashes at the right upper back area since November 2016. LVN 1 stated she reported Patient 1's skin condition to the director of nursing (DON) and the physician, but could not remember the exact date and time. LVN 1 stated the DON agreed to talk to the physician for further care instructions. When asked why LVN 1 did not document the skin assessment, she stated she missed it and she agreed that she should have documented her skin assessment daily in the nursing notes.
According to the County of Los Angeles Public Health Scabies Prevention and Control Guidelines, August 2015, scabies symptoms include rash (small red bumps), papules (pimple-like rash), track marks (thin thread-like lines) with intense itching / scratching causing sores on the body and scaly skin (flakes). The guidelines indicated the commonly involved areas of the body include wrists, finger webs, axillary folds, abdomen, and breast area.
During an interview with Certified Nursing Assistant 1 (CNA 1), on 1/27/17, at 2 p.m., she stated "Patient 1 always itched and scratched her skin until she developed liner skin red marks." CNA 1 stated since November 2016, the patient had dry, scaly rashes seen on her chest, abdomen and upper back.
A review of the nurses notes and skin assessments indicated there was no documentation Patient 1 had rashes and was itching from November 1, 2016 through January 18, 2017.
On 1/27/17, at 3 p.m., during an interview with the DON, she stated she was aware of Patient 1's skin condition and that Patient 1 always had dry, scaly rashes, which the patient would scratch until it bleeds. When the DON was asked why it was not documented the patient had dry, scaly rashes, she stated could not believe the staff did not document any skin assessments when they were assigned to Patient 1 on a daily basis. The DON stated the physician was notified about it, and ordered to apply Aveeno lotion to the skin. However, further review the clinical record indicated there was no physician's order of Aveeno lotion for Patient 1.
The DON stated she was informed by the GACH social worker (SW 1) that Patient 1 tested positive for scabies. When the DON was asked if she implemented their policy and procedure for infection control program for scabies after she found out Patient 1 had scabies, she stated she did not implement it. The DON stated she did not offer the facility staff members, who were exposed to Patient 1 for extended period of time, a prophylactic treatment, and did not provide teaching to staff regarding scabies or to seek medical advice on their own. The DON stated the facility's medical doctor examined each patient, including Patient 1's roommate (Patient 2), and no sign of rashes were found, which was why they were not treated. When the DON was asked if the facility had a copy of the policy and procedure for infection control for scabies management, she stated she could not find one.
On 1/27/17, at 3:30 p.m., during an interview with the facility?s medical director, he stated the last time he saw Patient 1 was December 2016, and he knew the patient had dry rashes on her body, but did not see it as scabies. The medical director stated he could have missed it, but he thought it was dry, scaly skin, and recommended the staff to apply lotion for it.
According to the County of Los Angeles Public Health Scabies Prevention and Control Guidelines, August 2015, all facilities should incorporate a scabies prevention program which involved all levels of the healthcare team. The program should include an assessment of skin, hair, and nail beds. The facility's prevention program should document pruritus, rashes and skin lesions and notify the nursing supervisor and physician for follow-up. The guideline indicated to immediately place patients with suspected scabies in contact precautions and perform environmental cleaning of affected unit.
The above violation had a direct or immediate relationship to the health, safety or security of the patients in the facility. |
| 100000032 |
Golden Living Center - Chateau |
030013532 |
B |
9-Oct-17 |
Y6VO11 |
5165 |
?483.15 (e) (1) Permitting residents to return to facility
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident?
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
The following citation was written as a result of complaints #CA00537772,
#CA00538752, #CA00540675, and #CA00544496.
An unannounced visit was made to the facility on 6/1/17 to investigate an allegation of refusal to readmit.
The Department determined the facility failed to:
Permit Resident 2 to return to the facility after Resident 2 was transferred to a general acute care hospital (GACH).
This failure had the potential to cause psychosocial distress and/or harm due to a disruption in Resident?s 2 care and services.
According to the Admission Record, Resident 2 was admitted to the facility in 2009 with diagnoses which included schizophrenia (mental disorder) and dementia (memory disorder characterized by personality changes and impaired reasoning).
Review of the clinical record for Resident 2 included:
A Minimum Data Set (MDS, an assessment tool) dated 2/27/17, which indicated Resident 2 was unable to complete the interview due to memory problems and disorganized thinking;
A document titled ?Transfer/Discharge Report? from the Skilled Nursing Facility (SNF), dated 4/26/17 at 1 p.m., indicated Resident 2 was sent to a GACH for ?Physical aggression. [Resident 2] struck another Resident (5150) [involuntary psychiatric hold]. Danger to others;?
A Physician?s Behavior Evaluation Summary dated 4/26/17 at 8:03 p.m., from the Emergency Department (ED) of the GACH indicated, ?Pt [patient] has no acute psychiatric need?At this time, pt does not meet criteria for 5150 hold, and will be discharged back to SNF.? The ED physician noted, ?SNF states he is not welcomed back and seems to dump him off at [name of GACH];?
A SNF progress note, dated 4/26/17 at 11p.m., contained nursing notes indicating the ADON (Assistant of Director or Nursing) spoke to the ED staff from the GACH earlier that day, and informed the GACH, ?The facility cannot (sic) meet the medical/mental health needs [of Resident 2]?The [GACH] keeps calling the facility.?
A Discharge Planning note from the GACH dated 4/27/17 at 9 a.m., ?[Name of the SNF] refusing to accept [Resident 2] back. Social Services is working?to enable him to return to [name of SNF].?
A facility progress note dated 4/27/17 at 9:25 a.m., indicated the facility Administrator (ADM) was contacted by a GACH physician who stated that Resident 2 was cleared to come back to the facility. The ADM informed the GACH physician, the ?Facility is not equipped to handle this resident?s mental behavior and he is a danger to the other residents.?
A Social Services/Case Management note from the GACH dated 6/28/17 at 10:30 a.m., indicated, ?Pending SNF placement; [name of the SNF] is not accepting pt back.?
A Discharge Summary from the GACH dated 7/10/17 indicated Resident 2 was discharged from the GACH.
According to the facility?s Daily Census reports, covering the period from 4/26 to 7/10/17, a total of 76 days, the facility had 1 to 5 available male beds for 75 of those days.
In an interview with Resident 2?s Case Manager (CM) from the GACH on 7/3/17 at 9:45 a.m., the CM stated Resident 2 had no behavioral issues since he was admitted to the hospital. The hospital tried to send Resident 2 back to facility, contacting the SNF daily.
A review of the facility's standard admission agreement, dated 5/11, indicated "...we are required by law...to offer you the next available appropriate bed in our Facility...if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted."
In an interview with ADM on 6/1/17 at 3:30 p.m., the ADM stated Resident 2 had a long history of aggressive behavior and many altercations with other residents. The ADM was adamant that under no circumstances would the facility take [Resident 2] back.
Therefore, the Department determined the facility failed to:
Permit Resident 2 to return to the facility after Resident 2 was transferred to a GACH.
This violation had a direct or immediate relationship to the health, safety or Security of Long Term Care patients or residents. |
| 100000092 |
Golden Living Center - Galt |
030013643 |
B |
30-Nov-17 |
892B11 |
11872 |
483.25 (d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The following citation is written as a result of an unannounced visit to investigate a complaint #CA00545761.
The Department determined the facility failed to adequately protect 1 of 5 sampled residents (Resident 1) from excessive duration of exposure to sunlight and heat when he was outdoors on the facility patio.
A review of Resident 1's facesheet indicated he was admitted to the facility in May 2017 with diagnosis including dementia (a disorder of the mental processes which cause symptoms including memory loss, personality changes, and impaired reasoning) and diabetes (a disease causing too much sugar in the blood). According to a physician's order, dated 5/16/17, Resident 1 was incapable of making medical decisions.
In a telephone interview with Licensed Nurse 1 (LN 1) on 7/28/17 at 12:30 p.m., LN 1 stated Resident 1 walked out onto the patio area unassisted using his walker at approximately 2:00 p.m. on 7/2/17. LN 1 stated, "It was warm out... maybe in the 90s" referring to the outside temperature. LN 1 stated Resident 1 was checked on after approximately 15 minutes and declined to come back into the facility and declined water. LN 1 stated the following day, 7/3/17, an intact blister was noted on the Resident 1's posterior left wrist/hand area and a ruptured blister was noted on the resident's scalp/forehead area. LN 1 stated, "I figured it [blisters] could be a sunburn because he was outside the day before."
A review of Resident 1's clinical record revealed a progress note dated 7/3/17 at 12:32 p.m., authored by LN 1, included, "Fluid filled blisters found on forehead and L [left] wrist... Spoke with resident regarding time spent in the sun/heat and how they may effect [affect] the blisters..."
In a 9/1/17, 3:30 p.m. telephone interview with LN 2, she stated Resident 1 was, "Already outside" when she had come on shift on 7/2/17 in the afternoon. According to LN 2, per a verbal report from the previous nurse, the resident had been outside for about, "45 minutes or so." LN 2 stated Resident 1 was wearing a bathrobe and pajama pants. When LN 2 went out to check on Resident 1, he was, "Hot to the touch" and described him as, "Very weak." At that time LN 2 had requested assistance of two other staff, Certified Nursing Assistant (CNA) 1 and CNA 2 to assist Resident 1 back into the facility. LN 2 stated Resident 1, "Seemed like he required a total assist (full staff assistance for weight transferring or walking)" and verified Resident 1 was, "Normally a stand by assist (staff supervision and cueing without providing physical assistance)." LN 2 described Resident 1 as responsive but, "Slow" and added, "Maybe the sun just drained him out." LN 2 stated Resident 1 was cooled off with cool, wet washcloths. LN 2 stated Resident 1 "became more responsive" after approximately 15 minutes after the intervention.
In a 9/7/17, 10:55 a.m. telephone interview with CNA 1, she stated Resident 1 was "outside" on 7/2/17. CNA 1 stated Resident 1 was wearing pajama pants, a long sleeved shirt, and a bathrobe over it. CNA 1 added, "it was very hot outside." CNA 1 said Resident 1 was, "Overheat [sic]" and "That's why he can't stand up." When asked what Resident 1's level of consciousness was, CNA 1 stated, he "Could open his eyes, but could not talk... tired... lethargic". CNA 1 explained, "The body was so warm". CNA 1 stated she took Resident 1's vital signs. CNA 1 indicated Resident 1 was too sleepy to take an oral temperature with a thermometer so she took an axillary (arm pit) temperature. She stated the reading was 100-101 degrees [Fahrenheit, normal adult axillary body temperature is approximately 95.9-98.6 degrees Fahrenheit]. When asked what interventions were performed for Resident 1, CNA 1 stated they removed Resident 1's clothing and, "Put cold towels on the neck and armpits". CNA 1 also confirmed after approximately 20 minutes of cooling intervention, Resident 1 "Wake up."
In an interview with CNA 2 on 9/6/17 at 2:00 p.m., CNA 2 stated he was summoned by LN 2 and CNA 1 to assist with Resident 1 on 7/2/17. CNA 2 described Resident 1 as, "Weak to stand up" and acknowledged Resident 1 was normally ambulatory. When asked what intervention was done for Resident 1 when he was brought back inside, CNA 1 confirmed Resident 1's clothes were removed and they gave Resident 1, "A cold bed bath to cool him down."
A review of Resident 2's facesheet indicated he was readmitted to the facility in early 2017 with diagnoses including heart disease and dementia. According to the most recent Minimum Data Set (MDS- an assessment tool), dated 6/29/17, Resident 2 was assessed as being cognitively intact. Resident 2 was roommates in the facility with Resident 1. In an interview on 7/27/17 at 12:45 p.m. with Resident 2, he stated, "[Resident 1] got a blister from being out in the sun."
A review of Resident 3's facesheet indicated he was admitted to the facility in 2016 with diagnoses including heart disease. Resident 3 was also a roommate of Resident 1 in the facility. Resident 3 had a 12/26/16 physician's order indicating he was able to make his own decisions. In an interview with Resident 3 on 9/6/17 at 3:15 p.m., Resident 3 stated Resident 1 had gone outside, "A couple weeks ago in that big robe." Resident 3 said, "It was over 100 degrees out... He [Resident 1] got too hot." When Resident 3 was asked what happened when Resident 1 was returned to the room that day Resident 3 stated, "[Staff] wrapped him up in ice to cool him off."
In an interview with the Director of Nursing (DON) on 9/6/17 at 4:00 p.m., the DON stated per her interviews with CNA 1, CNA 2, and LN 2, Resident 1's level of consciousness was, "Lower than usual" on 7/2/17 when brought back into the facility from the patio area. The DON stated per her interview with CNA 1, Resident 1 was, "Hot".
In a telephone interview with the Vice President of Operations (VPO) on 9/21/17 at 10:46 a.m., the VPO stated the facility's investigation concluded Resident 1 was outdoors on 7/2/17 for approximately 50 minutes. The VPO confirmed with interviews of LN 2, CNA 1, and CNA 2 that Resident 1 was, "Hot" upon their assessment of him.
During a review of Resident 1's clinical record, a Certified Wound Specialist Nurse (CWSN) assessed Resident 1 on 7/3/17. The progress note timed 4:09 p.m. indicated, "Type of Wound: Blistering likely 2/2 [secondary to] sun exposure... Location: frontal scalp... left dorsal [top] hand... developed second degree burns (blistering)..."
The CWSN documented a reassessment on 7/17/17 at 3:29 p.m., describing, "Scalp burn has dramatically deteriorated since my last visit 2 weeks ago. Now has full thickness tissue loss with slough (dead matter or necrotic tissue) and eschar (dead matter, material is crusty and scab like). Has not been in the sun since the initial injury... if wound continues to deteriorate, may need surgical consult..."
Another progress note for reassessment by the CWSN on 8/2/17 at 2:26 p.m., included, "...scalp in [sic] extremely tender and the patient will only tolerate short debridement (removal of dead or damaged tissue to improve the healing for the remaining healthy tissue) time despite using lidocaine gel for local pain management... surgical consult has been requested...scalp wound evolved into a third degree burn..."
In a telephone interview with the CWSN on 9/5/17 at 2:13 p.m., the CWSN stated Resident 1 had, "Second degree burns (serious damage extending beyond the top layer of skin, also called a partial thickness burn)" and described them as, "An intact blister on the left hand" and, "Blisters to the scalp that had ruptured". The CWSN stated per report from facility staff Resident 1 was outside within a few days prior and was, "Exposed to the sun." Upon assessment approximately two weeks later, the CWSN stated, "A large eschar had developed" on the scalp wound, "Which indicated it [the wound] was a third degree burn or full thickness wound." The CWSN explained with no report of trauma or a previous diagnosis of a skin condition, she stated the wounds appeared to be burns.
A review of Resident 1's physician progress notes, recorded by MD 1, included the following:
a. 7/17/17, 9:02 p.m.: "...Patient was seen by wound RN [name] on 7/3 for blistering on left dorsal hand and frontal scalp, felt due to sun exposure/sunburn. She saw patient again on 7/17 [sic] for follow up, and scalp burn was noted to have dramatically deteriorated since her last visit. Patient was noted to have full thickness tissue loss with slough and eschar... I saw and examined patient at the SNF [skilled nursing facility] this morning. He was in his room. He told me he had been out in the sun too long... Assessment/Plan: ulcer of skin... felt due to sunburn..."
b. 7/31/17, 3:15 p.m.: "... Initial insult to skin appears to have been due to sun exposure...He has no vesicles (fluid filled sac, like a blister) noted on exam today that would suggest a primary skin condition such as bullous pemphigoid (a skin condition causing blisters), and he has no prior history of this. Review of record shows that he was seen in Dermatology once in 2007 for dry skin... Since the scalp lesions have not responded as quickly to local treatment as hoped, will send [consult] to Surgery for evaluation..."
c. 8/20/17, 3:37 p.m.: "...Burn of head... due to prolonged sun exposure in early July, by report of SNF staff and daughter. ANA (antinuclear antibody, a blood test) result previously discussed with Rheumatology (relating to conditions including joints, soft tissues and immune system), and was felt to be non-specific and not suggestive of underlying rheumatologic condition such as lupus, etc..."
In a telephone interview with Medical Doctor 1 (MD 1) on 7/28/17 at 12:50 p.m., MD 1 confirmed she was notified on 7/3/17 that Resident 1 had blisters on the left hand and scalp. MD 1 stated Resident 1 did not have a primary skin condition that would cause blisters. When asked if the resident was prescribed medications that could cause photosensitivity (causing the skin to become more sensitive to sun exposure), MD 1 stated, "None of the typical ones." MD 1 stated, "In the absence of a primary or secondary condition, a sunburn would be the likely cause [of the blisters] with the history of recent sun exposure."
In an interview with the DON and Administrator on 7/27/17 at 2:18 p.m., they explained there was no policy and procedure for resident safety related to being outdoors. They confirmed with a company "consultant" of the absence of the policy also.
Therefore, the Department determined the facility failed to adequately protect 1 of 5 sampled residents (Resident 1) from an excessive duration of exposure to sunlight and heat when he was outdoors on the facility patio.
The above violations had a direct relationship to the health, safety, or security of patients. |
| 920000017 |
Glenoaks Conv. Hospital |
920013590 |
A |
2-Nov-17 |
CYWN11 |
17219 |
F314
483.25(b) (1) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES
(b) Skin Integrity ?
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
On 9/23/17, an unannounced recertification survey was conducted.
Based on observation, interview, and record review, the facility failed to prevent the development and promote healing of a pressure ulcer (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for Resident 8 by failing to:
1. Revise the plan of care to address pressure relief to Resident 8's contracted right arm to prevent skin breakdown while he is lying in bed.
2. Follow the physician's order to offload (remove or free surface of pressure by suspending on air) Resident 8's contracted right elbow.
3. Implement the facility's policy and procedure to monitor the skin condition and assess pressure ulcer on a weekly basis.
4. Provide treatment to Resident 8's contracted right elbow Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough [dead tissue usually light colored, soft, moist and stringy] or eschar [thick, leathery, frequently brown or black, dead or devitalized tissue] may be present on some parts of the wound bed, often includes undermining and tunneling).
5. Notify the physician of the Registered Dietician's (RD) recommendation for supplements to aid in wound healing.
These failures resulted in Resident 8 developing an avoidable Stage IV pressure ulcer to his right elbow and delayed healing of his pressure ulcer.
Findings:
A review of Resident 8's Admission Record indicated the resident was originally admitted to the facility on June 26, 2012 and was readmitted on April 20, 2016, with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage) following unspecified cerebrovascular disease (condition caused by problems that affect the blood supply to the brain), and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain) without behavioral disturbances.
According to the Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate a resident's risk of developing a pressure ulcer), dated January 16, 2015, the resident scored 10 and on May 17, 2017, the resident scored 12 (total score of 12 or less represents high risk).
A review of the Nurses' Admission Record dated April 20, 2016, indicated Resident 8 was admitted with a Stage II pressure ulcer (partial thickness loss of dermis [inner layer of the two main layers of cells that make up the skin] presenting as a shallow open ulcer with a red or pink wound bed, without slough and may also present as an intact or open/ruptured blister) on the coccyx (tailbone) area with perirectal (tissues surrounding the rectum) redness. According to the Weekly Pressure Ulcer Documentation dated May 5, 2016, the stage II pressure ulcer on the resident's coccyx resolved.
The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated May 17, 2017, indicated Resident 8 was severely impaired in his cognitive skills for daily decision making, rarely/never understood others and rarely/never made self understood, and required total assistance from the staff for all activities of daily living (ADL's). The MDS indicated the resident had functional limitation in range of motion on both sides of the upper extremities and one side of the lower extremity and was always incontinent of bowel and bladder. According to the MDS, the resident was at risk of developing pressure ulcers, but did not have any pressure ulcers.
A review of the Nursing Care Plan dated May 20, 2015, indicated Resident 8 had the potential for impairment of skin integrity related to bowel and bladder incontinence, decreased mobility, skin fragility, and impaired cognition. The care plan goal indicated Resident 8 will be free from tissue injury and skin breakdown daily and review every three months. The nursing interventions included to turn and reposition every two hours, keep clean and dry at all times, provide/assist with good skin care, provide pressure relieving device, and notify physician if resident has swelling, redness, skin tears, bruises, and discoloration. There was no nursing interventions on preventing pressure to resident's contracted right arm to prevent skin breakdown while Resident 8 is lying in bed.
A review of the Resident Care Plan dated May 20, 2015, indicated Resident 8 was at risk for further decline in ADL's and development of contractures. The care plan goal indicated the resident will maintain joint mobility status, minimizing decline daily for 90 days and review every three months. The listed nursing interventions included to provide rehabilitation treatment as ordered or restorative nursing assistant program as ordered.
A review of the Weekly Pressure Ulcer Documentation dated August 9, 2017, indicated Resident 8 had an unstageable pressure 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) to his contracted right elbow measured 1.0 centimeters (cm) in length (L) by 1.8 cm in width (W). There was no documented evidence that Resident 8's change of skin condition to his right elbow was reported to any staff until August 9, 2017, when the resident's right elbow was assessed with an unstageable pressure ulcer.
A review of a physician's order dated August 9, 2017, indicated to cleanse right elbow unstageable pressure ulcer with normal saline solution (NSS, a sterile mixture of salt and water), pat dry, apply silvadene (applied to the skin to treat and prevent wound infections associated with second or third degree burns), and cover with dry dressing (any of various materials used for covering and protecting a wound) daily.
According to a short term care plan dated August 9, 2017, Resident 8 had impaired skin integrity due to a right elbow unstageable pressure ulcer. The care plan goal indicated the resident's skin will be cleared and intact by 21 days. The listed nursing interventions included to administer treatment as ordered, notify the physician of signs and symptoms of infection and failure to heal and respond to the treatment plan, turn and reposition at least every two hours and position off site as much as possible, keep the resident clean and dry, and provide pressure relieving devices as needed. The care plan however, did not address how to position off site and relieve pressure on the right elbow.
A review of the wound consultant's progress note dated August 16, 2017, indicated Resident 8's right elbow was assessed with a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) which measured 2 centimeters (cm) in length by 2.7 cm in width by 0.2 cm in depth (L x W x D) with an area of 5.4 square (sq) cm and a volume of 1.08 cubic cm. The assessment indicated the wound had a light amount of serous (pale yellow and transparent) drainage with no odor, wound bed with 100% slough, and maceration (softened by surrounding liquid) on the periwound (tissue surrounding wound). Under plan and additional orders, the wound consultant indicated to cleanse and irrigate wound with NSS, pack wound with silvadene, and cover with foam dressing every day and as needed (PRN), implement pressure relieving measures and offloading as tolerated and registered dietician (RD) consultation to implement nutrition plan.
A review of the Resident Care Plan for Pressure Sore Potential dated August 17, 2017, indicated Resident 8 was at risk for further skin breakdown related to decreased mobility, incontinence of bowel and bladder, cognitive impairment, thin and fragile skin, and contracture of extremities. The care plan goal indicated Resident 8 will be free of skin breakdown and maintain comfortable positioning, adequate skin care and hygiene daily through the next review. The listed nursing interventions included to monitor for signs and symptoms of skin breakdown, keep skin clean and dry as possible, encourage and assist to turn every two hours, use pressure relieving device in bed and in wheelchair, refer to RD as needed (PRN) to evaluate diet, protein, fluids and supplement needs, and report changes to the physician and obtain treatment as ordered. The care plan however, did not include revised interventions to address offloading of the resident's right elbow Stage IV pressure ulcer as ordered by the wound consultant.
According to a physician's order dated August 30, 2017, continue right elbow pressure ulcer treatment, cleanse right elbow pressure ulcer with NSS, pat dry, apply silvadene and cover with dry dressing daily for 21 days.
A review of a Dietary Progress Note by the RD dated September 15, 2017, indicated Resident 8 with pressure ulcer on right elbow which measured 1.5 cm by 1.0 cm by 0.4 cm. RD indicated to continue tube feeding of Jevity 1.2 cal at 55 milliliters per hour (ml/hr) over 20 hours to provide 1100 ml/1320 calories and water flushes of 300 ml every shift and add multivitamin with minerals (used to treat vitamin or mineral deficiencies caused by illness or poor nutrition) and vitamin C (helps with growth, development and repair of all body tissues) to aid in wound healing.
During an initial tour observation of the facility with Licensed Vocational Nurse (LVN) 9 on September 21, 2017, at 6:25 p.m., Resident 8 was observed lying in bed on his back with eyes closed, receiving Jevity 1.2 cal at 55 ml/hr via gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach). Resident 8's right arm was contracted and his right elbow was observed wrapped with a dressing, directly resting on a pillow. LVN 9 stated that Resident 8 has a pressure ulcer on the right elbow.
During observations on September 22, 2017, at 2:45 p.m. and 3:30 p.m., Resident 8 was observed lying in bed on his back with eyes closed. Resident 8's right arm was contracted with a dressing on the right elbow. The right elbow was observed resting directly on a pillow. At 4:40 p.m. and 5:10 p.m., on the same day, Resident 8's right elbow was observed resting directly on a rolled towel.
During an interview on September 22, 2017, at 5:12 p.m., Certified Nursing Assistant (CNA) 2 stated that Resident 8 had a wound on the right elbow, but she had not seen it because it was always covered with a dressing. CNA 2 stated that she turns the resident every two hours and elevates his contracted right arm with a pillow to relieve pressure. CNA 2 was unaware that she needed to offload the resident's right elbow.
During an interview on September 22, 2017, at 5:30 p.m., the Director of Nursing (DON) was asked about Resident 8's skin. The DON was unaware that the resident had any skin problems. When told that the resident was observed with a dressing on the right elbow, the DON stated that the resident "probably just has a Stage 1 or Stage 2".
During an observation on September 22, 2017, at 5:30 p.m., the DON and the surveyor went inside Resident 8's room and observed Resident 8 lying in bed with the right arm contracted and right elbow covered with a dressing, resting directly on a pillow. The DON stated that Resident 8's right elbow should be suspended on the air and not touching the pillow.
During a subsequent observation on September 22, 2017, at 5:35 p.m., the DON removed the dressing from Resident 8's right elbow. Resident 8 was observed with a wound on the right elbow which approximately measured 0.3 cm by 0.5 cm with an area of 3 cm by 3 cm. The wound was dry and brown in color with a small amount of yellow slough. According to the DON, the wound was healing.
During an interview on September 22, 2017, at 5:51 p.m., the DON reviewed the resident's clinical record and stated that Resident 8's right elbow Stage 4 pressure ulcer developed in the facility and there were no documented interventions or revisions on Resident 8's plan of care to address pressure relief and prevent skin breakdown to Resident 8's contracted right arm. The DON also reviewed the Weekly Pressure Ulcer Documentation for the resident's right elbow Stage 4 pressure ulcer and stated that the last assessment and measurement of the wound was done on September 6, 2017. The DON stated that pressure ulcers should be assessed and measured every week to monitor progression of the wound. The DON also reviewed the nurse?s notes and was unable to find documented evidence of skin monitoring from August 1, 2017 to September 23, 2017. According to the DON, there were no nurse?s notes because Resident 8 did not have any change in condition.
During the same interview on September 22, 2017, at 5:51 p.m., the Treatment Record for September 2017 was reviewed with the DON. The Treatment Record indicated Resident 8 received treatment to his right elbow pressure ulcer as ordered by the physician from September 1, 2017 to September 20, 2017. The Treatment Record further indicated the treatment order ended on September 20, 2017, and the resident did not receive treatment for his right elbow pressure ulcer on September 21, 2017 and September 22, 2017. The DON stated that the physician should have been called to obtain further treatment orders when the treatment order was completed on September 20, 2017. Upon further interview, the DON was asked about the RD's recommendation to add multivitamin with minerals and vitamin C to aid in wound healing. The DON stated that the RD's recommendation was faxed to the resident's physician on September 15, 2017, but the physician prefers to write his own orders when he visits the facility. The DON was unable to find documented evidence that the facility made a follow up to the resident's physician regarding the RD's recommendations.
The facility's undated policy and procedure titled "Policy: Pressure Sores" indicated all available measures will be taken to prevent skin breakdown and pressure sores. If these conditions occur, treatment will be initiated immediately and preventive measures taken to prevent further deterioration of the skin. In cases where the resident's condition promotes a high risk of skin breakdown, preventive measures will be employed routinely. The policy indicated activities to be completed: assess resident care on a continuous basis to ensure that good skin care is being carried out, identify residents at risk for skin breakdown, evaluate resident with skin problem/s, complete weekly skin checks to ensure that skin problems are identified and treated on a timely basis, notify the physician when skin problems are identified and obtain treatment orders, document findings in the licensed nurse notes, identify problems on resident care plan and update as needed, initiate Skin/Decubitus Progress Report Form, pressure sore monitoring will be done daily, discuss with the dietary department any appropriate nutritional interventions, assess progression/regression of pressure sore and notify the physician and modify current preventive measures and request treatment change if necessary, use appropriate pressure reducing devices for residents identified with skin problems or has potential for skin problems, and turn/reposition residents in a manner that reduces the potential for skin breakdown.
The facility failed to:
1. Revise the plan of care to address pressure relief to Resident 8's contracted right arm to prevent skin breakdown while he is lying in bed.
2. Follow the physician's order to offload Resident 8's contracted right elbow.
3. Implement the facility's policy and procedure to monitor the skin condition and assess pressure ulcer on a weekly basis.
4. Provide treatment to Resident 8's contracted right elbow Stage IV pressure ulcer.
5. Notify the physician of the registered dietician?s recommendation for supplements to aid in wound healing.
These failures resulted in Resident 8 developing an avoidable Stage IV pressure ulcer to his right elbow and delayed healing of his pressure ulcer.
The above violations either jointly, separately, or in any combination presented either an imminent danger that serious physical harm would result or a substantial probability that serious physical harm would result. |
| 960001506 |
GABLE DIVISION |
960013492 |
B |
13-Sep-17 |
6IMB11 |
5371 |
Code of Federal Regulations (CFR)
(W112) The facility must keep confidential all information contained in the clients? records. Regardless of the form or storage method of the records.
On August 1, 2017 at 2:45 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI), regarding Client 1?s clinical record being stolen.
The facility staff failed to:
1. Ensure all information regarding Client 1 remained confidential and secured. Client 1's entire clinical record was taken out of the facility by the Registered Nurse (RN) and left in the RN?s car. Client 1's entire clinical record was stolen from her car. The administrative staff failed to ensure the client?s record remained secure.
On August 1, 2017 at 2:45 p.m., during a review of the clinical record the face sheet (identifying sheet) indicated, Client 1 was admitted to the facility with the diagnoses of profound intellectual disabilities (cognitive ability that is markedly below average level, incapable of self-care), spastic quadriplegia cerebral palsy (most severe form of cerebral palsy in with one?s ability to coordinate body movements of all four limbs and the trunk are affected including problems with muscles that control the mouth and tongue, and difficulty in speaking), chronic constipation, a history of intestinal obstruction, a history of colostomy (reversible surgical procedure in which a stoma is formed by drawing the health end of the large intestine or colon through an incision in the anterior abdominal wall, which provides a channel for feces to leave the body).
An ERI dated July 27, 2017, indicated Client 1's clinical record which contained all of the client's medical records, consultant reports and assessments was stolen from the car of the registered nurse (RN).
During an interview with the qualified intellectual disabilities professional (QIDP), on August 2, 2017, at 3:20 p.m., he stated on August 27, 2017 the RN removed Client 1's entire clinical record from the facility and it was stolen out of her car. The QIDP stated the RN was responsible for safeguarding Client 1's clinical record.
During an interview with the registered nurse (RN), on August 2, 2017 at 3:40 p.m., she stated on August 27, 2017 she removed Client 1's chart from the facility because there was an annual interdisciplinary team(IDT) meeting concerning Client 1?s needs, evaluation of objectives, and the possible need for revision of care. The RN stated the facility did not have a copy machine to make the copies she needed for the meeting so she had to remove the entire clinical record from the facility. The RN stated after the meeting, she placed Client 1's clinical record in her car on the front seat and went into the corporation?s main office. The RN stated when she returned to her car it was open and the chart was missing. When asked if she locked her car door before going into the office, she stated when she arrived to the car it was unlocked so she was not sure. The RN was asked if she may have misplaced the clinical record, she stated she called every place she went that day and no one reported seeing Client 1's clinical record.
During a review of the facility's policy regarding clinical record order, the following forms were supposed to be in the chart:
-individual service plan
-behavioral treatment review
-physician progress notes (including physician's orders, telephone orders, and pharmacy drug review)
-annual physical
-past medical history
-laboratory and special reports
-medical data, weight, seizure activity, and immunization record
-admission records
-rehabilitation and therapy (including bowel and bladder, sex education assessment, speech therapy, vocational assessment, psychological evaluation, and acute hospital history)
-medical evaluations (including dental record, audiology report, podiatry and optometry report)
On August 15, 2017, a review of the police report dated July 27, 2017, indicated the RN stated, Client 1?s clinical record was stolen from her locked car, but that when she went to lunch and opened the door it was unlocked, and that she was unable to determine how the suspect entered her vehicle. There was no obvious entry point.
The facility policy and procedure dated March 1989 titled "Client Record Policies and Procedure," indicated the facility must keep confidential all information contained in the client's records including information contained in an automated data bank. Protect the record from loss, damage, tampering, or use by unauthorized individuals. Information in each client's chart will be treated with consideration, and shall be protected from unauthorized access or use and released only to authorized persons in accordance with the federal, state and local laws. Each client will be given privacy during treatment and assistance with personal needs and have his records (information) treated confidentially.
The facility staff failed to ensure
1. All information regarding Client 1 remained confidential and secured. Client 1's entire clinical record was stolen. Failure of the administrative staff to ensure the client?s record remained secured violated the client's right to privacy.
The above violation presented had a direct relationship to the health, safety, and security of the clients. |
| 960001826 |
G M HOME II |
960013556 |
B |
19-Oct-17 |
OUXG11 |
3335 |
California Code, Health and Safety Code, ?1265.5
(f) Upon the employment of any person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check.
On July 31, 2017 at 5:55 AM, an unannounced annual Extended Recertification Survey was conducted.
The facility administration failed to:
Ensure a Direct Care Staff (DCS) was fingerprinted who works with 3 of 3 sampled clients (Clients 3, 4, and 5) and 3 of 3 non-sampled clients (Clients 1, 2, and 6). The facility administration did not ensure DCS 6 was fingerprinted and cleared when he was hired before working with the clients. This deficient practice had the potential for a person with a criminal history to work with the clients.
The clinical records for Clients 1, 2, 3, 4, 5, and 6, reviewed on 7/31/17, indicated Clients 1 and 3 were diagnosed with severe intellectual disabilities (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment) and Clients 2, 4, 5, and 6 were diagnosed with profound intellectual disabilities (cognitive ability that is markedly below average level, incapable of self-care). All clients depended on staff for all activities of daily living.
During an observation, on 7/31/17, at 6:02 AM, in the room of Clients 2 and 4, DCS 6 was providing patient care to the clients.
During a review of the employee file for DCS 6, on 7/31/17, he was hired on 12/5/16. DCS 6's employee file indicated there was no documentation to support a Live Scan application was completed and submitted to the Department of Justice for the purpose of securing criminal clearance.
On 7/31/17, the Interactive Voice Response Unit (IVRU) was called for verification of Live Scan Application. The IVRU indicated there was no record on file for DCS 6.
During an interview, on 7/31/17, at 11:39 AM, the Registered Nurse (RN) stated she submitted a Transmittal Application for Criminal Background Investigation on 10/8/16, and confirmed the Request for Live Scan was not completed at the bottom of the form where the Live Scan Operator documents that a Live Scan has been completed.
During an interview, on 8/1/17, at 7:25 PM, the RN stated that she missed getting DCS 6's Live Scan completed. The RN concluded that DCS 6 had not been fingerprinted.
The facility's policy and procedure titled "Allegations of Client Abuse," the policy statement indicates "Clients will be free from any form of abuse by others, including from other clients." The procedure section indicates "Fingerprints are required prior to employment of staff."
The facility administration failed to ensure a Direct Care Staff (DCS) was fingerprinted who works with 3 of 3 sampled clients (Clients 3, 4, and 5) and 3 of 3 non-sampled clients (Clients 1, 2, and 6). The facility administration did not ensure DCS 6 was fingerprinted and cleared when he was hired before working with the clients. This deficient practice had the potential for a person with a criminal history to work with the clients.
The above violation had a direct relationship to the health, safety and security of the clients residing in the facility. |
| 100000055 |
GARDEN CITY HEALTHCARE CENTER |
040013474 |
A |
7-Sep-17 |
CTB411 |
15058 |
F323
483.25 (d) (2) Accidents
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 12/20/16 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Entity Reported Incident CA 00515040 regarding a resident elopement (leaving the facility unsupervised and without permission) and subsequent fall with injury.
The facility failed to provide the necessary supervision to prevent accidents for Resident 20 when staff was aware Resident 20 had multiple elopement attempts and failed to monitor Resident 20's location and personal alarm system function as required by facility policy and Resident 20?s care plan.
As a result of this failure Resident 20 left the facility unattended, fell, sustaining a right hip and right arm fracture (broken bone), and a hand laceration (cut). Resident 20 was transferred to the acute care hospital (ACH) by ambulance for evaluation, treatment, and surgical repair of the right hip. Resident 20 suffered a decline in physical mobility and required extensive post-operative physical and occupational therapy as a result of the injuries sustained in the fall.
Review of Resident 20's clinical record titled, "Face Sheet (document with personal information of the resident)," indicated Resident 20 was 83 years old and had resided in the SNF since 5/11/14. The Face Sheet indicated Resident 20 had diagnoses that included Dementia (disorder causing impaired memory, reasoning and judgement), Alzheimer's Disease (a type of dementia that results in memory loss, decrease in intellectual abilities and personality changes), Anxiety Disorder (disorder characterized by feelings of apprehension, uneasiness or dread), and a history of falls.
Review of Resident 20's clinical record titled, "Care Plan" dated 9/28/14, indicated Resident 20 was at risk for elopement related to wandering around the facility inside and outside the front door. Resident 20's Care Plan Approach indicated, "Equip resident with a device that alarms when resident wanders. Check for proper functioning of device and alarms q (every) shift... Monitor resident's whereabouts frequently."
Review of Resident 20's clinical record titled, "Progress Note" dated 2/10/15 indicated, "She [Resident 20] has often tried to leave the facility..."
Review of Resident 20's clinical record titled, "Progress Note" dated 10/7/15, indicated, "Concern expressed by NHA [Nursing Home Administrator] and IDT [Interdisciplinary Team, a team composed of health care providers who plan resident care] team members ... regarding resident [Resident 20] ambulating outside of facility unattended and high risk for injury."
Review of Resident 20's Care Plan dated 5/29/16, indicated Resident 20 "Elects to go outside of the facility unescorted potentially related to Advanced Alzheimer's Dementia." Resident 20's Care Plan Goal indicated, "Resident [Resident 20] to remain safe within the facility."
Review of Resident 20's clinical record titled, "Progress Note" dated 5/31/16, indicated, "Resident is alert and oriented to family and some staff, otherwise very confused. She went out of facility unescorted. She was promptly brought back to facility."
Review of Resident 20's clinical record titled, "Progress Note" dated 8/4/16, indicated, "Patient has strong self determination to ambulate throughout the facility and outside grounds with poor insight to risks. Was found wandering outside of facility."
Review of Resident 20's clinical record titled, "Progress Note" dated 10/14/16, indicated, "[Resident 20] walks independently, daily, throughout the facility either pushing her W/C [wheelchair] or without. Often looking for the door. She is noted to become verbally irritable when redirection is attempted to guide her."
Review of Resident 20's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 11/18/16, indicated a Brief Interview for Mental Status (BIMS) score was 5 of 15 possible points. A score of 5 indicated Resident 20 had severe memory impairment. The MDS dated 11/18/16, indicated Resident 20 was able to ambulate (walk) in her room and in the facility corridor with staff supervision.
Review of Resident 20's clinical record titled, "Progress Note" dated 12/8/16, indicated, "IDT Discussion regarding multiple elopement attempts by patient [Resident 20]."
Review of Resident 20's Care Plan dated 12/8/16, indicated a problem of "Recurrent focus on leaving facility to look for family, her car, or because of delusions [false beliefs] or hallucination [false perceptions], and is increasingly more difficult to re-direct." The Care Plan Approach indicated, "As possible, keep within line of sight."
Review of Resident 20's clinical record titled, "Progress Notes" dated 12/14/16 at 6:04 p.m., indicated, "Call received from [local police department] with information resident was found outside of facility and had sustained a cut on her hand...PD [police department] officer asked what hospital she should be evaluated at...patient will be transported there..."
On 12/20/16 at 3:45 p.m., during an interview, the Administrator (Admin) stated Resident 20 had a history of constantly seeking to elope. The Admin stated the facility had been working for the past year on locating a locked facility placement for Resident 20 due to elopement attempts. The Admin stated Resident 20 eloped from the facility on 12/14/16 and had a fall outside the facility. The Admin stated Resident 20 was readmitted to the skilled nursing facility on 12/16/16 following treatment in the ACH for injuries sustained in the fall. The Admin stated Resident 20 required rehabilitation (physical and occupational therapy to help the resident regain strength and functional abilities) after having sustained a fractured hip during the fall.
On 12/20/16 at 4:03 p.m., during an observation and concurrent interview, Resident 20 was sitting in a wheel chair in front of the nurses' station. Resident 20 had a soft cast on her right arm. Resident 20 had difficulty staying awake during the interview and stated she had been given pain medication that made her drowsy. Resident 20 stated she knew she had a fall and broke her hip but did not remember the incident.
On 12/20/16 at 4:29 p.m., during an interview, Certified Nursing Assistant (CNA) 4 stated Resident 20 had a history of elopement attempts. CNA 4 stated Resident 20 usually tried to leave the building through the exit door at the end of the "short hallway." CNA 4 stated there was a Wander Guard Alarm (personal alarm worn by residents to alert staff when they approach an exit door) sensor (electronic device that senses the approach of the resident wearing the alarm) in the middle of the hallway and the exit door was alarmed. CNA 4 stated Resident 20 had to pass those alarms on 12/14/16, the day she eloped from the facility. CNA 4 stated, "I don't know how [Resident 20] passed the Wander Guard sensor and exit door alarm."
On 12/20/16 at 4:35 p.m., during an interview, Licensed Nurse (LN) 3 stated on 12/14/16, she observed Resident 20 walking back and forth down the "short hall" several times pushing her wheelchair. LN 3 stated she heard Resident 20 say repeatedly, "I want to see my kids." LN 3 stated Resident 20 had passed the area where there was a Wander Guard sensor. LN 3 stated she heard the alarm sound and redirected Resident 20 away from the sensor. LN 3 stated she last saw Resident 20 around 4 p.m. walking toward the employee exit door. LN 3 stated, "All shifts should check the Wander Guard Alarm [for proper function]. Make sure the button [on the alarm sensor] is fully pushed in." LN 3 stated Resident 20 was "very independent prior to elopement." LN 3 stated prior to her fall, Resident 20 was steady on her feet and went around the facility pushing her wheelchair. LN 3 stated Resident 20 required minimal assistance with dressing and showering before her fall on 12/14/16.
On 12/20/16 at 4:58 p.m., during an interview, CNA 2 stated on 12/14/16 she observed Resident 20 to continually walk toward the exit door. CNA 2 stated Resident 20 stated repeatedly she wanted to go home and see her family. CNA 2 stated she walked Resident 20 back from the exit door to the activity room several times on 12/14/16. CNA 2 stated Resident 20 had to pass the Wander Guard sensor and the exit door alarm to elope from the facility. CNA 2 stated, "For some strange reason, she [Resident 20] got past those alarms."
On 12/20/16 at 5:01 p.m., during an interview, the Facility Maintenance Director (FMD) stated the Maintenance Department was responsible for testing the Wander Guard system on a monthly basis. The FMD stated resident Wander Guards were checked once per week. The FMD produced a written log titled, "Wander Guards" which indicated a notation of "ok" written weekly from 9/5/15 to 12/15/16. There was no documentation of Resident 20's Wander Guard checked every shift by the staff.
On 12/20/16 at 6:10 p.m., during an interview, the Admin stated the local police department notified the facility on 12/14/16 Resident 20 was found by a bystander outside the facility. The Admin stated the bystander had called the police department to report the incident. The Admin stated the facility had not investigated the circumstances that allowed Resident 20 to leave the building unnoticed. The Admin stated there was no timeframe or guideline for frequency of monitoring Resident 20's location for prevention of elopement.
On 2/14/17 at 5:11 p.m., during an interview, the Director of Nursing (DON) stated the Maintenance Department was responsible for checking the Wander Guard system on a monthly and weekly basis. The DON stated the nursing staff checked to ensure the alarm was placed on the resident appropriately but nursing staff did not check the function of the alarm. The DON stated the facility did not have a policy or procedure to guide nursing staff regarding who should check the alarms, how to check the alarms or how often to check the alarms. The DON stated there was no system in place directing nursing staff in checking Wander Guard alarms.
On 4/6/17 at 3:20 p.m., during a telephone interview, the FMD stated, if working properly, the Wander Guard alarm in the "short hallway" would alarm continually until a staff member put the code into the alarm box to turn it off. The FMD stated, if working properly, all exit door alarms would continue to alarm until disarmed by staff. The FMD stated exit door alarms were tested every week.
On 4/6/17 at 3:30 p.m., during a telephone interview, the DON stated nursing staff check placement of the Wander Guard alarms on residents but do not document the check. The DON stated Resident 20 did not have a detailed monitoring plan for elopement prevention. The DON stated staff were instructed to keep Resident 20 within their line of sight as much as possible but there was no regularly scheduled or documented monitoring of her location prior to 12/14/16.
On 4/7/17 at 8:55 a.m., during a telephone interview, the Admin stated Resident 20 had been found by a bystander and the local police department on 12/14/16 about a block away from the facility on a side street. Resident 20 had her wheelchair with her when she was found. The Admin stated facility staff were unaware Resident 20 was missing until notified by the local police department. The Admin stated he was not certain how long Resident 20 was missing, but he had seen her that afternoon in the facility. The Admin stated facility staff were not able to determine how Resident 20 left the building. The Admin stated the door alarms were functioning when tested upon Resident 20's return. The Admin stated, "The only thing we can think of is she was very fast that day and by the time the staff silenced the alarms she was already out the door and out of sight."
Review of Resident 20's ACH clinical record titled, "Note Report" dated 12/16/16, indicated Resident 20 was admitted to the ACH on 12/14/16 following a fall. The "Note Report" indicated, "D/C [discharge] Diagnosis ...right Femur [the large bone of the lower extremity] Fracture FX [fracture], Right Humerus [upper arm bone] FX. Hip Fracture Cephalomedullary Nail [a treatment for fracture that involves insertion of hardware in the operating room to stabilize the bones] Insertion (right) 12/15/16. Distal [closer to the hand than to the shoulder] humerus fracture under conservative [non-surgical] management."
Review of Resident 20's ACH clinical record titled, "Physical Therapy Evaluation" dated 12/16/16, indicated, "Assessment...Status post [after] right hip...nail fixation of the...hip fracture. Patient presents with right/thigh pain, right lower extremity weakness, impaired functional mobility, demonstrated difficulty standing and inability to ambulate at this time. Patient would benefit from daily therapy upon discharge back to [Skilled Nursing Facility] where patient resides to maximize mobility and help patient return to prior level of function."
Review of Resident 20's clinical record titled, "Care Plan" dated 12/17/16, indicated, "Requires Skilled PT [Physical Therapy]: Problems related to impaired mobility, decreased strength and endurance, decreased balance and coordination, joint mobility limitation, positioning issue, gait issues. Requires Skilled OT [Occupational Therapy]: Problems related to impaired functional mobility, impaired ADL [activities of daily living such as bathing, grooming and eating] skill, decreased strength and endurance, decreased balance and coordination."
The facility policy and procedure titled, "Wandering, Unsafe Resident" dated December 2008, indicated, "...6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior."
Therefore, the facility failed to provide the necessary supervision to prevent accidents when staff was aware Resident 20 had multiple elopement attempts and failed to monitor Resident 20's location and personal alarm system function as required by facility policy and procedure and Resident 20?s care plan. As a result of this failure Resident 20 left the facility unattended, fell, sustaining a right hip and right arm fracture, and a hand laceration. Resident 20 was transferred to the acute care hospital by ambulance for evaluation, treatment, and surgical repair of the right hip. Resident 20 suffered a decline in physical mobility and required extensive post-operative physical and occupational therapy as a result of the injuries sustained in the fall.
These violations placed Resident 20 in imminent danger that death or serious harm would have resulted or a substantial probability that death or serious physical harm would result and therefore constitutes a class ?A? citation. |
| 910000043 |
GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA |
910013702 |
A |
29-Dec-17 |
9KQT11 |
10931 |
CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
483.25 (h) Accidents and Supervision
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 7/20/17, an unannounced visit was made at the facility to conduct a complaint investigation regarding Resident 1?s fall.
Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure Resident 1, who was assessed as high fall risk, with functional limitation in upper and lower extremities, and was totally dependent with transferring from bed to chair, was provided with supervision, assistance, and an environment free of accident hazards as is possible to prevent fall and injuries, including but not limited to:
1. Failure to monitor Resident 1's immediate environment for any safety or accident hazards such as wet/slippery, or malfunctioning equipment, as indicated in the facility policy.
2. Failure to ensure Certified Nurse Assistants (CNAs) provided proper technique during transfer of Resident 1 who was totally dependent on staff for transfer and personal hygiene, as identified in the comprehensive assessment.
3. Failure to develop an initial plan of care with interventions, including the mode of transfer, to address Resident 1?s identified self-care deficit.
4. Failure to develop and implement interventions to prevent falls and accidents and enforce safety procedures and rules to ensure well-being of Resident 1 as per facility policy and procedure.
As a result, on 7/11/17, while CNA1 and CNA2 were transferring Resident 1 back to bed after receiving a shower, Resident 1 fell off the Hoyer Lift sling (a mechanical or power lift device). Resident 1 sustained a bruise and a large hematoma (collection of blood outside of blood vessels commonly caused by an injury to the wall of a blood vessel) to the right leg, was transferred to the general acute care hospital (GACH), and treated for a comminuted intertrochanteric fracture involving the right hip (right hip fracture involving minute particles or fragments).
A review of the admission record indicated Resident 1 was admitted to the facility, on 3/28/17, with diagnoses including respiratory failure, severe sepsis (presence of harmful bacteria and their toxins), and pneumonia (an infection of the lungs caused by fungi, bacteria, or viruses).
A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 4/7/17, indicated Resident 1 had unclear speech, and rarely had the ability to understand others. Resident 1 was assessed as being totally dependent for transferring from bed, chair or wheelchair, and with personal hygiene. The MDS indicated Resident 1 was assessed as being impaired with functional limitation in range of motion to both upper and both lower extremities.
According to Resident 1's plan of care, updated 6/17/17, the resident was at risk for self-care deficit and required assistance with activities of daily living (ADL's) due to limited mobility and obesity. The plan of care interventions and approach indicated to assist the resident with transfers and locomotion as needed, and assist as needed with showers. The care plan interventions included mode of transfer, such as manual assist, Hoyer lift (a mechanical or power lift), or other devices for transfer, however they remained blank and did not specify what would be the most effective mode of transfer for Resident 1.
A review of another care plan, updated 6/17/17, indicated Resident 1 was at risk for fall or injury due to poor safety awareness and history of cerebrovascular accident (CVA - stroke). The care plan goal indicated to minimize risk for falls daily with the interventions including to keep close observation during activities to minimize potential falls and provide assistive devices if ordered. Again there was no indication / documentation regarding the use of a Hoyer lift.
A review of the fall risk evaluation form, dated 7/7/17, indicated Resident 1 was a high fall risk due to disorientation times three at all times, was chair bound, and not able to perform gait or balance.
According to the SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication), dated 7/11/17, at 11 a.m., the Certified Nurse Assistant 1 (CNA 1) informed the Registered Nurse Supervisor that Resident 1 fell out of the sling while transferring the resident back to bed after receiving a shower. The sling broke and the resident's legs and buttocks slid and fell to the floor. The SBAR form indicated an ice pack was applied to Resident 1's right leg where it was noted to have an injury, and at 11:15 a.m., Resident 1's physician was notified of the incident with orders to continue applying ice pack to the resident's right leg.
A review of Resident 1's Licensed Personnel Progress Notes, dated 7/11/17, at 11 a.m., indicated the resident was on the floor in the room with CNAs next to the resident. Resident 1 was alert making eye contact. The progress note indicated a large hematoma (collection of blood outside of blood vessels commonly caused by an injury to the wall of a blood vessel) was observed to the resident?s right lower extremity and Resident 1 was transferred back to bed.
A review of the physician?s order, dated 7/11/17, at 2:05 p.m., indicated an order to transfer Resident 1 to the general acute care hospital (GACH) via 9-1-1. Further review of the clinical record indicated there was no physician?s order for use of the Hoyer lift.
According to the general acute care records computerized axial tomography (CT scan) of Resident 1's pelvis, dated 7/11/17, Resident 1 had a new comminuted intertrochanteric fracture (hip fracture) involving the right hip.
On 7/20/17, at 11:15 a.m., an interview was conducted with CNA 2, who stated he was assisting CNA 1 to transfer Resident 1 from the shower chair to the bed with the Hoyer lift, after giving the resident a shower. CNA 2 stated the resident's Hoyer lift sling was left on the resident while the resident showered. After showering the resident, both CNAs attached the wet sling and straps to the Hoyer lift hooks while lifting the resident. CNA 2 stated the strap snapped on one side causing Resident 1 to fall with both hips and legs hitting the floor. CNA 2 stated they did not check the straps for loose stitching or tears.
A review of Resident 1's clinical record, conducted with the Administrator and Director of Nurses, indicated no documented evidence of an investigation report of the incident or that the Department of Public Health was notified of the incident that led to Resident 1's right hip fracture.
On 7/20/17, at 1:40 p.m., when the Administrator was asked about Resident 1?s fall and the hip fracture, she stated she was not aware they had to conduct an investigation or report the incident to the Department.
A review to the Proactive medical products instructions for the Hoyer lift full body sling, indicated a warning indicating to inspect sling (s) for wear, tears, and loose stitching. The medical products instructions indicated bleached, torn, cut, frayed, or broken slings were unsafe and may result in injury.
A review of facility's policy and procedure for Accidents and Incidents, undated, indicated it was the policy of the facility to implement and enforce all safety procedures and rules to ensure the safety and well-being of residents. Facility shall implement measures to prevent, monitor and record accidents and incidents whenever possible. In cases where accidents or incidents occurred, the facility would prepare and file all required reports and records and conduct a thorough investigation of the accident or incident to prevent recurrence. An investigation report shall be submitted to the Administrator and Director of Nurses for further review and action. The Administrator or Director of Nurses shall report to the Department of Public Health and/or other State and local agencies any unusual accident or incident.
The policy and procedure further indicated the Director of Nurses, Director of Staff Development, Nurse Supervisors, Charge Nurses and Certified Nurse Assistants shall also be responsible for monitoring resident's immediate environment for any safety or accident hazards such as wet/slippery, or malfunctioning equipment.
The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed as high risk for falls, with functional limitation in upper and lower extremities, and was totally dependent with transferring was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries, including but not limited to:
1. Failure to monitor Resident 1's immediate environment for any safety or accident hazards such as wet/slippery, or malfunctioning equipment, as indicated in the facility policy.
2. Failure to ensure Certified Nurse Assistants (CNAs) provided proper technique during transfer of Resident 1 who was totally dependent on staff for transfer and personal hygiene, as identified in the comprehensive assessment.
3. Failure to develop an initial plan of care with interventions, including the mode of transfer, to address Resident 1?s identified self-care deficit.
4. Failure to develop and implement interventions to prevent falls and accidents and enforce safety procedures and rules to ensure well-being of residents as per facility policy and procedure.
As a result, on 7/11/17, while CNA1 and CNA2 were transferring Resident 1 back to bed after receiving a shower, Resident 1 fell off the Hoyer Lift sling. Resident 1 sustained a bruise and a large hematoma to the right leg, was transferred to the general acute care hospital (GACH), and treated for a comminuted intertrochanteric fracture involving the right hip (right hip fracture involving minute particles or fragments).
The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |