| 020000047 |
Hayward Hills Health Care Center |
020009163 |
B |
20-Mar-12 |
1MH711 |
3972 |
483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALSThe facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The facility violated the aforementioned regulation by failing to report immediately to the Department and, investigate, a resident's (Resident 1) allegation of rape by a facility employee. This failure had the potential for continued sexual harm and or abuse of the identified resident and other residents by a facility employee.Findings: On 10/29/10, Resident 1 returned to the facility after evaluation by the local hospital for her continued refusal for personal care and her refusal to eat. The nurses care plan, dated 10/29/10, noted Resident 1 had made "false accusations" of being raped by a member of the facility staff " to a member of the facility nursing staff at the time of transfer. Further review noted a nursing care plan, dated 11/12/10, that indicated Resident 1 alleged "staff abusing her, raping her and calling her names other than her name."Resident 1 had been admitted to the facility on 10/20/10 with multiple diagnoses which included adjustment disorder secondary to social situation and agitation.During an interview with the Administrator on 11/15/10 at 1:30 p.m., the Administrator stated she did not report to the Department Resident 1's allegation of rape which was made on 10/29/10. The Administrator stated that after discussion with her corporation consultant she had been informed the allegation should have been reported and investigated. In an interview on 11/15/10 at 2:25 p.m., when asked if the allegation of rape made by Resident 1 on 10/29/10 had been reported to the Department, and investigated, the Director of Nurse (DON) stated the facility did not report the allegation, nor had they conducted an investigation. The DON further stated that Resident 1 had made another allegation on 11/4/10 while being transferred to the local acute care facility for a second time for evaluation of her behavior. When asked if the allegation of 11/4/10, had been reported and investigated, the DON indicated it had not. On 11/12/10 the Department received an entity reported incident by facsimile, dated 11/12/10, which reported an allegation by Resident 1 of an alleged rape by staff and family members which occurred on 11/4/10. The report failed to indicate the allegation of 10/29/10.Review of the facility policy and procedure titled, 'Abuse and Neglect Prohibition Addendum,' dated 10/2004, indicated:a. The facility Administrator or designee shall report incident of "alleged" or "suspected" abuse to the Department...immediately, or within 24 hours.b. The facility will investigate incidents of "alleged" or "suspected" abuse... The facility's failure to follow the regulation and their policy and procedure for reporting allegations of abuse put all residents at risk for potential sexual abuse.These violations had a direct relationship to the health and safety or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020012242 |
B |
11-May-16 |
Y7V011 |
5303 |
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 must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility violated the aforementioned regulation by failing to ensure Residents 1 was free from involuntary seclusion. The Certified Nursing Assistant (CNA 1) used a gait belt (belt used to transfer a person from one position to another or while walking with people who have difficulty with balance) to secure the outside door knob of Resident 1's room to the adjacent hand railing attached to the wall, leaving the resident "locked" inside her room.Review of Resident1's admission record on 2/11/16, showed the facility admitted Resident 1 in 2013 with a diagnosis of Adult Failure to Thrive. (Failure to Thrive: state of decline which can include weight loss, decreased appetite, and inactivity). Record review on 2/11/16 of the document titled, Resident Care Plan, dated 12/15, showed a concern/problem identified for Resident 1 was social isolation, with an intervention of, "...Provide one on one interaction for sensory stimulation." (social isolation: being alone and not engaging with other residents). Record review on 2/11/16 of the document titled, MDS 3.0 Nursing Home Quarterly, dated 1/14/16, showed Resident 1 was usually understood, and understood what others were saying to her. Record review of the MDS 3.0 Nursing Home Quarterly, dated 12/10/15, showed Resident 2 had clear speech, and was able to express ideas and wants. In an interview on 2/11/16 at 11:00 a.m., Resident 2 stated, Resident 1 often wanders into other resident's rooms at night. On 2/3/16 at approximately 5:15 a.m., Resident 1, wandered into Resident 2's room and was yelling in Spanish. Resident 2 pushed the call light and no one answered for 5 minutes. Resident 2 tried to get up out of bed and into his wheel chair. The nurse, (Licensed Vocational Nurse 1, LVN 1), and the CNA, (Certified Nursing Assistant 1, CNA 1), came in and told Resident 2 to sit down for safety reasons. He told them Resident 1 had been in his room and was yelling. At approximately 5:45 a.m., Resident 2 went towards Resident 1's room, and the door knob to her room was tied to the hallway hand railing with a belt. Resident 2 stated "There was no way she could get out. It was tied real tight." In an interview on 2/11/16 at 11:35 a.m., LVN1 stated she was in another resident's room. Resident 1, was in the hallway sometime between 5 and 6 a.m. The LVN wheeled Resident 1 in her wheelchair from Resident 2's room and took her to her room. LVN 1 and CNA 1 tried to calm Resident 1 down. LVN 1 stated that Resident 1 tries to go into other resident's rooms and the other residents are bothered by that. After they got Resident 1 to her room they asked her to quiet down, and went back to passing medications and making rounds. When LVN 1 went to give Resident 2 his medications, he told her Resident 1's door was tied with a belt. LVN 1 went to check it and saw it was tied. She looked for the CNA, but couldn't find her. When LVN 1 came back she saw the door was untied. The gait belt was gone. After that LVN 1 continued to pass medications to other residents. She did not talk to the CNA about the tied door. CNA 1 was not removed from resident care and continued to care for Resident 1.We both stayed until the end of the shift at 0730. She told the Director of Nursing at "9 or 9:30 a.m." LVN 1 stated, "I should have removed the belt from the door and stayed with the resident. I should have called the administrator at that time." In an interview on 2/16/16 at 9:40 a.m., Resident 1 stated she remembered being locked into her room on 2/3/16 and it made her feel, "bad." In an interview on 2/16/16 at 10:00 a.m., CNA 1 stated Resident 1 had been "disturbing" other residents. CNA 1 brought Resident 1 back to her room. The CNA got the gait belt and tied it around the door knob and tied it to the hallway railing. CNA 1 stated, "It stayed tied for about 10 minutes. Resident 1 kept on yelling in her room, she wanted to get out of the room. CNA 1 stated she got the gait belt to keep her from going out in the hallway because it was a busy time, around 5-6 a.m. She stated Resident 1 was "agitated." Record review on 2/16/16 of the facility's policy and procedure titled, Abuse Prevention, (no date), showed, "Abuse, neglect, abandonment, isolation, financial abuse, will not be tolerated in this facility at any time. If a resident incident is reported, discovered, or suspected, where the health, welfare, or safety of the resident is involved, this facility will take the following steps: Provide a safe environment for resident(s) as indicated by the situation. If the suspected perpetrator, (person causing the abuse), is an employee, remove the employee immediately from the care or vicinity of the resident." Therefore the facility failed to ensure Resident 1 was free from involuntary seclusion. The above violation has a direct relationship to the health, safety or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020013060 |
B |
24-Mar-17 |
W00P11 |
14818 |
483.12 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.
The facility violated the aforementioned regulation by failing to provide goods and services that were necessary to attain or maintain physical, mental, and psychosocial wellbeing. The facility did not pay wages to facility staff, or make payments to food or medical supply vendors.
Nine Residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) did not receive basic nursing care and all residents were served food from the emergency food supplies. Staff told Resident 4 they were too busy to get her out of bed. Prescribed physical therapy (PT) services were not provided for three Residents (Residents 1, 2, and 3). There was a shortage of medical supplies, such as diabetic (when the body can't use sugar normally) blood sugar testing supplies, for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, and 9).
During an observation and concurrent interview with Resident 4 on 2/16/17, at 11:27 a.m., Resident 4 was lying in bed. Resident 4 stated she wanted to get up into her wheelchair, but staff had told her they were too busy. Resident 4 stated she'd feel better if she was up.
During an interview with LVN 3 on 2/13/17, at 1:20 p.m., with LVN 2 on 2/14/17, at 3 p.m., with CNA 3 on 2/16/17 at 12:10 p.m., and with CNA 4 on 2/16/17, at 11:35 a.m., LVN 3, LVN 2, and CNA 3 each stated they often worked short of nursing staff (lacking the usual or necessary number of nursing staff).
During an interview with the ADM on 2/17/17, at 7:38 a.m., the ADM stated when the facility was short of nursing staff, he and the DON worked as nurses and the facility also used registry (an employment agency that provides nurses to work in temporary positions). The ADM stated the regular night shift nurse left around late November 2016. The ADM stated the facility used registry staff for the night shift almost every night in January 2017.
Review of the facility staffing assignment sheets, dated 1/1/17 through 1/31/17, showed:
a. During the day shifts, the facility was short nursing staff 6.4% of the time in January when one CNA was absent of 1/22/17 one 1/23/17;
b. During the Afternoon shifts, the facility was short nursing staff 3.2% of the time in January when one CNA was absent on 1/28/17.
The January 2017 staffing assignment sheets also showed the facility used registry staff 29% of the time on day shift, 41.9% of the time on the afternoon shift, and 90% of the time on the night shift.
Review of the facility staffing assignment sheet, dated 2/1/17 through 2/16/17, showed:
a. During the day shifts, the facility was short nursing staff 6% of the time in February when one LVN and two CNAs were absent on 2/14/17;
b. During the afternoon shifts, the facility was short nursing staff 6% of the time in February when one CNA was absent on 2/14/17;
c. During the nights shifts, the facility was short nursing staff 12.5% of the time in February when one CNA was absent on 2/4/17 and 2/11/17.
The February 2017 staffing assignment sheets also showed the facility used registry nursing staff 25% of the time on day shift, 37.5% of the time on the afternoon shifts, and 75% of the time on the night shift.
During an interview with LVN 4 on 2/16/17, at 3 p.m., LVN 4 stated "...we just provide adequate care...using registry is not as good...they do not know the residents..."
During an interview with LVN 3 on 2/16/17, at 12:50 p.m., LVN 3 stated "...staff is not motivated and don't want to provide care. Some things are not done for the residents according to their schedules...showers, treatments, and diapers (incontinent undergarments) are not being done as often as they should be done because we are short staffed...care isn't going to get done or not done as good...."
During an interview with CNA 4 on 2/16/17, at 1:10 p.m., CNA 4 stated "...Residents are not getting the care needed. We aren't trying to neglect (the residents), but attitudes are bad, so our care might not be as good...not enough manpower for priority needs...(like) prevent(ing) (residents) from falling...."
During an interview with the Social Services Director (SSD) on 2/6/17 at 11:25 a.m., she stated the paychecks that were due on 1/25/17 would not be available until the 1/31/17. The SSD stated the facility staff had not been paid to date.
A facility memo, dated 1/25/17, showed the following message "...The company is fully aware of the delayed in cashing some of employee's paychecks dated 1/10/2017 for (the facility)...The employees who have been affected will be paid $290.00 per work week or $58.00 per day (based on a 5 days of work schedule). We are anticipating to distribute the paycheck date 1/25/17 on or before 1/31/17 and the same rule mentioned above will apply for the delay in cashing their paychecks."
During an interview with the Administrator (ADM) on 2/6/17, at 12:48 p.m., the ADM stated the facility owners had issues with the Labor Department and the Internal Revenue Service (IRS) and hence, are in financial difficulty. The ADM stated facility employees were getting late payments and some have not been showing up for work.
During an interview with the ADM on 2/8/17, at 9:25 a.m., the ADM stated the facility owners told him paychecks would be delayed and there was an IRS levy (collection of taxes by force) issued against the corporate office.
During an interview with the Payroll and Medical Records Director (PMD) on 2/6/17 at 11:30 a.m., the PMD stated the delays in issuance of paychecks started July 2016 but got worse starting in December 2016.
During an interview with Certified Nursing Assistant (CNA) 1 on 2/6/17, at 11:57 a.m. and with CNA 2 on 2/6/17, at 12:10 p.m., CNA 1 and 2 both stated facility staff had to try to cash their paychecks as early as possible before funds ran out.
During an interview with CNA 3 on 2/16/17, at 12:10 p.m., with the Maintenance Supervisor (MS) on 2/16/17, at 12:20 p.m., and with LVN 3 on 2/16/17, at 12:50 p.m., and with CNA 2 on 2/16/17, at 1:10 p.m., each stated they were not getting paid.
During an interview with CNA 4 on 2/16/17, at 11:35 a.m., CNA 4 stated she had "no (pay) checks since January. Some of the staff calls in sick, and they (the facility) ask us to work over time."
During interviews on 2/16/17 at 12:50 p.m., LVN 3, with CNA 2 on 2/16/17, at 1:10 p.m., LVN 3 and CNA 2 each stated they call in sick sometimes because they were not getting paid.
During an interview with LVN 1 on 2/17/17, at 7:05 a.m., LVN 1 stated since she started working at the facility in August 2016, her pay had been delayed every time. LVN 1 stated this month they told her she would not be paid for the 2/10/17 payday until 2/22/17.
During an interview with LVN 3 on 2/13/17, at 1:20 p.m., with LVN 1 on 2/13/17, at 2:50 p.m., and with LVN 4 on 2/16/17, at 3 p.m., LVN 3 and LVN 4 each stated they have either already had, or were considering, resigning from working at the facility full-time and either working only part-time at the facility or getting a new job.
During an interview with the ADM on 2/8/17, at 1:20 p.m., the ADM stated the Dietary Manager resigned and the facility did not have a Dietary Manager.
During an interview with the DON on 2/17/17, at 7:33 a.m., the DON stated in January two CNAs resigned and two LVNs dropped from full-time to part-time status because of the pay issues.
Review of the facility document titled, "Employee Status," last updated 2/17/17, showed the following employee status changes:
a. LVN 4 had dropped from full-time to part-time status as of 1/1/17;
b.LVN 5 had dropped from full-time to part-time status as of 2/1/17;
c.CNA 5 had resigned as 1/22/17, and;
d.CNA 6 had resigned as of 1/26/17.
During an interview with CNA 1 on 2/8/17, at 12 p.m., CNA 1 stated the facility had problems with food orders last month (January 2017) and the facility did not receive food deliveries.
During a telephone interview with the food supply vendor representative on 2/15/17, at 9:34 a.m., the representative said the facility was behind in payments and the food vendor stopped delivering food to facility.
During an interview with the ADM on 2/17/17, at 7:15 a.m., the ADM stated the food vendor put a hold on the facility's account last month and the corporate office bought food from grocery stores instead.
During an interview on 2/16/17 at 12:30 p.m., Dietary Staff (DS) stated the facility ran out of some food last month (January) and used the facility's emergency food supplies.
During an interview with the ADM on 2/13/17 at 1 and 1:28 p.m., the ADM stated the facility did not have PT services since 1/20/17. The ADM stated the facility had three residents with PT orders.
During an interview with the DON on 2/14/17, at 1 p.m., the DON said the facility was still negotiating for a Physical Therapy company to come in.
Review of the "Record of Admission," dated 11/7/16, showed Resident 1 had multiple diagnoses that included a stroke (sudden death of brain cells due to lack of oxygen caused by a blood clot in or rupture of an artery in the brain resulting in the sudden loss of speech, weakness, or paralysis of one side of the body).
Review of the "Minimum Data Set," (MDS - a resident assessment tool used to guide care), dated 8/8/16, showed Resident 1 was cognitively intact (had the ability to think, reason, and remember clearly). The MDS also showed Resident 1 used a wheelchair and was dependent on one or two staff for bed mobility, transfers (to and from bed to wheelchair), dressing, and personal hygiene.
Record Review of Resident 1's medical chart showed the doctor ordered PT on 1/3/17 five times a week for four weeks and skilled Occupational Therapy (OT) to increase bed mobility and transfer ability from bed to wheelchair.
During an observation and concurrent interview with Resident 1 on 2/14/17, at 12:50 p.m., Resident 1 was lying in bed and eating lunch. Resident 1 stated he had made good progress in PT, until PT quit. Resident 1 also stated he needed PT to help him improve on doing things for himself. Resident 1 further stated he would like to go to an assisted living facility, but he needed PT to help him become independent.
Review of the "Record of Admission," dated 1/4/17, showed Resident 2 had multiple diagnoses that included a broken hip and stroke.
Review of the MDS, dated 1/11/17, showed Resident 2 was moderately cognitively intact (had some difficulty with being able to think, reason, and remember clearly). The MDS also showed Resident 2 used a wheelchair and a walker and required the assistance of one to two staff for bed mobility, transfers, dressing, and personal hygiene.
Review of Resident 2's medical chart showed Resident 2 had doctor's order for PT on 1/5/17 for five times a week for four weeks for therapeutic activities, therapeutic procedures, gait training, caregiver training for difficulty walking.
During an observation on 2/14/17 at 12:50 p.m., Resident 2 was in bed awake and alert but did not communicate.
Review of Resident 3's medical chart showed Resident 3 had a diagnoses that included generalized muscle weakness and difficulty walking.
Review of the "Physician's Orders," dated 1/2/17 showed Resident 3 had an order for the continuation of PT five times a week for four weeks for therapeutic activities, therapeutic procedures, gait training, caregiver training for difficulty walking.
A review of the "Order Acknowledgement," dated 2/6/17, from the medical supplier showed an order for items such as incontinent undergarments, exam gloves, dressing supplies, lancets, syringes, nutritional supplement drinks, and masks.
During a telephone interview with the medical supply vendor representative on 2/15/17, at 9:44 a.m., the representative stated they withheld the last shipment (dated 2/6/17) to the facility due to nonpayment and the facility's account was suspended.
During an interview with the ADM on 2/16/17, at 10:45 a.m., the ADM stated the medical supply company did not deliver the facility's last order (dated 2/6/17).
During an observation in the presence of the DON on 2/17/17, at 10:50 a.m., there were a total of 126 lancets (definition) and 231 test-strips (definition) in Medication Carts 1 and 2. The DON stated there were no other diabetic testing supplies in the facility.
Review of the "Physician's Orders," dated 2/1/17, indicated the following residents had a physician's order for a finger stick blood sugar test [FSBS - a procedure in which a finger is pricked with a lancet (a pricking needle) to obtain a small quantity of capillary blood for testing blood sugar]:
a. Resident 2 - FSBS one time per day;
b. Resident 3 - FSBS four times per day;
c. Resident 4 - FSBS five times per day;
d. Resident 5 - FSBS four times per day;
e. Resident 6 - FSBS four times per day;
f. Resident 7 - FSBS one time per day;
g. Resident 8 - FSBS one time per day, and
h. Resident 9 - FSBS twice per day.
Combined, Residents 2, 3, 4, 5, 6, 7, 8, 9, and 9 required 22 blood glucose test strips (test strips - a key component in the FSBS testing process) and 22 lancets each per day. Since there were 231 test strips and the Residents needed 22 test strips per day, the facility had enough test strip supplies for 10.5 days. Since there were 126 lancets, and the Residents needed 22 lancets per day, the facility had enough lancets to last 5.7 days. After 5.7 days, the facility would not be able to perform the prescribed FSBS tests for Residents 2, 3, 4, 5, 6, 7, 8, and 9.
During an interview with the Maintenance Supervisor (MS) on 2/16/17, at 12:20 p.m., the MS stated "...we are ok today with supplies today, but will run out soon...very stressful...I don't know what we'll do."
Therefore, the facility violated the aforementioned regulation by failing provide nine Residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) did not receive basic nursing care and all residents were served food from the emergency food supplies. Staff told Resident 4 they were too busy to get her out of bed. Prescribed physical therapy (PT) services were not provided for three Residents (Residents 1, 2, and 3). There was a shortage of medical supplies, such as diabetic (when the body can't use sugar normally) blood sugar testing supplies, for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, and 9).
These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020013072 |
B |
22-Mar-17 |
B3I511 |
5070 |
483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility violated the aforementioned regulation by failing to supervise Resident 2 (who had a neurological disorder that exhibited itself as a lack of impulse control) to prevent harm to Resident 1 when Resident 2 hit Resident 1 on his face, chest, and back.
Review of the "Minimum Data Set" (MDS - a comprehensive assessment tool used to guide resident care), dated 10/26/16, indicated Resident 1 was admitted to the facility with multiple diagnoses and required extensive to total assistance of staff for dressing, personal hygiene, and bathing.
Review of the MDS, dated 9/15/16, indicated Resident 2 had a neurological disorder in which nerve cells in certain parts of the brain waste away, or degenerate. The disorder exhibits itself as a person's lack of awareness of their own behaviors and abilities, a lack of impulse control that can result in outbursts or acting without thinking, and the tendency to get stuck on a thought, behavior, or action. The MDS also indicated Resident 2 had combative behavior related to poor impulse control, physical abuse, biting, and kicking.
Review of the "Combative Behavior Care Plan," dated 3/16/15, indicated Resident 2 had poor impulse control, anger, agitation, and biting, kicking, and hitting others. The care plan also indicated, to protect Resident 2 and others, the facility would monitor episodes of Resident 2's combative behavior and remove Resident 2 from the situation when combative.
During a telephone interview with Licensed Vocational Nurse (LVN 1) on 3/3/17, at 9:48 a.m., LVN 1 stated Resident 1 and Resident 2 were roommates. LVN 1 stated on 11/16/16, at 7 a.m., she heard Resident 1 state "get off my bed." LVN 1 stated she went to check on both residents in their room and saw Resident 2 sitting on Resident 1's bed while Resident 1 was lying in bed. LVN 1 stated Resident 2 got up, left the room to go the bathroom across the hall and went back to his room. LVN 1 stated within minutes she heard a pounding noise that came from the Resident 1 and 2's room. LVN 1 went to check again and saw Resident 2 over Resident 1 hitting him everywhere. LVN 1 stated Resident 2 swung back at her when LVN 1 attempted to stop Resident 2. LVN 1 stated Resident 2 stopped hitting Resident 1, left the room, paced the hall, and then went back to the room and hit Resident 1. LVN 1 stated Resident 1 had multiple bruises on his face, chest, back, and was bleeding across the nose bridge. LVN 1 stated Resident 1 told her "he (Resident 2) hit me, he hit me." LVN 1 also stated Resident 1 was transferred to the hospital. LVN 1 further stated Resident 2 was known to be physically aggressive to different people on multiple occasions, but "you never know what sets him off."
Review of the "Nurse's Notes," dated 9/30/16, indicated that during the night shift, Resident 2 became agitated and grabbed the licensed nurse by the left shoulder, chased a CNA across the hallway toward a resident's room, and chased a different CNA out of the building. Resident 2 was sent to the hospital following this incident. The Nurse's Notes also indicated the Director of Nursing (DON) and Administrator (ADM) were notified and an incident report was completed.
During a telephone interview with Certified Nursing Assistant (CNA 1) on 12/1/16, at 11 a.m., CNA 1 stated the incident on 11/16/16 was not the first one that involved Resident 2. CNA 1 stated over a month ago, Resident 2 attacked her and she had to lock herself in one of the resident rooms. CNA 1 stated Resident 2 chased another CNA out of the building.
Review of the aftercare instructions from the hospital dated 11/16/16 showed Resident 1 had diagnoses that included contusions (a region of tissues where blood vessels have been ruptured) of nose and face.
Therefore, the facility violated the aforementioned regulation by failing to supervise Resident 2 (who had a neurological disorder that exhibited itself as a lack of impulse control) to prevent harm to Resident 1 when Resident 2 hit Resident 1 on his face, chest, and back.
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020013073 |
B |
22-Mar-17 |
1QT711 |
7033 |
483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES
483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph ?483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on- (c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12. The facility violated the aforementioned regulation by failing to implement their policies and procedures for the protection of residents and for the investigation, and reporting of abuse. After Resident 1's report of Certified Nursing Assistant (CNA 2) placing a finger in Resident 1's anus, the facility continued to allow CNA 2 to provide hands on care to the residents, did not investigate the allegation of abuse that was documented on a grievance form and placed in the Grievance/Complaint book, and did not report the allegation of abuse to the local police or ombudsman, and the California Department of Public Health (CDPH). (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention.
During an interview with the Social Service Designee (SSD), who worked for the Temporary Manager (TM), on 3/2/17, at 1:50 p.m., SSD stated she found a grievance form dated 9/23 in the back of the grievance binder.
A review of the facility document titled, "Concerns/Grievance Registration Form," dated 9/23, indicated that Resident 1 made a grievance to CNA 1 which CNA 1 wrote as follows: "(Resident 1) informed (CNA 1) that CNA (CNA 2) put his finger in (Resident 1's) anus while changing him. He informed CNA (CNA 1) that the finger was placed in the anus intentionally to cause pain..."
During an interview with Resident 1 on 3/2/17, at 2 p.m., Resident 1 stated CNA 2 deliberately put his finger in Resident 1's anus, and it happened 3 or 4 times. Resident 1 stated that when it happened he told CNA 2 "Stop doing that!" and CNA 2 replied, "I'm not hurting you," to which Resident 1 said, "You are or I wouldn't tell you that, if you don't stop I will report this." Resident 1 stated that he felt that CNA 2 was being deliberately cruel. Resident 1 told the Director of Nurses (DON) on the date it happened around 9/23/16, but he could not be sure. Resident 1 also stated he told the DON "Don't schedule him (CNA 2) to work with me I don't want him!"
During an interview with the DON on 3/2/17, at 2:30 p.m., the DON stated that around 9/23/16 Resident 1 asked him to take CNA 2 off his assignment. The DON stated he did not ask Resident 1 why, he just took CNA 2 off Resident 1's assignment.
During a telephone interview with CNA 1 on 3/7/17, at 4:20 p.m., CNA 1 stated that Resident 1 told her on the night shift (couldn't remember the date) that CNA 2 put his finger in Resident 1's anus when giving care. CNA 1 stated "I thought that was serious and I told him I would let the charge nurse know." CNA 1 stated she couldn't recall who the charge nurse was, but Resident 1 told her, "Make sure...don't tell (CNA 2) because I don't want him mad at me." CNA 1 stated she told the charge nurse and filled out a grievance form. CNA 1 tried to give it to the charge nurse who told her to put it in the grievance book. CNA 1 stated she then put the form in the book of grievances and "I put it in the front so the next day when they open the book they can see it." CNA 1 further stated that nobody had ever asked her about the report and she quit her job a couple of weeks before Thanksgiving. CNA 1 stated that today was the first time anybody had asked her about the report she made.
During an interview with the Facility Social Service Designee (FSSD) on 3/2/17, at 3 p.m., the FSSD stated that if there was a concern any staff member can fill out the grievance form and place it in the grievance book. FSSD stated, "Sometime when I come I check it. I work here three times a week. I check the front of the book and if nothing is there then that's it."
During an interview with the ADM on 3/2/17, at 3:05 p.m., the ADM stated "FSSD is responsible for checking the book, nobody checks the book if FSSD is not here. The ADM also stated the DON did not tell him that Resident 1 did not want CNA 2 to take care of him.
A review of the Facility's undated document titled, "Policy and Procedure: Abuse Prevention" indicated the following:
"...Abuse...will not be tolerated in this facility at any time...Protection...If a resident incident is reported...this facility will take the following steps: Provide a safe environment for resident(s)...Remove employee immediately from the care or vicinity of the resident. Suspend employee during the investigation...Investigation...All incidents of suspected or alleged abuse will be investigated by the assigned staff...Reporting...All mandated reporters are required by law to report incident of known or suspected abuse...By telephone immediately or as soon as practically possible, to the local ombudsman or the local law enforcement agency...First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. Administrator or designee, and Director of Nursing must be notified as soon as possible but no later than 24 hours after the incident report. The Licensed Nurse shall be responsible for completing a physical assessment of the resident(s) involved and documenting all findings on an Incident Report...Administrator/DON shall investigate all suspected or alleged abuse...Administrator shall report all incidents of alleged abuse or suspected abuse to CDPH within 24 hours...and the results of the investigation to CDPH within 5 working days of the incident, and if the alleged violation is verified appropriate corrective must be taken...."
Therefore, the facility violated the aforementioned regulation by failing to implement their policies and procedures for the protection of residents and for the investigation, and reporting of abuse. After Resident 1's report of Certified Nursing Assistant (CNA 2) placing a finger in Resident 1's anus, the facility continued to allow CNA 2 to provide hands on care to the residents, did not investigate the allegation of abuse that was documented on a grievance form and placed in the Grievance/Complaint book, and did not report the allegation of abuse to the local police or ombudsman, and the California Department of Public Health (CDPH).
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020013074 |
B |
22-Mar-17 |
2N9311 |
3473 |
483.12(a)(1) FREE FROM ABUSE/INVOLUNTARY SECLUSION 483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
483.12(a) The facility must- (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
The facility violated the aforementioned regulation by failing to protect one Resident (Resident 1) from physical abuse when Certified Nursing Assistant (CNA) 1 CNA 1 struck Resident 1 in the head and back.
During an interview with Resident 1 on 2/21/17, at 12 p.m., Resident 1 stated Certified Nursing Assistant (CNA) 1 hit her twice. Resident 1 stated the first time CNA 1 hit her, he hit her on the back of the head. The second time, Resident 1 stated while pointing at her back, CNA 1 hit her on the back. Resident 1 stated, "It's scary, I'm afraid to go to sleep as long as he is here".
Review of the "Nurse's Notes," dated 2/20/17, at 11 a.m. indicated "...was notified by social services to do an assessment of (Resident 1). Was told by Social Services (SS 1) that (Resident 1) had stated that she was hit by of the CNAs...."
Review of the "Nurse's Notes," dated 2/20/17, at 12:28 p.m., indicated Resident 1 stated "It's pain when it happens and he really used a heavy hand. I don't think he'll be back." The Nurse's Notes also indicated Resident 1 stated the man who used a heavy hand was wearing "red."
During an interview with the Administrator (ADM) on 2/21/17, at 11:55 a.m., the ADM stated Resident 1 told him and the Temporary Manager (TM) that she was hit in the head and beaten up. The ADM stated the TM told him to send CNA 1 home.
During a telephone interview with the TM, on 2/21/17, at 11 a.m., the TM stated that on 2/20/17, Resident 1 came to the DON's office and Resident 1 stated she had been hit in the back of the head and was afraid. The TM stated the resident identified CNA 1 as the man in red who hit her. The TM stated the ADM told her Resident 1 was confused, and he did not want to listen to Resident 1.
During an interview with the TM on 2/21/17, at 6:35 p.m., The TM stated the ADM tried to remove Resident 1 from the DON's as she was trying to report being hit in the head. The TM stated the ADM did not want to send CNA 1 home because he did not know if CNA 1 did anything to Resident 1 and the facility needed CNA 1 to work or they would be short-handed (lacking the needed number of nursing staff). The TM stated she told the ADM to send CNA 1 home.
Review of the facility's undated policy and procedure titled, "Abuse Prevention" indicated "...Abuse...will not be tolerated in this facility at any time. Every Resident has the right to be free from...physical abuse. Residents must not be subjected to abuse by anyone...Identification of Abuse: Observations, suspicious, or reporting of...bruises (of suspicious or unknown origin) will be investigated to rule out abuse."
Therefore, the facility violated the aforementioned regulation by failing to protect one Resident (Resident 1) from physical abuse when Certified Nursing Assistant (CNA) 1 struck Resident 1 in the head and back.
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020013075 |
B |
24-Mar-17 |
1QT711 |
4219 |
483.12(a)(1) FREE FROM ABUSE/INVOLUNTARY SECLUSION 483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
483.12(a) The facility must- (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
The facility violated the aforementioned regulation by failing to protect Resident 1 from physical abuse when one Certified Nursing Assistant (CNA 2) put his finger in Resident 1's anus.
During an interview with the Social Service Designee (SSD) who worked for the Temporary Manager (TM) on 3/2/17, at 1:50 p.m., SSD stated she found a grievance form dated 9/23 (year not indicated) in the back of the grievance binder.
A review of the facility document titled, "Concerns/Grievance Registration Form," dated 9/23, indicated that Resident 1 made a grievance to CNA 1 which CNA 1 wrote as follows: "(Resident 1) informed (CNA 1) that CNA (CNA 2) put his finger in (Resident 1's) anus while changing him. He informed (CNA 1) that the finger was placed in the anus intentionally to cause pain..."
During an interview with Resident 1 on 3/2/17, at 2 p.m., Resident 1 stated CNA 2 deliberately put his finger in Resident 1's anus, and it happened 3 or 4 times. Resident 1 stated that when it happened he told CNA 2 "Stop doing that!" and CNA 2 replied, "I'm not hurting you," to which Resident 1 said, "You are or I wouldn't tell you that, if you don't stop I will report this." Resident 1 stated that he felt that CNA 2 was being deliberately cruel. Resident 1 told the Director of Nurses (DON) on the date it happened around 9/23/16, and he told the DON "Don't schedule him (CNA 2) to work with me I don't want him!"
A review of Resident 1's "Minimum Data Set (MDS) Resident Assessment and Care Screening" dated 1/25/17, indicated Resident 1 had no problems with memory or recall, had no problems with mood or behavior. He was continent of both his bowels and bladder but needed extensive assistance with the physical assistance of two persons to use the toilet.
During an interview with the DON on 3/2/17, at 2:30 p.m., the DON stated that around 9/23/16 Resident 1 asked him to take CNA 2 off his assignment. The DON stated he did not ask Resident 1 why, he just took CNA 2 off Resident 1's assignment.
During a telephone interview with CNA 1 on 3/7/17, at 4:20 p.m., CNA 1 stated that Resident 1 told her on the night shift (couldn't remember the date) that CNA 2 put his finger in Resident 1's anus when giving care. CNA 1 stated "I thought that was serious and I told him I would let the charge nurse know." CNA 1 couldn't recall who the charge nurse was, but Resident 1 told her, "Make sure...don't tell (CNA 2) because I don't want him mad at me." CNA 1 stated she told the charge nurse and filled out a grievance form. CNA 1 tried to give it to the charge nurse who told her to put it in the grievance book. CNA 1 stated she then put the form in the book of grievances and "I put it in the front so the next day when they open the book they can see it." CNA 1 further stated that nobody had ever asked her about the report and she quit her job a couple of weeks before Thanksgiving. CNA 1 stated that today was the first time anybody had asked her about the report she made.
CNA 2 was unavailable for interview and did not return phone calls to messages left on 3/6/17, 3/7/17 and 3/8/17.
Review of the facility's undated policy and procedure titled, "Abuse Prevention" indicated "...Abuse...will not be tolerated in this facility at any time. Every Resident has the right to be free from...physical abuse. Residents must not be subjected to abuse by anyone...."
Therefore, the facility violated the aforementioned regulation by failing to protect Resident 1 from physical abuse when one Certified Nursing Assistant (CNA 2) put his finger in Resident 1's anus.
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000065 |
Hayward Springs Care Center |
020013076 |
B |
22-Mar-17 |
2N9311 |
9366 |
483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES 483.12 (b)
The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph ?483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on- (c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention.
The facility violated the aforementioned regulation by failing to implement their policies and procedures for protection of residents and for the prevention, identification, investigation, and reporting of abuse. The Administrator (ADM), Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 2) did not report or investigate Resident 1's allegation of abuse and an incident of suspicious red marks. The Activities Assistant (AA), LVN 1, and CNA 1 and 2 did not report Resident 2's allegation of being slapped or the two incidents of suspicious red marks and one incident of bruising.
1. During an interview with the Administrator (ADM) on 2/21/17, at 11:55 a.m., the ADM stated Resident 1 told him and the Temporary Manager (TM) that she was hit in the head and beaten up. The ADM stated the TM told him to send CNA 1 home.
During a telephone interview with the TM, on 2/21/17, at 11 a.m., the TM stated that on 2/20/17, Resident 1 came to the DON's office and Resident 1 stated she had been hit in the back of the head and was afraid. The TM stated the resident identified CNA 1 as the man in red who hit her. The TM stated the ADM told her Resident 1 was confused, and he did not want to listen to Resident 1.
During an interview with the TM on 2/21/17, at 6:35 p.m., The TM stated the ADM tried to remove Resident 1 from the DON's as she was trying to report being hit in the head. The TM stated the ADM did not want to send CNA 1 home because he did not know if CNA 1 did anything to Resident 1 and the facility needed CNA 1 to work or they would be short-handed (lacking the needed number of nursing staff). The TM stated she told the ADM to send CNA 1 home.
During an interview with Resident 1 on 2/21/17, at 12 p.m., Resident 1 stated Certified Nursing Assistant (CNA) 1 hit her in the back of the head, and that had also done it before, while she was in her room with her roommate (Resident 2). Resident 1 pointed at her back with the back of her hand and stated CNA 1 "...hit me in the back the second time and ran out of the room, then he came back like nothing happened." Resident 1 continued and stated, "It's scary, I'm afraid to go to sleep as long as he is here".
In an interview with Licensed Vocational Nurse (LVN) 1 on 2/21/17, at 12:23 p.m., LVN 1 stated she did not report to the Director of Nursing (DON) when Resident 1 had red marks on her face about two months ago.
During an interview with LVN 1 on 2/21/17, at 3:30 p.m., LVN 1 stated that CNA 2 told her that when CNA 1 showered a resident, the resident would have red marks on their bodies. LVN 1 also stated that CNA 2 told her she had "said something before, but nothing is ever done."
2. During an interview with Certified Nursing Assistant (CNA 2) on 2/21/17, at 12:41 p.m., CNA 2 stated that whenever CNA 1 cared for a resident they end up with red marks on them. CNA 2 stated she and the Activities Assistant (AA) noticed Resident 2 had red cheeks about four or six months ago. CNA 2 also stated Resident 2 went into the activities room "...and started screaming he (CNA 1) hit me, I wanna die, and they wanna kill me...."
During an interview with AA on 2/21/17, at 1:30 p.m., the AA stated Resident 2's face was very red after her shower with CNA 1. The AA stated Resident 2 told her that someone beat her. The AA stated Resident 2 used her hands in a slapping motion at her face and said it burned. The AA stated she had seen Resident 2's face red a couple of times before.
During an interview with LVN 1 on 2/21/17, at 12:23 p.m., LVN 1 stated that on 1/12/17, she noticed a red mark on Resident 2's cheek and that she did not report it to the DON.
During an interview with LVN 1 on 2/21/17, at 3:30 p.m., LVN 1 stated that when she noticed the red mark on Resident 2's cheek (on 1/12/17), she told CNA 1 to write an "Incident Report". LVN 1 also stated she wrote up a "Change of Condition" regarding the new red marks on Resident 2's cheeks.
Review of Resident 2's "Change of Condition Documentation and Notification," dated 1/12/17, indicated "Situation...redness on right cheek....Assessment...redness noted to left cheek area noticed after shower by (CNA 1)...."
Review of the "Incident Reports," for December 2016, January and February 2017, indicated there was no reported incident to investigate the cause of Resident 2's red marks on her cheek.
3. During an interview with Certified Nursing Assistant (CNA) 2 on 2/21/17, at 12:41 p.m., CNA 2 stated she changed Resident 2's wet undergarment and checked her skin, which was clear, but when Resident 2 returned from the shower with CNA 1, she had a bruise on her right thigh. CNA 2 stated she did not tell anyone, she " ...didn't say anything...I watched...because there was no witness."
During an interview with Licensed Vocational Nurse (LVN) 1 on 2/21/17, at 3:30 p.m., LVN 1 stated that on 12/31/16, Resident 2 had a bluish mark on her left thigh "...It was a bruise." LVN 1 stated CNA 1 did not report to her the bruise on Resident 2's left thigh, she noticed it and instructed "CNA 1 to fill out an incident report."
Review of the "Nurse's Notes," dated 12/31/16, at 2:40 p.m., indicated a "CNA reported during shower care, noted skin discoloration to left above knee, skin intact, slightly swollen, reddened. (Resident) complained of slightly pain upon touch...."
Review of the "Incident Reports", for December 2016, January and February 2017, indicated there was no reported incident to investigate the cause of Resident 2's bruise on her thigh.
During an interview with the DON on 2/21/17, at 1:11 p.m., the DON stated LVN 1 reported to him the bruise on Resident 2's thigh and there was no incident report.
Review of the facility's staffing sheets for January 2017 indicated CNA 1 provided Resident care on: 1/1/17, 1/4/17, 1/5/17, 1/6/17, 1/7/17, 1/9/17, 1/10/17, 1/11/17,1/12/17, 1/13/17, 1/15/17, 1/16/17, 1/18/17, 1/19/17, 1/21/17, 1/22/17, 1/23/17, 1/24/17, 1/25/17, 1/28/17, 1/29/171/30/17, 1/31/17.
Record Review of the facility's undated policy and procedure titled, "Abuse Prevention," indicated "...Identification of Abuse: 1. Observations, suspicious, or reporting of...bruises (of suspicious or unknown origin) will be investigated to rule out abuse. 2. Occurrences, patterns and trends will be assessed by Administrative Staff, Licensed Staff, Interdisciplinary Team to determine the corrective action based on the results of the investigation....G. Reporting...1. All mandated reporters are required by law to report incident of known or suspected abuse in two ways. a) By telephone immediately or as soon as practically possible, to the local law enforcement agency. b) By written report, Department of Social Services Form (SOC 341), 'Report of Suspected Dependent Adult Elder Abuse' sent within two (2) working days. 2. It is this facilities policy that any known or suspected abuse will be reported by completing an Incident and Injury Report. 3. First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. 4. Administrator or designee, and Director of Nursing must be notified as soon as possible but no later than 24 hours after the incident report. 9. Administrator/DON shall investigate all suspected or alleged abuse and report incident to the local ombudsman or the local law enforcement agency. 10. Administrator shall report all incidents of alleged abuse or suspected abuse to (California Department of Public Health) CDPH within 24 hours....I. Administrative Procedure...2. Administrator or designee shall initiate and investigation immediately...."
Therefore, the facility violated the aforementioned regulation by failing to implement their policies and procedures for protection of residents and for the prevention, identification, investigation, and reporting of abuse. The Administrator (ADM), Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 2) did not report or investigate Resident 1's allegation of abuse and an incident of suspicious red marks. The Activities Assistant (AA), LVN 1, and CNA 1 and 2 did not report Resident 2's allegation of being slapped or the two incidents of suspicious red marks and one incident of bruising.
This violation had a direct or immediate relationship to the health, safety, or security of paitents. |
| 100000072 |
HY-LOND HEALTH CARE CENTER - MODESTO |
030009138 |
A |
16-Mar-12 |
JTYT11 |
6960 |
F323 Free of Accidents Hazards/supervision/devices - 483.25 (h)The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an unannounced visit to the facility on 6/10/09 for the investigation of complaint # CA00190334.The Department determined the facility failed to prevent a fall for Resident A. On 5/23/09 Resident A was transferred from the facility to the general acute care hospital for evaluation and treatment after the fall in the shower. Upon admission to the general acute care hospital it was determined he had a fracture of his left hip, secondary to a ground level fall. Resident A was a 69 year old male admitted to the facility on 8/23/06. His diagnoses included history of stroke with residual left sided weakness. A 5/08/09 Minimum Data Set (MDS- an assessment tool) described him as having no memory or cognitive deficits. He required physical assistance with bathing. The 5/08/09 MDS indicated Resident A had fallen within the last 31- 180 days.Resident A's Fall Risk Assessments dated 12/08/08 and 3/05/09 indicated he had fallen one to two times with each assessment, required assistance with elimination and had decreased muscle coordination. These risk factors placed him as a "high risk" for falls.An interview was conducted with Resident A on 6/10/09 at 8:15 a.m. When asked about his fall, he stated he had finished showering and CNA (Certified Nursing Assistant) 1 reached into the shower stall and pulled him in his shower chair out of the shower stall. After CNA 1 pulled him out of the shower stall, she let go of the shower chair and the chair rolled forward and tipped over and he fell off the chair onto the shower floor. He stated the floor was sloped downward toward the drain area and "the chair just rolled and tipped over."He stated, "Two or three nurses came in and used the lift and put me back in my wheelchair and took me back to my room. Then they took me to the hospital." Resident A then stated, "I could have done without that fall, it's painful." Resident A was transferred to the general acute care hospital for evaluation and treatment at 6:50 a.m. on 5/23/09. An Unusual Occurrence Record, dated 5/23/09 at 6:05 a.m. indicated Resident A fell from a shower chair onto the bathroom floor. Resident A "landed on his [left] side resulting in a skin tear to [left] elbow." In addition, documentation included Resident A complained of increased pain in his left hip and was transferred to the general acute care hospital.A review of the facility investigation of Resident A's fall in the shower room on 5/23/09 was conducted. The documentation within the investigation revealed, "[CNA 1] did not lock the shower chair and resident was situated close to the drain where it is slanted, she stated, 'I only turned my back for a moment to get another towel' she stated that she heard the resident say "ooh" and then the shower chair fell. CNA 1 stated resident was lying on his left side."An interview was conducted with Administrative Staff 1 on 6/10/09 at 9:00 a.m. She acknowledged shower chairs were to be locked at all times while care is being provided to prevent the chair from moving. On 1/17/12 Administrative staff provided a copy of a counseling memo related to safety precautions that was discussed with C.N.A. 1 on 6/02/09 after Resident A fell. The facility was unable to provide a facility policy that was in place at the time related to safety precautions.The shower area was observed with Administrative Staff 1 on 6/10/09 at 9:30 a.m. The floor in the shower room sloped downward toward the drain on all sides. Administrative Staff 1 acknowledged a shower chair would roll down toward the drain if left unattended without the brakes being locked.An interview was conducted with Administrative Staff 2 on 6/10/09 at 10:30 a.m. She stated the CNA's are trained to lock the brakes on the shower chairs any time the patients are being bathed. She stated CNA 1 should have locked the brakes on the shower chair to prevent it from moving. She stated CNA 1 had received a one on one in-service following the incident. A review of the one on one in-service for CNA 1 revealed the following: "on 5/23/09 you failed to maintain a safe environment and prevent injury to a resident." Nurse's Notes dated 5/23/09 at 12:25 p.m. indicated Resident A had been admitted to the general acute care hospital with a diagnoses of left hip fracture. A telephone interview was conducted with CNA 1 on 6/22/09 at 10:12 a.m. She stated she had taken Resident A to the shower room in a shower chair. She stated when she finished assisting Resident A to shower, "I turned my back to get another towel off the cart. And the shower chair tipped over and he was on the floor on his side."The general acute care hospital history and physical, dated 5/23/09 was reviewed. It was determined that he required admission to the hospital for surgery to repair a fracture to his left hip. Serious fractures may require open reduction(Repositioning of the broken bone using surgery). In some cases, devices such as pins, plates, screws, rods or glue are used to hold the fracture in place. Open fractures must also be cleaned thoroughly to avoid infection. On 5/23/09 at 5:00 p.m. Resident A had an open reduction and internal fixation of the left hip.Hip fractures are very serious. Nearly one in four hip fracture patients will die within 12 months because of the complications related to the injury and recovery period (April 2001. Falls and Hip Fractures. American Academy of Orthopedic Surgeons. Retrieved 5/29/07 from http://orthoinfo.aaos.org.fact .Post operative complications following a hip fracture include blood clots, pneumonia and infections (Complications of Hip Fractures. Retrieved 5/29/07 from http://orthopedics.about.com ). "Complications of enforced (prolonged) bedrest include joint contractures (persistent or permanent flexion of joints such as knees, hips, or elbows), deconditioning (loss of muscle mass or strength), pressure sores, deep vein thrombosis (clotting), pulmonary embolism (occlusion of major vessels in the lungs), pneumonia, osteoporosis and psychiatric disturbances.' Chapter 22 Fractures: Proximal Femoral Fractures. The Merk Manual of Geriatrics. Retrieved 5/29/07 from www.merck.com. The Department determined the facility failed to prevent a fall for Resident A which resulted in a transfer to the general acute care hospital with a fractured hip requiring open surgical repair.These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 630011271 |
Happy Ranch Program |
030009566 |
B |
25-Oct-12 |
O3WL11 |
7996 |
W&i Code 4502 Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. This citation was written as a result of an unannounced visit on 7/2/10 to investigate complaint number CA00233858. The Department determined the facility failed to provide adequate care and supervision to prevent a fracture of Client A's left leg. Client A was admitted to the facility on 4/28/08. His diagnoses included mental retardation and dysphagia (difficulty swallowing).The Comprehensive Functional Assessment (an assessment tool), dated 5/19/10, was reviewed. Client A was assessed as being totally dependent for bowel and bladder care, unable to sit independently, and was non-ambulatory and non-verbal. Client A's nutrition was provided by a liquid diet via a gastrostomy tube (a surgically implanted tube into the stomach). An acute care hospital History and Physical assessment, dated 6/26/10, revealed a spiral displaced fracture of the left femur (long bone of the upper leg) secondary to involuntary trauma. (A spiral fracture occurs when the bone is twisted.) An acute care hospital consultation, dated 6/27/10, indicated Client A "suffered injury to his femur." An x-ray completed in the emergency room on 6/27/10 revealed a left proximal comminuted femur fracture. (A comminuted fracture is a fracture in which the bone fragments into several pieces.) The facility investigation for Client A's femur fracture was reviewed. An Unusual Incident Report, dated 6/26/10 at 12:45 p.m., completed by Direct Care Staff (DCS) 1, was reviewed. Documentation on the report indicated, "I was checking [Client A] to see if he needed to be changed. When doing so, I noticed that his left leg was a [little] more wobbly then the right, so I ask another staff to check it out and she noticed the same thing - called [Registered Nurse], going to [Emergency Room]." An interview was conducted with Administrative Staff 1 on 7/2/10 at 12 p.m. She stated she and another administrative staff had conducted interviews with DCS 1 and DCS 2 who were on duty on 6/26/10 for day shift. She stated the DCS had been interviewed a second time "due to discrepancies" in their accounting of what occurred on 6/26/10. In addition, she stated both DCS 1 and DCS 2 had been terminated by the facility. Documentation in the facility investigation revealed that DCS 1 and DCS 2 were the only two employees on duty the morning shift, 7 a.m. to 1 p.m., on 6/26/10. DCS 1 had been employed since 9/8/09. DCS 2 was hired on 6/16/10. Both DCS had signed the Job Descriptions which included the directives: 1. The DCS is responsible for knowing, understanding and protecting client's rights. They are responsible for reporting immediately any reasonable suspicion of client abuse or neglect and to prevent abuse from occurring. 2. The DCS shall assist clients in and out of bed, chairs, couches, and wheelchairs. They shall assist the clients down to the floor and up from the floor as necessary and appropriate. In addition, both DCS had signed a Definitions of Terms document which included the following directive: Neglect: Means either of the following: 1. The negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care that a reasonable person in a like position would exercise. A written attestation statement from DCS 1, dated 6/27/10, was reviewed. The statement revealed DCS 1 had showered Client A on the morning of 6/26/10 at 8:45 a.m. After his shower he was placed in his wheelchair. She stated Client A "was grumpy, grunting and just didn't want to be touched, but I thought [Client A] was just [Client A]. At 12 p.m. or 12:10 p.m. I gave [Client A] his feeding. After his feeding I put him in his chair for about 45 minutes. We put him in the bean bag chair with the [mechanical lift]...till I was done with the rest of the 12 p.m. feedings." The documentation revealed that when DCS 3 came on for the afternoon shift at 1 p.m., DCS 1 and DCS 3 made rounds (walked and looked at each client). DCS 1 stated that was when she noted that Client A lifted only one leg when she touched him. "I thought it was not like him to only lift one leg, he always lifts them both, that's when I asked [DCS 3] to check out his leg. She checked his leg and agreed and that's when I called [the RN].A written attestation statement from DCS 2, dated 6/26/10, was reviewed. The statement revealed DCS 2 assisted DCS 1 in showering Client A on the morning of 6/26/10. She assisted DCS 1 to use the mechanical lift to put Client A in the wheelchair and into the bean bag chair. She indicated that DCS 1 was repositioning Client A at 12:45 p.m. and "noticed his leg was limp."Documentation provided by the facility included interviews and conclusions made by the facility. The facility interviews with DCS 1 indicated she had not noted anything wrong with Client A's left leg until she made rounds with DCS 3 at 1 p.m. The interview with DCS 2 indicated she reported that DCS 1 had "fed and changed" Client A in the bean bag chair. She stated she was told by DCS 1 "don't tell anyone I am doing this or I will get into trouble."An interview with DCS 3 was conducted by administration staff. DCS 3 indicated DCS 1 was repositioning Client A in the bean bag chair when DCS 3 came on duty. DCS 3 stated she was "bothered" by the way DCS 1 was repositioning Client A. She stated his body did move during the repositioning. She stated she began making rounds with DCS 1. During rounds, DCS 1 "casually asked" DCS 3 to check Client A's leg as "she thought it looked strange."Communication Notes, dated 6/26/10 "AM", revealed "[No] issues good morning [Client A] left leg I [noticed] something was wrong call [Qualified Mental Retardation Professional (QMRP)] let them know." There was no signature with this entry. There was no documented evidence the QMRP was notified prior to 6/26/10 at 1 p.m. after the RN had been notified of the injury to Client A's left leg. An interview was conducted with RN 1 on 7/8/10 at 3:30 p.m. She stated she had received a telephone call from DCS 1 on 6/26/10 at approximately 1:12 p.m. She stated DCS 1 told her Client A's left leg "looked weird and not moving." She stated she directed staff to call 911 to have Client A transported to the emergency department for evaluation of his left leg. An interview was conducted with DCS 3 on 7/19/10 at 2 p.m. She stated when she came on duty on 6/26/10 at 12:52 p.m., Client A was being repositioned in the bean bag chair by DCS 1. She stated DCS 2 had "nudged" Client A's feet and only one leg moved. She stated he would normally pull both legs up when his feet were nudged. She stated DCS 1 went into the kitchen and "as I looked towards Client A, [DCS 1] saw me looking and said 'can you check out [Client A's] leg, it looks funky.'" DCS 3 stated she went to Client A and touched his left leg. The left leg was "not positioned normally. I looked at the knee cap it was purplish. I put my hand behind the knee and lifted and it flopped. The left [leg] felt cold." The Department determined the facility failed to provide adequate care and supervision to prevent a fracture of Client A's left leg. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000072 |
HY-LOND HEALTH CARE CENTER - MODESTO |
030009602 |
B |
19-Nov-12 |
2T2011 |
8239 |
F204 - Preparation For Safe/orderly Transfer/dischrg - 483.12 (a)(7) A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. The following citation was written as a result of an unannounced visit to the facility to investigate complaint #CA00206861. As a result of the investigation, the Department determined the facility failed to: Develop and implement a discharge plan for Resident A that ensured discharge to a safe environment with needed equipment and services in place. This failure resulted in Resident A being discharged home in a taxi to an unsafe environment without the benefit of the assistance she required or physician ordered home health services.Resident A was a 64 year old female admitted to the facility on 10/15/09. Her diagnoses included an altered level of consciousness, drug overdose and generalized weakness. An admission Minimum Data Set dated 10/19/09 documented Resident A had short-term memory impairment and difficulty with cognition in new situations. Resident A required extensive assistance from staff for bed mobility, transfers, walking, dressing, toilet use and personal hygiene. Resident A utilized a wheelchair as her primary mode of locomotion.A discharge summary dated 10/15/09 and completed at the General Acute Care Hospital (GACH) on the day Resident A was admitted to the facility indicated Resident A had an altered level of consciousness related to an overdose of prescription medications. The discharge summary documented at the end of her hospital stay, Resident A's mental status had cleared but she was "not really able to make prudent decisions for her care." Documentation in the summary indicated Resident A would be "sent to short-term rehab in order to gain some strength prior to being discharged home or to another facility, as deemed necessary at that time." Physician's Orders dated 10/16/09 indicated Resident A was to receive Physical Therapy six times a week times four weeks. She also received Occupational Therapy five times a week and Speech Therapy five times a week. Resident A's October 2009 Physician's Orders had a section which was too be completed by the physician and related to Resident A's capacity to participate in making her own decisions. The section to be completed questioned if Resident A had been informed of her medical condition, what her rehabilitation potential was and if resident A was capable in participating in her own plan of care. This section of Resident A's Physician's Orders had not been completed. A Quarterly Social Services Discharge Planning Note dated 10/15/09 documented Resident A's discharge goals were to discharge home with her significant other. The note indicated Resident A's discharge date was uncertain and no referrals had been made. Resident A's clinical record contained a letter dated 10/4/09 which was submitted to the GACH "staff/doctors" and written by Resident A's "attorney in fact." The letter was regarding any discharge plans that were being made on behalf of Resident A. The letter documented Resident A had recent and multiple hospitalizations due to her inability to manage at home independently. The letter documented Resident A did not have any family available to assist her and "any discharge plan needs to comprehensively embrace the above facts with supreme concern for Patient's safety." The letter was signed by Resident A's designated Power of Attorney.A Notice of Medicare Non-Coverage dated 10/27/09 documented Resident A's coverage for Skilled Nursing Services would end on 10/29/09. The notice was sent via certified mail to Resident A's Power of Attorney. A Physician's Order dated 10/29/09, documented, "D/C (discharge) home [with] meds, home health and P.T. Eval on 10/30/09." A Physical Therapy note dated 10/29/09 documented, "Pt. [patient] d/cd [discharged] home, will need assistance by caregiver or family member for safety, as pt is impulsive [with] poor safety judgment and still weak. Assist [with] ADLs (activities of daily living). A Social Service Note dated 10/29/09 documented the following; "Meeting set up [with Ombudsman] at 10:30 on 11/02/09. Nursing Assessment Notes dated 10/30/09 (no time indicated) documented, "Pt. to be DC'd today, paperwork done and awaiting p/u [pick-up]. Pt. states she has no one to pick her up and she wanted to call cab. Cab does not have w/c [wheelchair] access- will wait until tomorrow.The next Nursing Assessment Note was dated 10/31/09 at 9:45 a.m. "Pt d/cd home. Condition good. VSS [vital signs stable]. Meds and instructions sent home w/ pt." A Transfer/Discharge Summary dated 10/30/09 documented the medications Resident A was taking at discharge. The number of pills Resident A received on discharge was not documented as required on the summary form. The section titled, Resident Teaching for Home; documented, follow up with personal care physician. The section titled, Summary of Stay; documented, discharge home with meds and PT evaluation and home health. An interview was conducted with Licensed Nurse 1 (LN), who participated in Resident A's discharge on 11/10/09 at 11:00 a.m. LN 1 stated the nursing department was given notification that Resident A was to discharge on 10/30/09. LN 1 stated Resident A asked her to call a cab. LN 1 stated she gave Resident A teaching regarding her medications and Resident A used a wheelchair to get out to the cab. LN 1 stated she did not know if Resident A took a wheelchair with her in the cab, or if she had a wheelchair at home. LN 1 did not know if home health assistance or physical therapy assistance had been obtained to assist Resident A when she arrived home.An interview was conducted with the Social Service Director (SSD) on 11/10/09 at 10:30 a.m. The SSD stated a utilization review meeting was conducted with Resident A's Medicare Health Maintenance Organization (HMO) on 10/27/09. The HMO said Resident A's Medicare coverage would be discontinued 0n 10/29/09. The Medicare denial letter was sent via registered mail to Resident A's Power of Attorney. The SSD stated Resident A's Power of Attorney had not been in the facility during Resident A's stay and he had not signed any of Resident A's admission paper work. The SSD stated Resident A's discharge paperwork was completed on 10/27/09 and placed in the physician's box at the nursing station for his signature.During the interview the SSD stated she had been aware Resident A was not ready to go home independently and the facility's plan was to keep Resident A over the weekend and attempt to find her an assisted living facility. The SSD stated she telephoned the Ombudsman's office and set up an appointment for Monday 11/2/09, to discuss Resident A's discharge options. The SSD stated she forgot to pull Resident A's discharge paperwork from the physician's box at the nursing station and Resident A was "accidentally" discharged home over the weekend.An interview was conducted with Ombudsman Staff on 11/10/09 at 3:00 p.m. Ombudsman staff stated on 10/30/09, Resident A telephoned the Ombudsman crisis line and said she had no furniture in her apartment or heat. Ombudsman Staff stated they were supposed to have an Interdisciplinary Team Meeting at the facility on 11/2/09 to discuss Resident A's discharge plans but the facility called and cancelled the meeting because Resident A had been discharged. Ombudsman Staff stated they had spoken with Resident A's Power of Attorney and he did not live with Resident A, however he did live in the same apartment building. Ombudsman Staff stated Resident A's Power of Attorney saw Resident A lying on a mattress in her apartment through a window on 10/30/09 and took her blankets and something to eat. Ombudsman Staff stated Resident A had no services to assist her, she didn't know how to turn the heat on and she had no way to get food.Therefore, the Department determined the facility failed to: Develop and implement a discharge plan for Resident A that ensured discharge to a safe environment with needed equipment and services in place. These violations had a direct or immediate relationship to the health, safety or security of long-term care facility patients or residents. |
| 040000050 |
HY-LOND HEALTH CARE CENTER-MERCED |
040010702 |
B |
05-May-14 |
4OZ011 |
4229 |
483.13(c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATION The facility must implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of property. An unannounced visit was made on 1/10/14 to initiate investigation of entity reported incident CA00382436 concerning theft of a residents cell phone by a staff member. Based on staff interview, and clinical record and administrative document review, the facility failed to implement written policies and procedures that prohibit misappropriation of resident property for one resident (Resident A) when a Certified Nurse Assistant (CNA) 1 was in possession of Resident A's cellular (cell) phone and had attempted to sell the phone on the internet.Findings: On 1/10/14 at 10:00 a.m., during an interview at the facility, the Administrator (ADM) stated, on 12/20/13, (Resident A) plugged his cell phone in to charge at the bedside and left his room. When the resident returned to his room the cell phone was missing.On 12/27/13 a Licensed Nurse reported to the ADM she had observed a Certified Nurse Assistant (CNA 1) who worked at the facility posting a picture of her with a cell phone advertised for sale. At this point the police were called in to investigate.Resident A was a 71 year old male admitted to the facility on 12/19/10. Resident A's Minimum Data Set (MDS) version 3.0 dated 7/22/13, was reviewed on 1/10/14. The MDS indicated Resident A's cognitive status was oriented to person, time, and place with recall ability.On 1/10/14 at 10:00 a.m., during a concurrent interview/ administrative document review at the facility with the Administrator the following details of the incident were acknowledged by the Administrator. A facility document titled, "Pre Termination Form" dated 12/30/13, indicated on 12/20/13 an employee (CNA 1) was advised through a nursing team huddle (meeting) at North Station that a resident's cell phone was missing. On 12/27/13 the employee (CNA 1) was observed by a charge nurse at the facility, to post on a social network a picture of her holding the missing cell phone advertised for sale. Resident A's phone had been reported missing to both the Police Department and the Cell phone provider. A Police Investigator came to the facility on 12/27/13 at 2:00 p.m., and interviewed CNA 1 about the advertised cell phone. CNA 1 told the Police Officer the phone had been given to her by a family member. The Investigator and CNA 1 both left the facility after the interview. A short time later CNA 1 returned to the facility with the missing cell phone and provided a signed statement to the administrator she had received the cell phone from a housekeeper to sell for extra money. CNA 1 acknowledged to the Administrator she had lied earlier in the day to the Investigator.The Housekeeper was contacted by the Administrator and denied all accusations. The cell phone in CNA 1's possession was identified by the serial number as belonging to Resident A. The information card was not in the phone and no personal information was found on the phone. It was unknown and undetermined what had happened to the phone card holding Resident A's personal information.A facility document titled "Abuse Policy and Procedure" dated 1/10, indicated "...Types of abuse: Misappropriation of funds and property. Taking money or other personal items from the resident." A facility document titled, "California Notice of Patients' Rights" dated 12/30/13 indicated Patients keep all their fundamental civil or human rights and liberties when admitted to a nursing home. In addition, Federal and State laws grant nursing home Patients these specific rights..."To retain and use personal clothing and possessions..." A facility document titled "Abuse Policy and Procedure "dated 1/10, indicated"...Types of abuse: Misappropriation of funds and property taking money or other personal items from the resident."Therefore the facility failed to ensure Resident A was free from misappropriation of personal property and to retain and be able to use his own personal property.The above violation had a direct relationship to the security and independence of Resident A and constitutes a class "B" citation. |
| 040001150 |
Hollywood Home |
040011223 |
A |
12-Jan-15 |
YNF711 |
13275 |
Class `A` Citation 42 CFR 483.460 (c) Nursing ServicesThe facility must provide clients with nursing services in accordance with their needs. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA00413411. The facility failed to provide nursing services to assess and monitor Client A when she had a fever of 102รธ Fahrenheit (F) (normal range 97.5 - 98.6รธ F) and diarrhea (loose and watery bowel movements) for one week (9/8/14 to 9/14/14). This failure placed Client A at risk for dehydration and decline of her health condition. Client A was sent to an acute hospital on 9/14/14 and transferred to the Intensive Care Unit (of another acute hospital) for 16 days (9/14/14 - 9/29/14).Client A's Comprehensive Functional Assessment (CFA) dated 7/28/14, contained documentation she was ambulatory, was able to perform basic activities of daily living with minimal to no staff assistance (i.e., feeding self, dressing, grooming, toileting, and bathing needs). The CFA indicated Client A understood and spoke both English and Spanish, and was able to make her needs known. On 10/1/14 at 9:25 a.m., during an interview, Client A stated she was feeling bad on the day she was sent to the hospital (9/14/14). Client A further stated she felt hot and cold, she was breathing hard, had stomach pain, and diarrhea five times that day. Client A stated her diarrhea was not relieved by Pepto Bismol (medication to treat upset stomach, heart burn, or diarrhea).On 10/1/14 at 10:05 a.m., during an interview, the Program Manager (PM) reviewed Client A's clinical record and stated she was not able to find documented evidence a Registered Nurse (RN) had assessed Client A for a change in condition from 9/8/14 to 9/14/14.On 10/2/14 at 9:04 a.m., during an interview, the House Manager (HM) stated from 9/8/14 until 9/14/14, Client A had watery stools, "like wetting herself." She further stated Client A was "dizzy, confused, and had stomach discomfort." She stated on 9/10/14 at 9:30 p.m., Client A's temperature was 102รธ (degrees) F, so she called the (non-licensed) Administrator, who instructed her to give Tylenol. She stated after rechecking the client's temperature (30 minutes later) it went down to 100.1รธ F. The HM stated when she went into Client A's bedroom on 9/13/14 at 7:15 a.m., the client smelled of feces (bowel movement), and stated the client's clothes were "soaked wet with it." She stated she showered Client A and informed the Administrator of the client's diarrhea, and confusion. She stated (in response to this information), he instructed her "to monitor the client." The HM completed an Incident Report dated 9/13/14 at 7:15 a.m., which contained documentation when she went to wake Client A up for her medication, she noticed magazines scattered on the floor by Client A's bed and a dresser moved out of place. She noticed a scrape on the client's right arm, a small bruise on the client's back and shoulder. The form contained documentation the HM notified the Administrator of the fall. The form also contained documentation from the Administrator, Client A "sustained an injury to Rt (right) Elbow. She said she fell out bed (sic) onto magazine rack or wall."On 10/2/14 at 2:40 p.m., during an interview, Direct Care Staff (DCS) 4 stated she worked at the facility Monday (9/8/14) - Friday (9/12/14) from 6:30 a.m. until 2:30 p.m. DCS 4 further stated she called the Administrator every day and informed him of Client A's condition (fever and diarrhea). DCS 4 stated the Administrator told her to give Client A the ordered medicine for fever (Tylenol 500 milligrams [mg] two tablets [tabs]) and the ordered medicine for diarrhea (Pepto Bismol two tablespoons [Tbsp]), and to "continue to monitor the client." DCS 4 stated she would normally have called the nurse, however the facility was in transition at that time and they did not have a nurse.Client A's Physician Orders dated 7/31/14, contained orders to "Call MD (Medical Doctor) for temp. (greater than) 101.5 (degrees Fahrenheit [F])... Tylenol 500 mg 2 tabs po (by mouth) q (every) 6 hr (hours) PRN (as needed) ... for pain or temp. (temperature) of 101.5... Pepto Bismol OTC (over the counter) 2 tbs (tablespoons) po bid (twice daily) prn ... for gastro intestinal discomfort..."On 10/2/14 at 2:30 p.m., during an interview, the PM also stated the facility did not have an RN working from 9/1/14 until 9/18/14. On 10/3/14 at 8 a.m., during a telephone interview, the facility's former Registered Nurse (RN 1) stated if a client had diarrhea and fever, she would have expected the staff to initially administer medications per physician's order. RN 1 stated with a fever of 102รธ F which went down to 100.1รธ F after 30 minutes of medication administration, the staff should have continued to monitor and document the client's temperature. If it did not return to a normal reading (98.6 รธ F),the physician should have been contacted.RN 1 stated, if diarrhea persisted after the initial dose of the physician's ordered medication, an RN and a physician should have been notified so that further instruction could have been provided (i.e., to give Gatorade or Pedialyte to the client to replace electrolytes lost due to diarrhea).On 10/13/14 at 1:08 p.m. during an interview, the Administrator stated when he was informed of Client A's fever and diarrhea, he instructed the staff to administer the physician's PRN orders for fever and diarrhea (Tylenol and Pepto Bismol).The Administrator stated when the HM called him on 9/10/14 at approximately 9:30 p.m., informing him Client A had a fever of 102.0รธ F, he instructed her to administer Tylenol. He further stated since Client A's temperature went down to 100.1 รธ F after 30 minutes, he did not inform the physician about it. The Admininstrator stated when he was informed on 9/13/14, about Client A's diarrhea and confusion, he stated he instructed staff to give Client A medication for diarrhea (Pepto Bismol). He stated Client A was confused because of her recent fall from her bed and stated he did not notify a doctor. On 10/13/14 at 2:30 p.m., during an interview, the Administrator stated the facility had no RN from 9/1/14 until 9/18/14. The Administrator provided written documentation (Resignation Letter from RN 1) that she resigned her position effective 8/31/14. On 10/17/14 at 2:20 p.m., during an interview, the Administrator stated he was not a licensed medical professional, but stated he followed the PRN medication physician's order for treatment of Client's A's diarrhea and fever. The Centers For Disease Control's (CDC's) Guidelines for the Management of Acute Diarrhea included: "... The primary goal of treating any form of diarrhea ... is preventing dehydration or appropriately rehydrating persons presenting with dehydration... Refer ... adults with acute diarrhea for medical evaluation if any of the following are present: Fever 102.2รธF, high output of diarrhea, including frequent and substantial volumes of stool (bowel movement), change in mental status (e.g., ... lethargy [weakness])..."The International Foundation for Functional Gastrointestinal Disorders (IFFGD) defined diarrhea as "the too frequent and often urgent passage of loose or watery stools..." The IFFGD recommended if a person had "anything more than mild, short-term diarrhea, you should consult a physician to obtain a diagnosis and specific treatment. If you have ...signs of dehydration, weight loss, or fever such a consultation is urgent."On 10/2/14 at 2:25 p.m., during a telephone interview, DCS 3 stated she was on duty when Client A was sent to the hospital (9/14/14). DCS 3 stated Client A was breathing heavy and she was warm to touch. DCS 3 stated when she called the Administrator; he informed her he would take Client A to the hospital.Client A's Emergency Department Reports (EDRs) dated 9/14/14 from Acute Hospital 1 (AH 1) contained documentation the client arrived at 5:36 a.m. by "Walk-In." Client A's vital signs were documented as: Temperature 102รธ F (by mouth), Pulse (heart rate): 111 beats per minute - bpm (normal adult resting heart rate 60 - 100 bpm); Respiratory (breathing) rate: 28 per minute (normal 12 - 16 per minute); Blood Pressure 117/60 mmHg (millimeters of mercury - normal less than 120/80).The Emergency Department (ED) Physician Notes dated 9/14/14 at 6:02 a.m., contained documentation Client A presented with, "diarrhea, abdominal cramping and associated with fever and SOB (shortness of breath). The onset was 7 days ago... Associated symptoms: abdominal pain, vomiting and fever. The patient presents with difficulty breathing and cough. The onset was 1 days (sic) ago... Review of Systems: fever, chills... Respiratory symptoms: shortness of breath, cough... Cardiovascular (involves heart and blood vessels) symptoms: Palpitations (feelings of having rapid, fluttering or pounding heart). Gastrointestinal symptoms: Abdominal pain, nausea, vomiting, diarrhea... Pulse Oxymetry: 77 % ...LOW... hypoxemic (a lower than normal level of oxygen in the blood which prevents normal body functions) ..." Client A's Arterial Blood Gas (ABG - blood drawn from an artery to reveal the acid-base balance) report drawn on 9/14/14 at 11:03 a.m., showed the following data: A "Critical" low pO2 (oxygen tension in the blood - inability to oxygenate body) at 46.0 mm/Hg [millimeters of mercury] (normal 80.0 - 100.0). The report also showed a low [acidic] ph (acid - base blood levels) at 7.27 (normal 7.35 - 7.45). The HCO3 (bicarbonate level - kidneys release HCO3 in response to acidic ph) was low at 19.8 mmol/L (millimoles per liter) (normal 20.0 - 26.0); TCO2 (measures carbon dioxide blood levels) was low [acidosis] at 21.1 mmol/L low (normal 24.0 - 30.0); base excess (amount of buffering components in the blood) was -6.8 mmol/L low [deficit indicates acidosis] (normal 0.0 - 3.0); O2 Sat (oxygen saturation) was 75.0% [oxygen saturation levels of 70% or less indicates inability to oxygenate tissues for vital functions] (normal 95 - 100%).Client A's EDR at AH 1 dated 9/14/14 at 6:25 a.m., showed her pulse was 101 bpm and her blood pressure dropped to 92/48 mmHg; and her blood pressure remained low when checked again at 7:10 a.m. (91/49 mmHg). The EDR contained documentation, "Due to decreasing sats (oxygen saturation levels) and blood pressure, pt (patient) sedated (placed under anesthesia) and intubated (introduction of a tube into a hollow organ such as the trachea - for the purpose of mechanical ventilation [machine assisted breathing])..."Client A's "Transfer Certification" form from AH 1 dated 9/14/14 contained documentation, "Benefits/Reason For Transfer ... Level of Care Needed ... ICU." The form contained documentation Client A was transferred to Acute Hospital 2 (AH 2) on 9/14/14 at 10:45 a.m. by ambulance. Client A's History and Physical notes from AH 2 dated 9/14/14 at 1:57 p.m., contained documentation, "Chief Complaint: Patient was transferred from (AH 1) Emergency Department for pneumonia (infection that inflames the air sacs in one or both lungs) with respiratory failure (respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination) and hypoxia... Patient was seen by (MD 1) and (MD 1) has placed a central line (a long, thin, flexible tube often inserted into a large vein near the heart; used to give medicines, fluids, nutrients, or blood products usually over several weeks) for the IV (intravenous) access... Patient ... ABG shows respiratory acidosis (condition where the lungs cannot remove all of the carbon dioxide the body produces; causing body fluids, especially the blood, to become too acidic) with hypoxia. Patient is admitted for respiratory failure with pneumonia and hypoxia... heart rate 89; blood pressure is low 87/45; saturation is 88% on arrival... The patient is sedated on vent (ventilator [breathing machine])... Patient's condition is critical (a condition involving danger of death) and prognosis (forecast of the likely outcome of a situation) is guarded (prognosis given by a physician when the outcome of a patient's illness is in doubt)..." Client A's Discharge Summaries Notes dated 9/29/14 at 1:14 p.m., contained documentation, she remained on a ventilator in the ICU from 9/14/14 - 9/27/14 (14 days). She was transferred from the ICU on 9/28/14 and was discharged back to the facility on 9/29/14 (after 16 days of hospitalization). The facility failed to provide nursing services to assess and monitor Client A's health status when she had a fever of 102รธ F and diarrhea for one week (9/8/14 to 9/14/14). Due to the facility's failure to provide Client A with a nursing assessment, medical evaluation and treatment during that time, her health status declined: She was sent to the acute hospital on 9/14/14, diagnosed with respiratory failure, she required intubation, central line placement, IV therapy, and mechanical ventilation in the ICU for 14 days. Client A's condition was identified as "critical" and her prognosis was identified as "guarded." This violation presented a substantial probability of death or serious physical harm would result and therefore constitutes a Class 'A' Citation. |
| 040000050 |
HY-LOND HEALTH CARE CENTER-MERCED |
040011710 |
A |
04-Sep-15 |
ZQZ611 |
9640 |
CFR (Code of Federal Regulations) 483.25 (h) (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. The Entity Reported Incident CA00408885 was investigated during an on-site visit on 8/11/14. The facility failed to provide adequate supervision to ensure Resident 1 received the assistance necessary to prevent an avoidable accident when Resident 1 fell out of bed when one Certified Nursing Assistant 1 (CNA) provided care without the assistance of a second CNA. Resident 1 fell out of bed and sustained a right hip fracture and a laceration on the forehead on 8/9/14. The facility's failure to implement a safe environment by not using a sufficient amount of staff assistance to provide care for Resident 1 who required extensive assistance resulted in a hip fracture and a laceration to the forehead.Resident 1 was a 78 year old female admitted to the facility on 11/2/11 with diagnoses which included a cerebrovascular accident [CVA] (stroke) with right sided paralysis, abnormal weight gain, and Hypertension [high blood pressure]. On 8/11/14 at 2:50 p.m., during an observation and a concurrent interview, Licensed Nurse 1 (LN) stated she had investigated Resident 1's fall of 8/9/14. LN 1 stated CNA 1 was performing care and a linen change while the resident was in bed when Resident 1 fell out of bed and sustained injuries. LN 1 stated, "I think she is a two person assist."On 8/13/14 at 2:10 p.m., during a telephone interview, Resident 1's family member stated, "They (facility) had one CNA handling [Resident 1] and they need two CNAs for a woman of her size." On 8/13/14 at 2:45 p.m., during a telephone interview, CNA 1 stated, she had been working at the facility about a month. CNA 1 stated no one [staff] ever told her Resident 1 required the assistance of two persons to assist with her care. CNA 1 stated, CNA 2 told her she [CNA 2] cared for Resident 1 by herself. CNA 1 stated, there was a sign on the door which indicated, "Assistive," but the sign had not indicated what type of assistance or how many staff was required to provide assistance. CNA 1 stated, during orientation she was told by the CNA who trained her, the CNA's normally do a "two- person assist" by one person (CNA) instead of two. CNA 1 stated she asked LN 1 for help before she went into Resident 1's room and LN 1 told her she would send someone to help her, but no one went to assist. CNA 1 stated on 8/9/14 she had been in the process of doing a full bed change for Resident 1 by herself when the resident fell out of bed. CNA 1 described the process of the bed linen change and the fall as follows: CNA 1 turned Resident 1 on to the resident's right side, placed the sheets under Resident 1's side, turned Resident 1 on to her left side, then rolled Resident 1 closer to the right side of the bed when Resident 1 reached for the dresser on the right side of the bed and fell face down to the floor.On 8/27/14 at 2:32 p.m., during an interview, Resident 1 stated she had fallen and broken her hip. Resident 1 further stated, the facility should have sent two people to help CNA 1. Resident 1 stated, "I can't remember them ever sending two people to help me. I am a large woman." On 8/27/14 at 3 p.m., during an interview, CNA 1 stated she had not had training on repositioning residents in bed other than what she had observed other CNAs doing during orientation.On 8/27/14 at 3:30 p.m., during an interview, LN 1 stated CNA 1 asked [LN 1] for help with Resident 1 about a half hour before the resident's fall. LN 1 stated she had notified CNA 2 of CNA 1's request for help with Resident 1. LN 1 stated she had not been aware if CNA 2 had provided help to CNA 1 after her conversation with CNA 2. Review of Resident 1's Quarterly Minimum Data Set Assessment (MDS) (a federally mandated assessment of residents in a nursing home to identify cognition , functional abilities and health problems) dated 4/22/14, in the section under, "Brief Interview for Mental Status" (BIMS) indicated a score of 9. A score of 9 indicated Resident 1 had the ability to recall (memory) without cues given by the staff performing the assessment. The assessment indicated Resident 1's functional status for bed mobility scored a 3. A score of 3 indicated extensive assistance was needed by Resident 1 and two or more persons were needed for physical assistance. The assessment indicated Resident 1 weighed 224 pounds.Resident 1's "Fall Risk Assessment" dated 6/29/14 indicated Resident 1 had a fall risk score of 12. A score of 10 or more indicated a higher risk for falls and a care plan must be initiated. On 8/9/14 a "Fall Risk Assessment" was completed for Resident 1 which indicated Resident 1 was at a higher risk for falls as indicated by a score of 15. Review of Resident 1's care plan identified Resident 1 as a fall risk effective 2/19/13 to the present. There was no documented evidence on the care plan which identified and included the need for a two-person assist with bed mobility. On 8/27/14 at 4:30 p.m., during an interview, CNA 2 stated LN 1 had not asked her to help CNA 1 on the day of Resident 1's fall. CNA 2 stated she was in a nearby resident room when she heard a scream from Resident 1's room. CNA 2 stated she then went into Resident 1's room in order to help and saw Resident 1 on the floor.Resident 1's, "Clinical Notes" dated 8/9/14, indicated LN 1 found Resident 1 lying on the floor face down and bleeding from her forehead. The document indicated at that time (9:15 a.m.), LN 1 got help, then assessed Resident 1 for injuries, and applied a pressure dressing to the forehead to stop the bleeding.The unit manager then called 911. The document indicated Resident 1 was checked for further injuries by the nurse and indicated, "Possible of fracture as resident complained pain to lower extremity." On 8/9/14 at 9:35 a.m., Resident 1 was transferred to the acute care hospital (ACH 1) ER (Emergency Room) by ambulance.Resident 1's report from ACH 1, titled, "... Report 0809-0105, dated 8/9/14," dictated by the Medical Doctor (MD), under "Medical Decision Making," indicated, "The patient presents status post ground level fall at the skilled nursing facility complaining of right hip pain. The patient had CT's (Computerized Tomography) (A scan which combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside the body.) of the head, cervical spine, and bilateral (both sides) hands and pelvis ordered because she has a large laceration on her forehead which is approximately 5 cm [centimeters-a method of measurement] horizontal which was sutured up with 3-0 nylon, approximately 10 sutures sewn by myself...and she does have a right hip fracture..." Under the section "Disposition," the document contained, "In serious condition, she will be transferred to [...ACH 2] for further evaluation for Ortho [orthopedics, bone specialty]." Resident 1's transfer report from ACH 2 indicated, Resident 1 was admitted on 8/9/14 for a right hip fracture. The X-ray result dated 8/10/14 indicated, "Impression: Right hip severe acute comminuted fracture (A fracture in which the bone is splintered, crushed, or broken into pieces)." Resident 1 had a surgical procedure, "Open Reduction Internal Fixation (ORIF)" (hip surgery to repair fracture) of right hip on 8/12/14. Resident 1 was discharged from ACH 2 on 8/15/14 back to the facility.Resident 1's Medication Administration Record (MAR) dated 8/1/14 to 8/8/14 indicated Resident 1 had a pain level of "0" which indicated "No pain." Review of Resident 1's MDS readmission assessment dated, 8/28/14 indicated, Resident 1's pain level was constant, rated the pain level as a 10 (0 being no pain and 10 being worst pain) and made it hard for the resident to sleep . The facility's administrative document titled, "Prevention & Minimization of Serious Accidents," dated, 12/09 indicated, "The facility must ensure that the resident's environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent/minimize serious accidents..." The facility failed to provide adequate supervision to ensure Resident 1 received the assistance necessary to prevent an avoidable accident when Resident 1 fell out of bed when one Certified Nursing Assistant 1 (CNA) provided care without the assistance of a second CNA. Resident 1 fell out of bed and sustained a right hip fracture and a laceration on the forehead on 8/9/14. The facility's failure to implement a safe environment by not using a sufficient amount of staff assistance to provide care for Resident 1 who required extensive assistance resulted in a hip fracture and a laceration to the forehead.The facility failed to ensure Resident 1, who had assessments identifying high risk factors for falls, which included right sided weakness and inability of Resident 1 to use her right arm with functional capability, was not provided the 2 person assistance needed to prevent her from falling out of bed. Resident 1 sustained a hip fracture and laceration to the forehead which required an emergency transport to the hospital for sutures, a surgical procedure, and an increased pain level during the recovery period.This violation presented a substantial probability of death or serious physical harm would result and therefore constitutes a Class "A" Citation. |
| 040000050 |
HY-LOND HEALTH CARE CENTER-MERCED |
040011741 |
A |
23-Sep-15 |
ZQZ611 |
12948 |
AMENDED EVALUATOR NAME TO CORRECT EVALUATOR ON 1424 AND CMS 2567 9/24/15.During an investigation of Entity Reported Incident (ERI), CA00410687, the Department determined the facility failed to review and revise the comprehensive plan of care for 1 of 2 Residents sampled (Resident 2) after Resident 2 had a change in functional status which required staff assistance when using a wheelchair (w/c).This failure resulted in a fall of Resident 2 from the wheelchair, while unassisted outdoors, and sustained a fracture to the lower leg, transportation by emergency services to an Acute Care Hospital. Review of ERI dated 8/27/14, revealed an event which occurred on 8/24/14 at 9:36 a.m. as follows: "Passerby came into facility stating that resident who is wheelchair (w/c) bound was on the ground outside the facility. Resident was found flat on back and complaining of lower extremity (leg) pain. Resident stated she was outside on the paved sidewalk getting sunshine when her wheelchair went straight instead of turning left, gaining momentum she fell from the wheelchair when it reached the curb which caused resident to fall into street." The document indicated an X-ray showed an acute fracture (break in bone) of the tibia (lower leg bone).Review of the facility investigation document indicated an interview with the Director of Nursing (DON) on 8/27/14 had revealed: "DON stated...Resident had an electric w/c up until last month when the resident hit a sliding glass door in the facility and staff felt she was unable to control the electric wheelchair so they gave her a manual (w/c). Resident has left sided hemiparesis [one sided partial paralysis] due to Cerebral Vascular Accident (CVA) [stroke-damage to the brain caused by a disruption of the blood supply to a part of the brain]. Resident developed a blood clot in the leg and is now in the [Acute Care Hospital 2] ..." Review of the facility document, "Verification of Investigation Report," (VIR) indicated Resident 2 could not remember why she went straight on the sidewalk instead of left toward the front door. The VIR indicated, Resident 2 stated the pavement had a decline and when Resident 2's wheelchair veered toward the area of the decline, the resident rolled off and fell from the chair. The VIR indicted a passerby entered the facility and called out to staff that Resident 2 had fallen outside. The VIR indicated Licensed Nurse (LN) 4 and LN 5 responded and found Resident 2 lying on her back, on the pavement at the curb. The VIR indicated Resident 2 thought the Activity Associate (AA) was assisting her by pushing the wheelchair from behind, but when she noticed her wheelchair was going too fast she informed the AA and received no response, realizing the AA was not behind her. The VIR indicated Resident 2 complained of pain to the LLE (lower left extremity). The VIR indicated an X-ray of Resident 2's Left Ankle revealed a proximal (closest to) tibia fracture. The VIR indicated, Resident 2 was wheelchair bound, had decreased activity tolerance, and left sided weakness due to late effects of a CVA. Review of Resident 2's Annual Minimum Data Set Assessment (MDS) (an assessment tool used in nursing homes to identify functional abilities and health problems) dated 5/1/14, and 8/1/14, Quarterly Assessment was done. On the annual assessment, dated, 5/1/14, Section C, "Brief Interview for Mental Status" (BIMS) documented a score of 15 (a score of 15 indicated no cognitive impairment) which indicated Resident 2 had the ability to recall without cues. The MDS assessment, dated 8/1/14, indicated Resident 2's BIM score was 11 which indicated Resident 2 had declined in the mental status score. The MDS assessment, dated 5/1/14, indicated Resident 2 required two or more persons for physical assistance. On 8/1/14 the MDS indicated Resident 2 now was totally dependent and required full staff assistance, which reflected a decline in functional status. On 5/1/14, in the section of the MDS assessment section which was titled, "Care Area Assessment" (CAA) (items which indicated if a new or revised care plan would be necessary) indicated all areas were checked under activities of daily living, physical function, and falls that indicated the care plan should have been reviewed, revised and implemented. Review of Resident 2's Nursing Care Plan (CP), undated, indicated Resident 2 had a history of falls in the facility. The CP indicated assistance would be given by the staff when using the manual wheelchair due to a "Weakside." Review of Resident 2's "Fall Risk Assessment," dated, 6/14/14 indicated a "Fall Risk Score" of 11. On 8/9/14 a "Fall Risk Score" of 15 was documented. Score of 10 or more indicated Resident 2 was a higher risk for falls and the identified problems and interventions must be documented on the care plan, and interventions carried out. The facility policy and procedure titled, "Fall Prevention Program" dated 5/10, indicated "...designed to ensure a safe environment for all residents ...each resident will be evaluated ...to assess ...individual level of risk ...to gather accurate ...data for the purpose of implementing an individualized plan of care to meet the resident's needs ...implementation of preventative measures to assist with reduction of falls ...results will be scored to identify resident's risk ...The Fall Risk Decision Tree will be utilized to identify preventative measures specific for each resident. All residents receiving a score of 10 or more will be considered at higher risk for falls. " The DON provided Lippincott Nursing Procedure in response to the request for a policy and procedure on revision of care plans. Review of "Lippincott Nursing Procedure" indicated on page 45 under Implementation "...Be sure to address all of the patients significant needs when determining nursing diagnoses...Select interventions that will help the patient achieve the stated goals..." On 8/27/14 at 3:15 p.m., during an interview, the Interim DON (IDON) stated Resident 2 was outside the facility unsupervised on the day of the fall from the wheelchair. The IDON stated, "No one is scheduled to be out here to watch residents." The IDON stated Resident 2 was found, "Lying on the street with the wheelchair next to her."On 8/27/14 at 4:40 p.m., during an interview, Resident 4 stated she observed Resident 2 fall from an electric wheelchair approximately a month ago. Resident 4 stated, "No one comes out to supervise the residents outside." On 9/4/14 at 4 p.m., during an interview, Resident 2's Responsible Party (RP) stated, "They (facility staff) took [Resident 2's] electric wheelchair away... they did not think she was safe in it...I was told [Resident 2] had been leaving the premises ....I was called whenever she went to [fast food restaurant]."Review of Resident 2's Social Service note, dated, 8/6/14 at 10:31 a.m., indicated, "... Nursing staff has suggested [Resident 2] not use the electric wheelchair ... [Resident 2] has been using a manual wheelchair since the [prior] elopement (a time when Resident 2 left the facility unsupervised) [Resident 2] has left sided weakness and staff assist with propelling [Resident 2] around the facility as [Resident 2] chooses."On 9/4/14 at 4:10 p.m., during an interview, Resident 2 stated she went to [fast food restaurant] (across the street). Resident 2 stated she thought the [Activities Aide] was behind her when she had fallen outside in the wheelchair. Resident 2 stated when she looked behind her [for the Activities Assistant] there was no staff present. On 6/16/15 at 12:45 p.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, "I was the one that found her [when Resident 2 had fallen outside the facility ]...a car stopped to block other cars and to see if [Resident 2] was alright." CNA 3 stated she became aware of Resident 2's fall when a passerby stopped, came into the facility and called for help because one of the residents was on the road. CNA 3 stated she found Resident 2 outside on the pavement. CNA 3 stated she used her cell phone to call LN 4. CNA 3 stated, "[Resident 2] told me something hurt." CNA 3 stated, "[Resident 2] would always go outside...everyday... [Resident 2] wasn't supervised..." On 6/16/15 at 1:15 p.m., during an interview, License Nurse 2 (LN 2) stated, Resident 2 would let her know, before the fall from the wheelchair, if the resident was going out. LN 2 stated Resident 2 would have little memory lapses, and would forget the time, the day, and was forgetful. LN 2 stated Resident 2 had a history of bumping into things while in the wheelchair. LN 2 stated, "One time [Resident 2] got stuck in the garden area... We had to pull her out." LN 2 stated a staff member called her once telling her [Resident 2] was at the fast food restaurant parking lot unattended.LN 2 stated there had been no revision of the nursing care plan to reflect a change of status of Resident 2 in functional and cognitive ability which would have required staff assistance with mobility. Upon inquiry of Resident 2's fall into the public street on 8/24/14, LN 2 stated, she had assessed Resident 2 after the fall out of the wheelchair. LN 2 stated Resident 2 at that time had soft tissue swelling on the left leg. LN 2 notified the MD and an X-Ray was done and the resident sent to the Acute Care Hospital for further evaluation and treatment.On 6/16/15 at 2 p.m., during an interview and concurrent record review, the Unit Manager stated, "[Resident 2] would go outside unsupervised." The care plan for Resident 2 was reviewed. The Unit Manager stated she did not recall doing anything with Resident 2's care plan. The Unit Manager stated there were no revision dates on the care plan to show what intervention was needed for Resident 2. The Unit Manager stated the care plan contained no update which would apply to the dates after the resident's cognitive and functional decline, except for the dates after the fall from the wheelchair when the resident fell and fractured her leg. Review of the Acute Care Hospital document titled, "Emergency Room Report" indicated an admission date of 08/25/2014. The report indicated Resident 2 arrived at the hospital by ambulance at 12:40 p.m. with a chief complaint of left knee pain. Under the section of the report titled, "History of Present Illness" the report revealed, "...The patient was in her wheelchair yesterday when she fell out landing on the left knee. There was immediate knee pain, knee swelling...x-ray showed a left proximal tibia fracture. The patient was placed in a knee immobilizer and was kept overnight. The patient was reevaluated this morning and they found her to have a cold left foot, they sent her to the emergency department...She [Resident 2] states she has pain everywhere..." The report indicated the resident was tachycardiac (high heart rate). Under the section marked extremities the report indicated, "...There is obvious swelling and bluish discoloration at the left anterior (front side) knee that is painful to palpation (touch). The left thigh and the left lower extremity and foot has cool skin. There is a very faint palpable dorsalis pedis pulse (an artery of the upper surface of the foot that is a direct continuation of the anterior tibial artery).The ER report revealed, "...The left knee...had decreased cap (capillary) refill [which may indicate poor circulation to the area due to a lack of blood supply]...I ordered a CT (Computerized Tomography-scan) The CT...came back, it showed actually a thrombus (blood clot) in the left atrium, which is probably the source of the embolus. She has a small right lower lobe PE (Pulmonary [lung] embolus and she has a proximal (closest to) left femoral thrombus as well as non occlusive...blood flow significantly decreased...the patient has an ischemic (lack of blood supply) to the lower left extremity... The patient was transferred in serious condition [to a second acute care hospital where there was a vascular surgeon available]."The facility's administrative document titled, "Prevention & Minimization of Serious Accidents" dated 12/09 indicated, "The facility must ensure that the resident's environment remains as free from accident hazards as is possible and that each resident receives adequate supervision ...to prevent/minimize serious accidents."The facility failed to update and revise the nursing care plan for Resident 2 after documented observations and history of behavioral and physical decline and history of falls. The failure to revise and implement the care plan which would have addressed the need for supervision of Resident 2 when using the wheelchair, directly resulted in an injury causing an avoidable fracture of the left lower leg.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. |
| 040000014 |
HORIZON HEALTH AND SUBACUTE CENTER |
040011885 |
B |
09-Dec-15 |
1BM411 |
9368 |
The facility must ensure that resident environment remains free of accidents as possible and each resident receives adequate supervision and assistance devices to prevent accidents. This requirement is not met as evidenced by: The facility failed to identify environmental hazards and provide supervision to prevent accidents when Resident 1 fell and sustained a fractured arm after exiting through an exit patio door that failed to alert staff. This failure resulted in a fall and a fracture to Resident 1's left humerus (upper arm) which caused Resident 1 pain and a decline in physical function.On 6/29/15, 7/1/15 and 11/12/15, unannounced visits were made to the facility to investigate the Entity Reported Event CA00446735.Resident 1 was a 92 year old female who was admitted to the facility on 05/06/14. Resident 1's diagnoses included Dementia (cognitive impairment) and a history of falls. Resident 1's Minimum Data Set (MDS-measure of resident level of function and health care needs) assessment dated 6/23/15, indicated Resident 1 had long and short term memory impairment.Resident 1's "Fall Risk Assessment" dated 5/14/15, indicated, Resident 1 had a score of 18 which indicated the resident was at a high risk for falls. The assessment indicated Resident 1 had a history of multiple falls, was frequently disoriented, and required staff assistance with transfer, and had a decrease in muscle coordination.Review of Resident 1's physician orders dated 3/18/15, indicated, "Alarm: Wander Guard (An alarm system providing notification to staff when residents try to leave the facility or wander into restricted areas) -related to Dementia -check placement and function q (every) shift..."Resident 1's plan of care (POC) dated 5/6/14, indicated, "The resident is high risk for falls r/t [related to] unaware of safety needs, confusion, gait balance problems; ...The resident will not sustain serious injury...staff to anticipate and meet the resident needs..."On 6/29/15 at 11:20 a.m., during an interview, LN 1 stated Resident 1 required more assistance in activities of daily living (ADL's). LN 1 stated prior to Resident 1's fall and fracture, Resident 1 required extensive assistance (staff provide weight bearing support) with her ADL's and was able to propel around in the wheel chair. LN 1 stated Resident 1 now required maximum assistance (total care) which required the assistance of two persons with ADL's.On 6/29/15 at 12 p.m., during an observation, LN 2 walked to the outside patio to the location where Resident 1 had fallen. There was an empty flower bed which was lower than the sidewalk, with three protruding sprinkler heads creating a trip and fall hazard. LN 2 stated Resident 1 had gone outside in her wheelchair on 6/14/15, when the wheel of the chair tipped over the edge of the side walk, causing Resident 1's fall to the ground with her wheelchair.On 6/29/15 at 12:20 p.m., during an observation, the call light system displayed an alert to staff by signaling a light over each resident room and by sending an audible signal to the nursing station each time a call button was pressed. The patio exit doors had an audible alarm located at Resident 1's nurses station and did not have a light above the door to alert staff visually when Resident 1 exited the door.On 6/29/15 at 12:25 p.m., during an interview, LN 2 stated, "There were no noise making alarms (an alarm triggering the attention of staff) at the doors during the day of [Resident 1's] fall."LN 2 stated the door to the patio was not set to alarm as a response to a wander guard alarm when a resident wearing an alarm exited the door.On 6/29/15 at 12:35 p.m., during an interview, CNA 1 stated at approximately 2:10 p.m., she was notified by another CNA that someone was in the outside patio on the ground. CNA 1 stated, "We ran outside and we found [Resident 1], on the floor [ground]." CNA 1 stated she and another CNA ran back inside to call for help leaving the resident alone on the ground. CNA 1 could not explain how Resident 1 had gotten out unassisted. CNA 1 stated, "Residents like [Resident 1] are not allowed to be outside on their own." CNA stated Resident 1 needed supervision because of her diagnoses of dementia and unsafe wandering.On 6/29/15 at 1 p.m., during an interview, LN 9 stated she was the nurse in charge on 6/14/15 day Resident 1 fell. LN 9 stated, "It was around 2 p.m., one CNA came to me and told me [Resident 1] was on the floor [ground]." LN 9 stated Resident 1 was found on her right side, and stated Resident 1 had a broken arm and was in pain. LN 9 stated Resident 1 "Cannot be outside, she needs to have supervision." LN 9 stated there were no alarms at the door to alert her of Resident 1's exiting through the patio doors. LN 9 stated the alarms at the patio doors could only be heard at the nurses' station and she had not heard it. LN 9 stated Resident 1's fall should have been avoided. On 6/29/15 at 2:10 p.m., during an interview, the Director of Staff Development (DSD) stated there were no alarms triggered at the patio door because; there were no sounding alarms present on the patio doors prior to Resident 1's fall.On 6/29/15 at 3:15 p.m., during an interview, the Maintenance Director (MD) stated he was responsible for the safety check of the facility grounds. The MD stated he was part of a safety committee, and stated, "I am responsible for my team of 12 members, we identify things or potential risks that can affect the safety of all in the building."The MD stated the unleveled ground surface on the outside patio had not been identified as a hazard.On 6/29/15 at 3:20 p.m., during an observation and concurrent interview outside on the patio, the MD measured the unleveled ground along one side of the side walk where Resident 1 had fallen. There were three measurements taken alongside the sidewalk. The first measurement was the location where Resident 1 had fallen and measured a drop of three and half inches from the cemented walkway to the ground. A second area measured a two inch drop from the sidewalk to the ground, and the third area measured a four inch drop from the side walk to the ground. The MD stated, "Yes, I agree the ground is unleveled"On 7/1/15 at 11:45 a.m., during an interview, the MDS Coordinator (MDSC) stated Resident 1 had a significant change in overall function following her fall and fracture. MDSC stated, " [Resident 1] has had noted decline in several areas, she declined in transfers, locomotion on unit and off unit, dressing, eating, toilet use, and bathing." On 7/1/15 at 12 p.m., during an interview, The MD stated he had not done "anything" to the ground next to the patio, and it was still unlevel.On 7/1/15 at 12:10 p.m., an observation and concurrent interview with the Administrator (Adm) and the Operations Regional Director (ORD) was conducted.A video recording of Resident 1's fall from 6/14/15 was viewed. The recording was dated 6/14/15 at 1:19 p.m. Per the recorded video Resident 1 was observed sitting in her wheel chair in the hallway near the exit patio doors. LN 9 was observed standing in front of a medication cart near Resident 1. LN 9 was seen going into a resident room, when Resident 1 wheeled herself in the wheelchair toward the exit patio door at 1:20 p.m. The video recorded Resident 1 fell alone outside at 1:22 p.m. On 11/12/15 at 1:40 p.m., during an interview, the DON stated Resident 1 had sustained a fall on 6/14/15 because the ground was unlevel.Resident 1's Plan of Care (POC) dated 3/17/15, indicated, "The resident is an elopement (run-away) risk/wanderer [as evidenced by] Resident wanders aimlessly, Disoriented to place..." The POC indicated, "The resident will not leave facility unattended...The residents safety will be maintained...Assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities...Wander Alert when up in chair to alert staff of where about."Resident 1's X- Ray report dated 6/14/15 at 4:51 p.m., indicated, "There is a left humerus helical (spiral) midshaft (mid way between the end of a long bone) fracture...Extensive soft tissue swelling." An undated job description for the MD titled, " Job Description Maintenance Supervisor," indicated, "...The primary purpose of your position is to assist...day to day activities of the Maintenance Department in accordance with current Federal, State and local standards...to assure that our facility is maintained in a safe and comfortable manner..." The facility policy and procedure titled, "Fall Prevention Program" dated 12/1/2011, indicated, "...To identify residents who are at risk of falling and prevent accidents by providing an environment that is free from hazards...all residents will receive adequate supervision and assistive devices to prevent accidents..." The facility failed to maintain a safe and comfortable environment as indicated in the MD's job description, and an environment that was free from hazards as indicated in the policy and procedure for fall prevention. The facility failed to ensure Resident 1 who had identified risk factors of elopement and wandering be provided with the necessary supervision to prevent Resident 1's fall with injury.The above violation had an immediate direct relationship to Resident 1's health, safety and wellbeing and therefore constitutes a Class "B" Citation. |
| 050000052 |
HILLSIDE HOUSE INC |
050012385 |
B |
26-Jul-16 |
4Z6M11 |
2150 |
California Health and Safety Code 1418.91 (a) (b)-Failure to Report (a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. During an annual Recertification Survey, the Department determined the facility was in violation of the above statute by its failure to report to the Department an allegation of abuse immediately or within 24 hours. Review of the facility incident report sent to the Department via fax on 6/20/16 at 10:38 a.m., indicated, on 6/17/16 at 7:30 p.m., 62 hours after the alleged physical abuse, a direct care staff observed a roommate, Client B, placing a pillow over Client A's face. When Client B saw the staff, Client B threw the pillow and reached for a towel and tried to place this over Client A's face again. During the review of "Interdisciplinary Progress Notes" dated as late entry for 6/17/16, 7:30 p.m. indicated, at around 7:30 p.m., staff saw Client B suffocating Client A by placing a pillow on Client A's face. When the staff told Client B to stop, Client B threw the pillow and got hold of another small cloth and tried to suffocate Client A again. Resident A was a 63 year old male admitted to the facility with diagnoses including moderate intellectual disability and stroke. Resident A was non-ambulatory and was on bed rest except for meals. Resident B was a 20 year old male admitted to the facility with diagnoses including mild mental retardation and seizures. Resident B was ambulatory, and had a history of verbally and physically assaulting other residents. During an interview on 7/6/16 at 2:15 p.m., the facility's director of operations was unable to provide documentation to indicate the alleged physical abuse between Clients A and B on 6/17/16 at 7:30 p.m. was reported to the Department with 24 hours. The facility should know or should have known, they have to report to the Department immediately, or within 24 hours, the allegation of physical abuse between clients under its care. |
| 060001278 |
HARBOR HEALTH CARE, INC. - BLACK STAR DIVISION |
060008999 |
A |
14-Feb-12 |
S5I311 |
11270 |
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 following violation was identified during a facility reported incident investigation initiated on 1/3/12. The findings were based on interview, medical record review, review of facility documents, and review of the facility's policy and procedures. The facility failed to ensure six of six clients (Clients 1, 2, 3, 4, 5, and 6) were not left at the facility unattended.On 12/27/11, the Department received a report from the facility that the La Palma Police Department contacted the facility's CEO (Chief Executive Officer) on 12/24/11 at 2340 hours, informing her they were at the facility and no responsible staff could be found.On 1/3/12, the facility was visited to initiate an investigation of the above incident. At 1630 hours, the QMRP (Qualified Mental Retardation Professional) was asked what happened the night of 12/24/11. The QMRP stated on 12/24/11 a gentleman saw Client 1 walking towards the park. The gentleman was aware that Client 1 was from the facility. The gentleman was able to get Client 1 in his car and took him back to the facility. The gentleman called the La Palma Police Department. When the QMRP was asked where Client 1 was found, he stated Client 1 was two streets away from the facility. The QMRP stated the police met the gentleman with Client 1 at the facility. The police walked through the facility and found the five other clients were in bed asleep. However, there was no staff on the premises. The QMRP stated he got a call and went to the facility. The QMRP stated when he got to the facility the police was interviewing the direct care staff (DCS 2), who was scheduled to work the night shift. The QMRP also stated DCS 2 had told the police officer she had come to work and left. After being questioned more by the police officers, DCS 2 changed her story.When asked how long the clients were left unattended in the facility, the QMRP stated the clients were left unattended for about 30 to 40 minutes. The statements from the evening shift staff and night shift staff were reviewed. The following was identified: - DCS 1's statement dated 12/28/11 indicated DCS 2 arrived at the facility at 2255 hours, knocked on the door and told DCS 1 she would be outside. At 2300 hours, DCS 1's shift ended. When DCS 1 left the facility, she saw DCS 2 sitting in a car with someone else. DCS 1 and DCS 2 waved at each other. DCS 1's statement showed the only mistake she made was forgetting to clock out at the end of her shift. - DCS 2's statement dated 12/24/11 indicated DCS 2 called the facility around 1933 hours to let DCS 1 know she would be late to work. DCS 1 became argumentative stating she was not going to stay all night because she had a party to attend. DCS 2 assured DCS 1 she would only be about 30 minutes late. DCS 1 was still upset with DCS 2 being late. DCS 2 told DCS 1 if she had any problems with her being late to call the QMRP. At 2345 hours, DCS 2 arrived at the facility with her cousin and noticed the police were there. DCS 2 wanted to find out what was going on and asked her cousin to wait while see went to find out. DCS 2 went to the side entrance of the house to get in but the door was locked. DCS 2 went to the other side entrance of the house and saw a client's door open and went inside. As DCS 2 entered the kitchen a police officer began questioning her about who she was and who was DCS 1. DCS 2 replied "what, DCS 1 is not here?" DCS 2 showed them the facility's telephone caller ID showing the time she had called the facility telling them she would be late. Review of DCS 1's time card showed she clocked in on 12/24/11 at 1429 hours, took a break from 2130 hours to 2200 hours, but did not clock out at the end of her shift. DCS 1's shift was from 1430 hours to 2300 hours. Review of DCS 2's time card showed she did not clock in on 12/24/11 for her shift. DCS 2's shift was from 2300 hours to 0800 hours.On 1/13/12 at 1700 hours, the QMRP was asked what is the facility's policy regarding leaving clients by themselves unattended. The QMRP stated the clients are not to be left alone at any time. The QMRP was asked if DCS 1 and DCS 2 were aware of the facility's policy. The QMRP stated both DCS 1 and DCS 2 were given and signed the New Employee Orientation Information handout. The New Employee Orientation Information handout had information regarding not leaving the clients alone. The QMRP was asked to provide documentation of the information that was given to DCS 1 and DCS 2. Review of the New Employee Orientation Employee Handbook Receipt no date, showed the employee received a copy of the company's Employee Handbook. The handbook indicated the employee understood and agreed that it was their responsibility to read and familiarize themselves with and follow the policies and procedures contained in the handbook. Review of the New Employee Orientation Do's and Don'ts, page 11, showed the following: - Do maintain full supervision over each and every resident in your charge at all times. - Do know positively your exact population count at all times and the exact location of each individual resident. - Do not leave any resident or group of residents unsupervised at anytime, anywhere. -The physical safety of residents is your responsibility. DCS 1 signed the New Employee Orientation Employee Handbook Receipt on 11/10/11.DCS 2 signed the New Employee Orientation Employee Handbook Receipt on 7/5/08. The clients (Client 1, 2,3,4,5 and 6) medical records were reviewed. The following was found: Client 1 was admitted to the facility on 10/28/10, with diagnoses including severe mental retardation, cerebral palsy, autism, history of seizures, and schizophrenia. Client 2 was admitted to the facility on 10/15/03, with diagnoses including severe mental retardation, seizure disorder, convulsions, spinal cord degeneration, and gastrostomy tube (GT) insertion due to history of aspiration pneumonia.Client 3 was admitted to the facility on 6/6/05, with diagnoses including traumatic brain injury and seizure disorder. Client 4 was admitted to the facility on 4/24/01, with diagnoses including severe mental retardation, GT, and legally blind.Client 5 was admitted to the facility on 11/20/02, with diagnoses including severe mental retardation, cerebral palsy and seizure disorder. Client 6 was admitted to the facility on 6/25/98, with diagnoses including profound mental retardation, GT and seizures. On 1/17/12 at 1625 hours, the QMRP was asked the level of care for each of the clients at the facility. The QMRP stated all the clients required total care and should not have been left by themselves. The police report dated 12/24/11 was reviewed on 2/1/12. The police report indicated the following: - On 12/24/11 at approximately 2323 hours, the police officer responded to a call regarding a disabled person found walking in the middle of the street by himself and possibly resided in a group home nearby. A dispatch further advised the police officer that the caller was with the disabled male and was parked in front of a residence on Santiago Street. When the police officer arrived, the gentleman caller and the disabled male, later identified as Client 1, were sitting in a car. The gentleman stated he saw Client 1 walking in the middle of the street and immediately realized he was disabled. He attempted to contact Client 1, but Client 1 fled. The gentleman knew of the facility and assumed Client 1 had walked away from there. The gentleman went to the residence and attempted to contact an employee at the facility. However, the front door was wide open and no one answered. The gentleman left the facility, found Client 1 and called 911. The police officer asked the gentleman to follow him to the facility. - As the police officer arrived at the facility, he noticed the front door was wide open. The police officer knocked on the front door, rang the doorbell and announced their presence numerous times, but no one answered. The officers toured the facility attempting to find a responsible employee. As the officer walked through the facility he observed five severely disabled males and females in various bedrooms. All the clients were sleep and did not wake up while the officer was there. The officer noticed an empty bed at the end of the hall and assumed it was Client 1's room. The officer escorted Client 1 into the facility and followed as he walked into the rear bedroom. The officer assisted Client 1 into bed and left the room. - The police officer located a telephone number for the CEO of Harbor Health Care, Inc. At approximately 2343 hours, the officer contacted the CEO via telephone and explained the situation to her. The CEO was clearly shaken and stated she would have a responsible employee at the facility quickly. At approximately 2347 hours, the CEO called the officer back on the facility phone and stated the facility Administrator is on his way to the facility.- As the police officers were examining the living conditions, DCS 2 stormed into the facility from a rear door. DCS 2 stated she was the DCS on-duty and had stepped out of the facility for a minute. DCS 2 was speaking fast, was sweating on her brow and appeared very nervous. She stated she began work at 2300 hours, but left the facility with her cousin and quickly returned. The officer asked DCS 2 if she had left to get something to eat and DCS 2 did not answer the question. DCS 2 spoke so quickly, and changed her story so often it was difficult to understand her. For the first few minutes DCS 2 attempted to persuade the officer to believe she left the facility to run an errand. However, DCS 2 eventually admitted she was just arriving to work. She stated she called DCS 1 whom she was supposed to relieve at 1915 hours. DCS 2 told DCS 1 she would be "a few minutes" late. DCS 2 admitted she told DCS 1 to leave at 2300 hours, and secure the front door at the handle with a chain. DCS 2 stated she thought the clients would only be alone for a short while and she would be able to come to work and no one would have known.The facility failed to ensure six clients with mental disabilities and health issues, and requires total care were not left alone unattended at the facility. This resulted to Client 1 leaving the facility and wandering the street by himself in the middle of the night.The violation of this regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 060000056 |
Hy-Lond Garden Grove |
060010851 |
B |
08-Jul-14 |
None |
8120 |
Welfare and Institutions Code, Section 4502(g). 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (g) A right to physical exercise and recreational opportunities. The facility must ensure all clients were provided opportunities to participate in activities. On 5/19/14, the Department received a complaint with the following allegations:a. There was only one activity staff for the 99 clients in the facility. b. The facility was not providing enough activities for all the clients and clients were left with nothing to do.c. Clients are stuck in their rooms and have nothing to do for 10 hours per day without or very little program activity.On 5/22/14, an unannounced visit was initiated to investigate the above allegations.The facility is a 99 bed facility for individuals with intellectual disabilities. The facility had a census of 97 clients. On 5/22/14 at 1625 hours, the following was observed: Clients were in the front corridor. Eight clients in wheelchairs were lined up against the wall facing toward the front door with nothing to do. One client was folding papers on the far left area. Another client was sitting in a chair near the television.An activity calendar for the month of May 2014 was observed posted on the wall in the hallway. The calendar did not have any activities listed on all Wednesdays and Thursdays for the entire month of May 2014.At 1635 hours, the Administrator was asked why there were no activities scheduled on Wednesdays and Thursdays. The Administrator stated the Activity Director was off on those days. On 5/29/14 at 1100 hours, the Activity Director was interviewed. The Activity Director was asked what qualifications she has for the job. The Activity Director stated she worked 3 years as an activity assistant in Ohio. When asked if she had someone to assist her with activities, the Activity Director stated, no. The Activity Director further stated she would ask the Program Coordinator (a Certified Nurse Assistant) for a DCS (direct care staff) who was on light duty to help. She stated on most times she did not get help. When was asked how she provided activities for all of the clients by herself, the Activity Director stated she does as much as she could do. She stated some of the activities are the same each month because she cannot see all of the clients since she tries to see different clients each time. The Activity Director stated she makes a list with names of clients to be brought to the activity, but the DCS would bring the same clients who regularly attend instead of bringing other clients who had not been brought to an activity. The Activity Director stated it is difficult because she is by herself and a lot of the clients require hand over hand assistance. When asked how she provided activities to the bed bound clients, the Activity Director stated she did room to room visits at least twice a week and see how the clients are doing. The Activity Director also stated when she made room visits, she brought a radio, books, lotion, and other things.The Activity Director was asked if she had taken the clients on any outings. She stated the facility has a van and she had taken some clients to the beach. When asked what things were done at the beach with the clients, the Activity Director stated when she has help with her she had taken the clients to walk to the pier; however, when she did not have any help with her they would just sit in the van. The Activity Director stated she would like to take them all out but it is just her providing activities to the clients.When asked how many clients she can take with her on outings, the Activity Director stated two wheelchair bound clients and one client that could walk (total of three clients).When asked how she picked who could go on the outings, the Activity Director stated she would ask the Program Coordinator who she should take and she would take clients that had no family.When asked if the other clients left at the facility had activities to do when she was with the three clients on an outing, the Activity Director stated, no. The Activity Director further stated when she scheduled different activities for the staff on light duty to do with the clients, the activities were not done because the staff did not have time to do them. For example: A letter dated 5/25/14, written by the Activity Director instructing staff that in light of her absence that day, activity supplies, DVD/Blu Ray player, and the Karaoke machine are available for use. At the bottom of the letter was a handwritten note, dated 5/26/14, from the Program Coordinator stating the following: "I am sorry but I do not have the staff or the time to do activities."Review of a client list form used by the Activity Director showed two clients' names were listed per hallway. When asked why there were only two clients listed per hallway, the Activity Director stated she was only allowed to have a total of twelve clients at a time in her activities since she was by herself. The Activity Director stated she makes a list with names of clients to be brought to the activity but the DCS would bring the same clients who regularly attend instead of bringing other clients who had not been brought to an activity. The Activity Director was asked if she had any other information to share. The Activity Director stated she really liked her job and felt the clients were emotionally and spiritually deprived. The Activity Director further stated the clients are not used of being touched and some of the clients do not like to be touched because they are not used to it. The Activity Director stated it is only her and she tries to do what she can. On 5/29/14 at 1700 hours, the Administrator was asked about the lack of activities on Wednesdays and Thursdays when the Activity Director is off duty. The Administrator stated there were activities scheduled on the days the Activity Director was off but it was difficult to assign staff to do it on the PM shift. The activities were not being done so he had the Activity Director take them off the calendar. The Administrator stated with the Activity Director working on the weekends the clients could stay a little longer and not have to worry about being tired for day program the next day.The Administrator was informed of the concern regarding the Activity Director only being able to take three clients on outings and the rest of the clients at the facility with no activities being provided. When asked about the number of clients the Activity Director could have during activities, the Administrator stated the ratio of twelve clients to one staff was for the Activity Director not to be overwhelmed. The Administrator was informed of the concern regarding the Activity Director trying to provide activities to the clients by herself and does not get any help when she had asked other staff for help. The Administrator stated the DCS who are on light duty are supposed to help with activities after they had finished their assigned tasks. When asked if he felt the clients were getting effective leisure activities, the Administrator stated, no. The Administrator also stated it was difficult with their timeline since most of the clients get home from day program around 1530 hours, dinner is being served at 1630 hours, and the clients have individual programming at 1800 hours.The facility failed to ensure all the clients were provided opportunities to participate in activities. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 060001291 |
HARBOR HEALTH CARE, INC. - REDWOOD DIVISION |
060011122 |
B |
13-Nov-14 |
NH1K11 |
9288 |
Welfare and Institutions Code, Section 4502 (h). 4502 - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. On 10/2/14, an unannounced visit was made to the facility to investigate an entity reported event (ERI) related to Client 1. The Department was unable to substantiate the complaint allegation. However, during the investigation, the Department determined there was a violation of the W&I Code statute. Based on observation, interview, and review of clinical records and facility documents, the facility failed to protect Client 1 from verbal abuse. Client 1 experienced repeated verbal abuse that caused social isolation and sadness.On 10/2/14 at 0750 hours, the surveyor entered the facility. There were five clients observed eating breakfast in the dining area. When asked where Client 1 was, the direct care staff (DCS 1) replied the client was in his room because he did not want to get up.Client 1's clinical record review was initiated on 10/2/14. The Admission Record, undated, showed Client 1 was admitted to the facility on 4/1/09 with diagnoses including moderate intellectual disabilities (a disorder of mental functioning, with an IQ scores ranging from 35-55), cerebral palsy (CP - a neurological problem causing abnormal movement), and paralysis (a loss of muscle function to part/parts of the body).On 10/2/14 at 0910 hours, Client 1 was still in his room. An interview was conducted with Client 1. Client 1 was very tearful during the discussion and at one time did not want to talk without encouragement. Client 1 complained of his new roommate (Client 2) being mean to him, and stated things such as, "you're ugly" and "no one wants to be around you." Client 1 also stated he felt the staff was being short with him, even though they had known him longer. He stated the staff "sides with" Client 2. Client 1 became tearful again, and stated he felt "uncomfortable" in the house. He stated he had told his mother and his regional center coordinator that he wanted to change homes.Review of the Interdisciplinary Team (IDT) notes showed the following entries from the DCS:- On 9/5/14 during the morning shift, the DCS documented Client 1 did not appear to be very happy but had no complaints. - On 9/5/14 during the evening shift, the DCS documented Client 1 had unexplained emesis once. - On 9/11/14 during the morning shift, the DCS documented Client 1 was not talking very much and still appeared to be a little sad. - On 9/11/14 during the evening shift, the DCS documented Client 1 "appears to be OK just a little sad." - On 9/17/14 during the evening shift, the Program Manager (PM) documented Clients 1 and 2 were talking together a little bit more today. - On 9/28/14 during the night shift, the PM documented Client 1 was snoring loudly, staff attempted to raise the head of the bed, but Client 1 did not like it.An interview with the Qualified Intellectual Disabilities Professional (QIDP) was conducted on 10/2/14 at 0905 hours. The QIDP stated Client 1's mother had called yesterday and requested a room change because Clients 1 and 2 were not getting along. The QIDP further stated it had not been done yet because permission had not been obtained from the responsible parties.Clinical record review for Client 2 was initiated on 10/2/14. Client 2 was admitted on 8/28/14 with diagnoses of CP and moderate intellectual disability. Review of the most recent Individual Service Plan (ISP) from his last home showed Client 2 will at times curse at others. Client 2 had a behavior plan that collected data on episodes of verbal aggression.Documentation in the clinical record showed a pre-admission assessment performed by the QIDP on 7/14/14. The assessment noted Client 2 could become verbally aggressive at times. The QIDP also noted Client 2 had a goal to decrease aggressive verbal attacks on staff members, and a need to increase self-control. The QIDP listed areas for potential intervention as decreasing behaviors and increasing self-control. The possible barriers to the program included behavioral outbursts and verbal aggression.Review of Client 2's IDT notes showed the following entries from the DCS: - On 9/11/14 = having trouble sleeping with his roommate snoring. - On 9/11/14 = requested new room because he was not sleeping enough due to noise. - On 9/17/14 = complained that he could not sleep and this pattern was off. - On 9/28/14 during the night shift, the DCS documented Client 2 was having a problem with his roommate snoring very loudly. Further review of the clinical record showed Client 2 did not have a care plan or any behavior plans to address his verbal outbursts and verbal aggression. During an interview with the QIDP, he stated the first 30 days were for assessment only and he did not perform any data collection.On 10/2/14 at 1020 hours, during an interview with the Licensed Vocation Nurse (LVN), she stated Client 2 was a "bully" towards Client 1. The LVN further stated Client 2 was loud and tended to get most of the attention. When asked if the facility had done anything about the strife between Clients 1 and 2, the LVN stated that today was the first time, and they will be changing the rooms.On 10/2/14 at 1025 hours, an interview was conducted with the DCS who stated the only conflicts he knew about between Clients 1 and 2 had to do with Client 1 snoring, but he was unaware of any interventions the facility was using. On 10/2/14 at 1030 hours, the PM was interviewed. The PM stated Client 1 and Client 2 were having some problems getting along. Client 1 was jealous of Client 2 because Client 2 was loud and got a lot of attention.On 10/2/14 at 1120 hours, the surveyors were sitting at the table with Client 1 when Client 2 came to the table to talk to the surveyors. Client 1, who had tremors on his upper extremities, was observed to experience an obvious increase in his tremors and began trying to move his wheelchair away from Client 2. The facial expression of Client 1 was observed to change from smiling to a scared expression. Client 1 only sat with the surveyors before lunch. Also, Client 1 was not noted to interact with any peers throughout the day.Further interview with the QIDP, on 10/2/14 at 1230 hours, confirmed there was no documentation in either client's clinical record to address the discord between the two clients.The QIDP and company's Vice President (VP) confirmed there was no documentation of any interventions for Clients 1 or 2.Review of the facility's policy and procedures (P&P) titled, "Prevention of Abuse, Neglect, and Mistreatment", dated 8/21/06, showed a section titled, "Allegation of Resident Abuse by Another Resident" which showed the following procedures: - redirect the aggressor - temporarily redirect the client away from other residents - implement the individual behavior plan - counsel the resident to determine the cause of the behavior - notify the QIDP/Administrator - complete an incident report - notify each resident's representative, attending physician and medical director - the QIDP/Administrator will evaluate the circumstances leading up to the incident - the QIDP/Administrator will develop or revise the behavior plan, including interventions to prevent a recurrence - the QIDP/Administrator will inform staff in the care of the resident of the details of the behavior plan and to notify the QIDP of any behavior changes- staff will document all interventions and their effectiveness - QIDP/Administrator will consult psychiatric services as needed, and - transfer the resident if deemed to be a danger to self or others The facility was unable to provide any evidence or documentation showing the P&P for abuse was followed even though interviewed staff stated they were aware Client 1 was sad and uncomfortable.The facility failed to ensure: 1. Client 1 was free from verbal abuse from Client 2. Client 1 experienced repeated verbal abuse causing social isolation and sadness.2. Identify or address specific behavior management needs for Client 2. The facility did not collect objective and current data needed for an IPP (Individual Program Plan).3. Ensure staff were trained on the behavior needs of Client 2 when the behaviors he was admitted with were not being monitored or addressed by a behavior program.The facility's failure to ensure Client 1 was protected from Client 2's verbal aggression resulted in Client 1 being subjected to verbal abuse on numerous occasions by Client 2 causing psychosocial harm manifested by social isolation and sadness.These violations had a direct relationship to the health, safety and security of the clients. |
| 060001278 |
HARBOR HEALTH CARE, INC. - BLACK STAR DIVISION |
060011170 |
A |
11-Dec-14 |
HJ9J11 |
8499 |
CLASS A CITATION - Clients not subjected to abuse Welfare and Institutions Code, Section 4502 (h). 4502 - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) - A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. Client 1 was a 16 year old nonverbal, nonambulatory, blind female with diagnoses including severe intellectual disability (person with an IQ score of 20-40).On 10/26/14 at 2134 hours (Sunday), the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program, received an Entity Reported Incident (ERI) via fax. The report indicated Client 1 was sexually assaulted by a staff member on "10/25/14 at 11:35 pm."On 10/27/14 at 1630 hours, the facility was visited to investigate the above ERI.On 10/27/14 at 1635 hours, an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). The QIDP stated the Licensed Vocational Nurse (LVN 1) came in to work on 10/24/14, on her regularly scheduled shift and observed the Direct Care Staff (DCS 1) having sex with Client 1. The QIDP stated the LVN instructed the DCS to get out of Client 1's room and she notified the QIDP and the police. The QIDP further stated the police came and took DCS 1 into custody. The police detectives collected evidence. Client 1 was escorted by the police to the hospital and a rape kit was completed. The QIDP stated DCS 1 had worked at the facility since February 2014. The QIDP stated Client 1's roommate (Client 2) was asleep at the time of the incident and slept all night. The QIDP also stated all clients in the facility were nonverbal and unable to be interviewed. The QIDP verified the date of the incident was 10/24/14. Review of the QIDP's note dated 10/25/14, showed the QIDP received a phone call from LVN 1 stating that when she arrived at the facility no one answered the front door after knocking loudly three times. The LVN opened the front door and found one client's bedroom door closed. The LVN opened the bedroom door and found DCS 1 having sex with Client 1.Review of LVN 1's written statement dated 10/25/14, showed she arrived at the facility on "10/25/14 at 2335 hours" to make her rounds. She knocked on the front door a few times, there was no answer, so she used the key to enter the house. As she entered the house, she noticed all bedroom doors were open except for the door for the bedroom shared by Clients 1 and 2, which was slightly cracked. She was able to see Client 2 through the crack and she was fine. Then, LVN 1 pushed the door to open it a little further and observed DCS 1 with his pants around his ankles, no underwear on, and he was thrusting against Client 1. The LVN told him to stop and come out of Client 1's room. The LVN immediately turned and walked to the front door and noticed DCS 1 poked his head out of Client 1's room. She told DCS 1 to leave the bedroom and to not enter any of the clients' rooms. The LVN notified the QIDP and the police. The LVN further stated DCS 1 began to vacuum and clean the counters as if nothing had happened. Review of the facility's Policy and Procedure (P&P) titled Prevention of Abuse, Neglect, and Mistreatment dated 8/21/06, showed in part, all new hire employees, who will work directly with or have access to the developmentally disabled, will be investigated for criminal convictions. The P&P also indicated the employment application will be examined and previous job references will be verified, including dates of employment and position held. In addition, new employees who do not have a current clearance on file with the Department of Health Services (DHS) will have a set of their fingerprints submitted to DHS and processed by the Department of Justice (DOJ) for criminal background investigation prior to entering the facility or working directly with individuals receiving services.On 10/27/14 at 1753 hours, review of DCS 1's employee file was conducted with the QIDP. DCS 1's date of hire was listed as 2/24/14.Review of the Transmittal Application for Criminal Background Investigation dated 2/15/14, showed a notation indicating, "10/14: Still under review" with a confirmation number. When the QIDP was asked what the notation meant, he stated he did not know.A telephone interview with LVN 1 was initiated on 10/31/14 at 1040 hours. She stated she went to the company's different facilities when she started her night shift at 2300 hours to make sure everything was okay at the facilities. She said when she arrived at this facility on 10/24/14, the door was locked. When she knocked no one answered the door so she used the key to get in the facility. She stated all of the clients' bedroom doors were open except Client 1's door. Client 1 shared a bedroom with Client 2. Client 1's shared bedroom door was cracked open. LVN 1 stated she observed Client 2 sleeping. She further observed Client 1 was lying on her side facing the wall. DCS 1 was observed standing next to the bed of Client 1 with his pants down, thrusting back and forth. LVN 1 stated she thought DCS 1 did not know she was at the door. She backed out of the room and made a noise so DCS 1 would hear her. She stood at the front door and yelled for DCS 1 to get out of the bedroom. LVN 1 called the QIDP and the police and stayed at the facility until they arrived. On 11/3/14 at 1415 hours, a follow-up interview was conducted with the company's Vice President (VP) regarding DCS 1's personnel file. The VP verified she documented, "10/14: Still under review" with the confirmation number on DCS 1's Transmittal Application for Criminal Background Investigation form. When the VP was asked for the date she requested the results of DCS 1's criminal background investigation, she stated she called for the results on 10/25/14, the day after the sexual assault. The VP verified she had not contacted the CDPH, Criminal Background Section to follow up on the result of the criminal background for DCS 1 until 10/25/14. The VP stated it was not unusual for it to take more than one year to receive the results of the criminal background clearance. The VP verified all staff started working with the clients prior to receiving results of the criminal background investigation and prior to receiving finger print clearance. A telephone interview with the CDPH, Criminal Background Section, Program Technician 1 was initiated on 11/4/14 at 0920 hours. She stated her job was to process criminal background check results and send results to facilities. Program Technician 1 stated for criminal clearance, the CDPH, Criminal Background Section needed a transmittal form and a Live Scan (fingerprints) to process and receive criminal background clearance results. The Program Technician stated the time it took to receive results varied, some results could be received within a couple of days and some could take months. She stated she had never seen results take longer than five months. The Program Technician further stated criminal clearance could be delayed if facilities neglected to send the appropriate paperwork. Program Technician 1 further stated the facilities should receive the results to the criminal background check in the mail. She also said the facilities could call for results. DCS 1 had worked at the facility for eight months at the time the sexual abuse occurred. There was no documentation in the employee's file showing the facility attempted to get the results of DCS 1's criminal background clearance prior to the incident on 10/24/14. There was no documentation showing the facility made an effort to contact the DOJ to ensure DCS 1's application for his criminal background investigation was being processed or to inquire about the cause of delay in processing. 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. |
| 070001365 |
HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF |
070009407 |
B |
20-Jul-12 |
HYC811 |
7481 |
F514 - 483.75(l)(1) RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized.The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes. The facility failed to ensure the medication administration records (MARs) for two of six sampled residents (1 and 2) were accurate. Resident 1's behavior monitoring was not accurate from 3/14/12 through 6/4/12 when licensed nurses stated entries made for their shifts were not their documentation. Resident 2's vitamin D medication administration was not accurate from 2/1/12 through 4/ 23/12. The facility's failure to ensure accurate MARs had the potential to cause inaccurate resident assessments.1. Resident 1 was admitted to the facility with diagnoses including Parkinson's disease. The 6/4/12 Minimum Data Set (MDS) indicated the resident was feeling "down" and had no hallucinations or delusions.During record review on 6/26/12, handwritten entries dated 3/14/12 on the March 2012 MAR indicated licensed staff were to monitor Resident 1 every shift for three behaviors: accusing staff during care, fabricating stories towards staff, and making inappropriate remarks or jokes to others, residents, staff and family. Each day and shift starting 3/14/12 had a handwritten "0" on the MAR indicating the resident did not exhibit the behaviors.The 3/14/12 MAR behavior monitoring entry was typed into the April 2012 MAR (page 5) and May 2012 MAR (page 5A). The behavior monitoring for April 2012 indicated "0" for all shifts. The behavior monitoring for May 2012 indicated "0" for all shifts except on day shift 5/29/12 when staff placed a "1" indicating one episode of accusations toward staff.An additional handwritten behavior monitor was added to the May 2012 MAR dated 5/28/12. The new behavior monitor note indicated staff was to monitor the resident for making negative statements towards staff. On 5/28/12 a "1" written by evening shift staff indicated Resident 1 made a negative statement towards staff.The June 2012 MAR indicated staff placed "0's" each shift on June 1, 2, and 3. On June 4, the MAR indicated "1"s, the resident had episodes of accusing staff and making negative statements towards staff on day and evening shift. On 6/4/12 the MAR indicated the resident fabricated a story against staff on evening shift.During an interview and record review on 7/10/12 at 10:53 a.m., LN A reviewed Resident 1's clinical record and stated she provided care to Resident 1 on certain days in April 2012 and May 2012. LN A stated she never monitored Resident 1 for the behaviors in April and May 2012 when she worked because the behavior monitoring was not on the MARs. LN A stated the "0'" indicating Resident 1 had no behaviors on the days she worked were inaccurate and were not hers.During an interview and record review on 7/10/12 at 11:40 a.m., licensed nurse B (LN B) stated she provided care to Resident 1 on certain days in March 2012, April 2012, May 2012, and June 2012. LN B stated the "0's" and "1's" documented on the MARs on the days she worked were inaccurate, were not recorded by her, and none of them were in her handwriting. LN B stated she did not monitor Resident 1's behaviors because there were no behavior monitors on the MARs in March, April, and May. During an interview and record review on 7/10/12 at 2:09 p.m., licensed nurse C (LN C) stated she provided care to Resident 1 on certain days in March, April, and May 2012. LN C stated the "0's" marked for the behavior monitors on the days she worked were inaccurate and were not hers. LN C stated her "signature" on the bottom of the May 2012 MAR page 5A was not written by her. During an interview on 6/27/12 at 11:00 a.m., the ward clerk (WC) stated she was the one who typed Resident 1's behavior into the computer so they would print out on the MAR and nurses could monitor the behaviors. The WC stated she did not remember exactly when she put the information into the computer.During an interview on 7/10/12 at 9:30 a.m., licensed nurse D (LN D) stated there was no way to tell the exact date and time when Resident 1's behavior monitors were entered by the ward clerk into the computer. LN D stated the 3/14/12 handwritten behaviors on the 3/2012 MAR were written by the director of nurses (DON). During an interview and record review on 7/10/12 at 1:21 p.m., the DON reviewed Resident 1's 3/14/12 handwritten behavior monitoring on the March 2012 MAR and stated she handwrote the behaviors for staff to monitor. The DON stated the "0's" were done by the licensed nurses working at the facility. The DON reviewed the 3/2012 and 5/2012 and stated the "0's" were done by staff and she did not know who else would write the "0's." 2. Resident 2 was admitted to the facility with diagnoses including anxiety. The 6/11/12 MDS indicated the resident had severe cognitive impairment.During record review on 6/26/12, the 12/30/12 physician's order indicated Resident 2 was to be given 800 units of vitamin D once a day. The 12/30/12 physician's order was handwritten on the 2/2012, 3/2012, and 4/2012 MARs, and the administration time was 9:00 a.m. The reviewed MARs indicated staff had initialed each of the days indicating the resident was given vitamin D at 9:00 a.m.During a confidential telephone interview on 6/22/12 at 1:00 p.m., LN A stated initials on Resident 2's 2/2012 MAR regarding vitamin D administered by her was inaccurate, and the initials were not hers. LN A stated she never gave the resident the vitamin because the vitamin D order was not on the 2/2012 MAR when she worked in February 2012.During an interview and record review on 7/10/12 at 8:06 a.m., licensed nurse D (LN D) stated she handwrote Resident 2's vitamin D order on the February, March, and April 2012 MARs but did not remember exactly when she wrote the orders. LN D stated she could not recall when she caught the transcription mistake that caused the vitamin D physician orders to be omitted from the MARs. LN D was unable to explain why it took three months before the vitamin D order was correctly entered into the computer.During an interview and record review on 7/10/12 at 10:53 a.m., LN A reviewed Resident 2's clinical record and stated she provided care to the resident on certain shifts in February 2012. LN A stated she never gave Resident 2 the vitamin D, and the 9 a.m. entries on the MAR were not accurate. LN A stated those initials were not hers. LN A stated the handwritten vitamin D entry was not in the MAR when she worked in February 2012. During an interview and record review on 7/10/12 at 11:40 a.m., licensed nurse B (LN B) stated she took care of Resident 2 on certain days in February 2012, March 2012 and April 2012. LN B stated she did not give vitamin D to the resident during the days she provided the care because the vitamin D entry was not on the MARs. She stated the entries were not accurate.Therefore, the facility failed to ensure the accuracy of medication administration records resulting in the potential for inaccurate resident assessments. The deficient practice had a direct relationship to the health, safety or security of residents. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070011563 |
B |
30-Jun-15 |
ALHJ11 |
6389 |
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 when the alleged abuse of one of three residents (1) by a staff member was not immediately (within twenty-four hours) reported to the California Department of Public Health (CDPH) and the ombudsman. The facility did not start to investigate the abuse allegation or report it to the CDPH and the ombudsman for six days and allowed the alleged abuser access to Resident 1 prior to the completion of the abuse investigation. Failure to report the abuse prevented an analysis of the occurrence to determine any necessary changes designed to prevent abuse in the future. Failure to investigate the abuse in a timely manner potentially allowed the abuse to continue, allowed the alleged abuser to have access to the resident and failed to protect the resident and others from harm.Resident 1's clinical record was reviewed and indicated he had diagnoses including Alzheimer's disease and dementia. His minimum data set (MDS, an assessment tool) indicated he had severe cognitive impairment, contractures (abnormal shortening of muscles, tendons and/or ligaments rendering the muscles highly resistive to passive stretching) and was nonverbal.During an interview on 6/5/15 at 1:30 p.m. with certified nurse assistant A (CNA A), she stated she provided care for Resident 1 on the day shift. When CNA B came on duty for the evening shift, CNA B was upset because Resident 1 had soiled his brief and was not changed. CNA A went into Resident 1's room and observed CNA B change the resident. She stated Resident 1 was in bed and CNA B aggressively pushed open his legs to clean and change him. She stated she told CNA B not to treat her resident "like that".CNA A stated she thought CNA B's treatment of Resident 1 was abusive and on 5/16/15 she gave the administrator (ADM) a written statement about the incident. She also stated she told licensed vocational nurse C (LVN C) about the incident on 5/19/15. In addition, she stated, on 5/20/15, copies of her statement were given to the director of staff development (DSD) and the resident care coordinator (RCC). CNA A never reported the incident to the CDPH and the ombudsman.During an interview on 6/5/15 at 2:10 p.m. with the RCC, she stated she first heard of the alleged abuse incident during the stand-up meeting (daily short organizational meeting) on 5/20/15. The participants decided LVN D should report the incident to the CDPH and the ombudsman the next day.During an interview on 6/12/15 at 12:30 p.m. with LVN D, she stated she first heard CNA B was unhappy about receiving Resident 1 with a soiled brief at change of shift on 5/15/15. She stated Resident 1's legs were contracted and some force must be applied to open his legs to clean him. She stated she was unaware CNA A thought the care rendered by CNA B was abusive until 5/21/15. She stated she reported the suspected abuse to the CDPH and the ombudsman on 5/21/15. Resident 2's clinical record was reviewed and indicated he was cognitively intact. During an interview on 6/12/15 at 1:30 p.m., he stated he was Resident 1's roommate and he was present when CNA B changed Resident 1's soiled brief. Although he could not see CNA B change Resident 1 because the curtain was closed, he stated he could hear the conversation between CNA A and CNA B. He stated he heard CNA A tell CNA B not to treat her resident "like that". He stated he did not think CNA B hurt Resident 1 when she changed him because he did not cry out at the time. He also stated he thought CNA A accused CNA B of abuse because she thought she was in trouble for failing to change Resident 1 prior to the change of shift.During a telephone interview on 6/16/15 at 11 a.m. with the DSD, she stated she was uncertain of the date CNA A spoke to her about the incident but she thought the conversation occurred on 5/16/15. She stated CNA A thought the care rendered by CNA B was abusive so she told CNA A to write a statement and report the incident to the ADM. Several days later, she saw the statement at one of the nursing stations and she gave the statement to the RCC and they discussed giving the statement to the ADM. She did not know what happened after the RCC received the statement. She never reported the incident to the CDPH and the ombudsman. During a telephone interview on 6/16/15 at 3:30 p.m. with CNA B, she stated when she came to work on 5/15/15 Resident 1 was sliding down in his bed so she asked CNA A to help her pull him up. CNA A then left the room and CNA B changed the resident. CNA B stated CNA A did not say anything to her about the way the resident was treated. CNA B stated Resident 1 had contractures in his legs and his legs needed to be pushed open. She stated she did not treat Resident 1 roughly. A review of the facility's investigation indicated the incident occurred on 5/15/15 and was reported to the CDPH and the ombudsman on 5/21/15. An investigation was initiated on 5/21/15 and CNA B was suspended while the investigation was completed. Review of the facility's undated policy, "Prevention of Abuse", indicated all employees were mandated reporters and were responsible for informing the immediate supervisor and initiating a report of the incident. The ADM or his designee must be notified as soon as possible but no later than twenty-four hours after the incident was reported and all incidents of alleged or suspected abuse must be reported to the CDPH within twenty-four hours. Therefore, the facility failed to implement their abuse policy when the alleged abuse of one of three residents (1) by a staff member was not immediately (within twenty-four hours) reported to the CDPH and the ombudsman. The alleged abuse occurred on 5/15/15 and was not reported to the CDPH or the ombudsman until 5/21/15. The facility allowed the alleged abuser to continue to work with the resident before they had investigated the validity of the allegations, subjecting the resident, as well as other residents to harm. The investigation was not started until six days after the incident occurred.The above violations had a direct relationship to the health, safety, or security of the residents. |
| 070000057 |
Herman Health Care Center |
070011679 |
B |
04-Sep-15 |
N88T11 |
5214 |
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report and investigate an allegation of abuse to the proper authorities for one resident (1) when her family members (FMs) complained to a few facility staff regarding Resident 1's bruise of unknown origin noted on 7/3/15.Resident 1's clinical record was reviewed and indicated she was admitted to the facility in 6/2015 with diagnoses including dementia with behavior disturbance and anxiety.A nurses note dated 7/3/15, indicated licensed vocational nurse C (LVN C) noted the resident had multiple, irregular skin discolorations on her right upper and lower arm and her left breast. The resident was unable to explain what had happened and the RP observed the discolorations. The Summary Bruising Report on Resident 1 indicated the director of nurses (DON) investigated the bruises on 7/7/15 which was four days after the initial new skin bruise was noted on Resident 1's right arm and left breast.During an observation of two certified nurse assistants' (CNAs) care of Resident 1 on 7/17/15 at 3:30 p.m. and accompanied by UM A, multiple scattered dark brown bruises were noted on Resident 1's arms and her back. UM A attempted to assess a bruise on Resident 1's breast, but the resident refused. During a telephone interview with CNA F on 8/12/15 at 11:25 a.m., she stated Resident 1's family member P (FM P) told her someone beat up Resident 1 and caused the bruises on the resident's body. CNA F stated she reported FM P's complaint to the charge nurse, but she could not remember the charge nurse's name. She stated she did not follow-up with the charge nurse to determine if the alleged abuse was reported. CNA F stated she thought the charge nurse, the UM, the DON or the administrator (ADM) had already reported the abuse allegations. During an interview with the DON on 8/14/15 at 8:15 a.m., he stated the facility should conduct an investigation of alleged abuse and injuries of unknown origin.During a telephone interview with the ADM on 8/17/15 at 11:50 a.m., he stated the facility should do an investigation of any bruises of unknown origin. He stated the DON performed the investigation and then he reviewed it. The ADM or the DON reported the bruises of unknown origin investigation results to the state agency and the ombudsman as soon as possible, ideally within twenty-four hours. The ADM stated there was no need to report a bruise of unknown origin to the police department.The Department did not receive any Report of Suspected Elderly Abuse form (SOC 341) from the facility. Review of the facility's 4/2011 policy, "Investigation Unexplained Injuries", indicated an investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) should be conducted by the DON and should follow the facility's abuse investigation guidelines.Review of the facility's 12/2007 policy, "Unusual Occurrence Reporting", indicated the facility should report allegations of abuse via telephone to the appropriate agencies within twenty-four hours of the incident followed by a written report detailing the incident and the actions taken by the facility after the event within forty-eight hours as required by federal and state regulations. Review of the facility's 7/2014 policy, "Abuse Investigations", indicated all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by the facility management.Failure to report and investigate the alleged abuse prevented an analysis of the occurrence to determine any changes necessary to prevent future abuse and potentially allowed the abuse to continue. These violations had a direct or immediate relationship to the health, safety or security of the residents. |
| 070000057 |
Herman Health Care Center |
070011680 |
B |
04-Sep-15 |
N88T11 |
5333 |
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report and investigate Resident 1's bruise of unknown origin noted on 7/15/15. Resident 1's clinical record was reviewed and indicated she was admitted to the facility in 6/2015 with diagnoses including dementia with behavior disturbance and anxiety. A nurses note dated 7/15/15 indicated licensed vocational nurse C (LVN C) noted Resident 1 had multiple skin discolorations on the right side of her back and Resident 1 could not verbalize what happened.During an observation of two certified nurse assistants' (CNAs) care of Resident 1 on 7/17/15 at 3:30 p.m. and accompanied by unit manager A (UM A), multiple scattered dark brown bruises were noted on Resident 1's arms and her back. UM A assessed the bruises on Resident 1's back including a greenish-dark purple circle-shaped bruise measuring 6.5 x 5.5 centimeters (cm, a unit of measurement) on her right upper back, two greenish circle-shaped bruises measuring 4 x 3.8 cm and 3 x 3 cm on her upper middle back, two red-purple rectangle-shaped bruises measuring 3.5 x 2 cm and 3 x 2 cm on her middle back and two red-purple rectangle-shaped bruises measuring 13 x 3.5 cm and 6 x 3 cm on her lower back.During an interview with UM B on 7/1715 at 3:10 p.m., she stated she was aware of Resident 1's back bruise, but did not file an incident report, perform an investigation or report the incident to the state agency and the ombudsman. During an interview with the director of nursing (DON) on 8/14/15 at 8:15 a.m., he stated the facility should conduct an investigation of alleged abuse and injuries of unknown origin. If his investigation ruled out abuse, he stated there was no need to report the incident to the state agency, the ombudsman or the police.During a telephone interview with the administrator (ADM) on 8/17/15 at 11:50 a.m., he stated the facility should do an investigation of any bruises of unknown origin. He stated the DON performed the investigation and then he reviewed it. The ADM or the DON reported the bruises of unknown origin investigation results to the state agency and the ombudsman as soon as possible, ideally within twenty-four hours. The ADM stated there was no need to report a bruise of unknown origin to the police department.Review of the facility's 4/2011 policy, "Investigation Unexplained Injuries", indicated an investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) should be conducted by the DON and should follow the facility's abuse investigation guidelines.Review of the facility's 12/2007 policy, "Unusual Occurrence Reporting", indicated the facility should report allegations of abuse via telephone to the appropriate agencies within twenty-four hours of the incident followed by a written report detailing the incident and the actions taken by the facility after the event within forty-eight hours as required by federal and state regulations. Review of the facility's 7/2014 policy, "Abuse Investigations", indicated all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by the facility management. Suspected incidents of resident abuse, injury of unknown source should be reported and the ADM should provide a written report of the results of all abuse investigations and the appropriate actions 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. Failure to report and investigate the alleged abuse prevented an analysis of the occurrence to determine any changes necessary to prevent future abuse and potentially allowed the abuse to continue. These violations had a direct or immediate relationship to the health, safety or security of the residents. |
| 070000057 |
Herman Health Care Center |
070011698 |
B |
04-Sep-15 |
BCNQ11 |
8650 |
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to follow their abuse and unusual occurrence policies to thoroughly investigate and report a suspected verbal abuse incident between two residents (1 and 2) within twenty-four hours when a suspected verbal/mental abuse incident was unidentified by the facility's abuse coordinator and designee, undocumented in an investigative report and unreported to the California Department of Public Health (CDPH, the state survey and certification agency) and the ombudsman (government appointed advocate for residents of nursing homes, board and care homes and assisted living facilities). These failures left the CDPH, the ombudsman and Resident 2's physician and conservator (a court appointed individual to act on the behalf of an incapacitated person) unaware of the event for appropriate follow-up and had the potential to compromise the resident's care.Review of Resident 1's face sheet indicated he was diagnosed with dementia (a condition marked by deteriorated cognitive functioning) and was conserved. According to the Minimum Data Set (MDS, an assessment tool), dated 5/25/15, Resident 1 had clear speech and was able to make himself understood to others when he expressed ideas and wants verbally and non-verbally. Review of Resident 2's face sheet indicated he spoke English. According to the MDS, dated 6/4/15, Resident 2's ability to see and hear was adequate and he was usually able to understand others' verbal content. His social work progress note, dated 7/14/15, indicated he was sitting quietly in the small dining room when another resident yelled at him and threatened to stab him in the back and beat him down. The resident appeared mildly shaken up. There was no nursing documentation indicating any follow-up. During an interview on 8/3/15 at 2:45 p.m. with nurse care manager C (NCM C), after she reviewed the clinical records of Residents 1 and 2, she stated the 7/14/15 incident was a resident-to-resident abuse case and a "Report of Suspected Dependent Adult/Elder Abuse" (SOC 341, a form completed by persons working with vulnerable populations when an incident of abuse was known or suspected) should have been filled out and given to the director of nurses (DON) or the alternate designee to submit to the ombudsman, the local police, and the CDPH. During an interview on 8/4/15 at 7:25 a.m., licensed vocational nurse A (LVN A) stated he was the nurse for Residents 1 and 2 on 7/14/15 and witnessed the incident. He stated, on 7/14/15 during lunch time in the small dining room, Resident 1 wanted Resident 2 to move somewhere else. Resident 1 left the room briefly, returned and told Resident 2 he was going to stab him in the back and side with a knife, put him down on the floor and beat him. LVN A stated he then called the unit manager and the DON, who arrived shortly thereafter. During an interview on 8/4/15 at 10:15 a.m. with LVN A, he stated the incident was a resident-to-resident abuse case and he did not report it to the ombudsman, the police or Resident 2's physician and conservator because he thought the DON and/or the nurse supervisor (NS) were reporting it. During an interview on 8/4/15 at 10:55 a.m. with the administrator (ADM), he stated the staff knew the comments Resident 1 made were directed at Resident 2, but Resident 2 may not have known. He said if Resident 2 knew the comments were directed at him, the incident would have been reported to the ombudsman and the local law enforcement. During an interview on 8/4/15 at 11:08 a.m. with the DON, he stated when he arrived at the scene of the incident on 7/14/15, Resident 2's back was facing Resident 1. He stated Resident 2 appeared oblivious to what Resident 1 was saying. He stated the incident was not reported to the ombudsman or the CDPH and no investigative report was done. During an interview on 8/4/15 at 11:20 a.m. with certified nurse assistant B (CNA B), she stated on 7/14/15 during lunchtime in the small dining room, Resident 1 walked in, looked at and pointed his finger at Resident 2, and stated, "Get that f*cker out of the way, I don't want him in here." She stated at that time, Resident 2 was seated at a table with his right side turned towards Resident 1. Resident 1 then walked out of the room. She stated she then left the room. During an interview on 8/5/15 at 11 a.m. with the DON, he stated the ADM was the abuse coordinator and he was the alternate designee. He stated he was on the way to the small dining room after he was paged and heard Resident 1 yelling, "I want this f*cking guy out of here." He stated Resident 1 became mute when he saw him. He stated there was never any suspected or possible abuse because Resident 1 did not indicate to whom he was directing his comments. He stated he discussed the incident with the ADM.Review of the facility's 7/2014 policy, "Reporting Abuse to Facility Management", indicated verbal abuse was defined as any use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Mental abuse was defined as, but was not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. An immediate investigation should be made and a copy of the findings of the investigation should be provided to the ADM within five working days of the occurrence of the incident. Review of the facility's undated policy, "Licensed Nurse and/or Nursing Supervisor Initial Step-by-step Procedure for Abuse Allegations", indicated the resident's physician and responsible party should be notified, the witness reports should be obtained in writing and the person reporting the incident, any witnesses to the incident, the resident's roommate, family members, visitors and other residents who may have witnessed the event should be interviewed. A telephone report must be made to the ombudsman and the CDPH as soon as practicably possible but within twenty-four (24) hours and the completed SOC must be faxed to the ombudsman and the CDPH within twenty-four (24) hours of the event. The "Resident Abuse Investigation Report Form" must be completed and the final report must be done within five days. All employees are mandated reporters and any staff member or person affiliated with the facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect or any other criminal offense shall immediately report, or cause a report to be made of the mistreatment or offense. Review of the facility's 12/2007 policy, "Unusual Occurrence Reporting", indicated the facility will report allegations of abuse, neglect and misappropriation of resident property to the appropriate authorities. Unusual occurrences shall be reported via telephone to the appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of the incident or otherwise required by federal and state regulations. These violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000057 |
Herman Health Care Center |
070011730 |
B |
18-Sep-15 |
9YP511 |
3725 |
F225 - 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/Report Allegations/Individuals The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) and initiate an investigation in a timely manner, when Resident 1's allegation was not reported and investigated within 24 hours as required by law.Review of Resident 1's clinical records on 8/19/15, the Minimum Data Set (MDS, an assessment tool) dated 7/22/15 indicated Resident 1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of the activity director's (AD) written report on 8/21/15 indicated on 8/7/15 Resident 1 had reported that two black certified nurse assistants (CNAs) were in his room the night before, woke him up and were moving a white plastic thing near his face. Resident 1 stated he asked them to stop after a CNA's finger had touched his left cheek near his eye. The same written report indicated, the allegation was immediately reported to the director of nursing (DON) and Resident 1 was informed the DON would follow-up. During an interview on 8/21/15 at 10:05 a.m., the DON stated he was aware of Resident 1's allegation on 8/7/15 but did not begin an investigation and did not report the allegation to CDPH until 8/11/15, which was four days after the incident was reported to him.During an interview on 9/11/15 at 9:00 a.m., AD stated on 8/7/15 at 11:00 a.m., Resident 1 came to her and reported, two CNAs came to his room, holding a "white thing" and waving it to his face. Resident 1 also stated when he told them to stop, one CNA touched his cheek with her finger. AD stated this incident was reported immediately to the DON whom he stated would follow-up.Review of the facility's undated policy on Incident Report/Investigation indicated the facility will report patient safety events as they occur per state and federal regulations. Any type of abuse with no serious bodily injury will be reported within 24 hours. Failure to report and investigate the alleged abuse prevented an analysis of the occurrence to determine any changes necessary to prevent future abuse and potentially allowed the abuse to continue. These violations had direct or immediate relationship to the health, safety or security of the residents. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070011783 |
B |
22-Oct-15 |
XL2I11 |
2384 |
F223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to provide an environment free from physical abuse when a licensed vocational nurse (LVN) hit Resident 39 on the buttocks. Resident 39's clinical record was reviewed and indicated his diagnoses included lack of normal physical development and cognitive deficits (learning disability and lack of intellectual functioning). His Minimum Data Set (MDS, an assessment tool), dated 8/18/15, indicated Resident 39 had severe cognitive impairment.The nurses notes, dated 10/6/15, indicated Resident 39 poured LVN P's coffee in the sink. LVN P then hit him with a medicine cup package and "hit his bottom."During an observation and interview with Resident 39 on 10/7/15 at 3:25 p.m., he was alert but nonverbal. He responded to questions by making sounds and smiling.During an interview with LVN P on 10/8/15 at 9 a.m., she stated when she saw Resident 39 drink her coffee and pour it down the sink, she "smacked the butt" of the resident. She stated she should have controlled herself better.During an interview with restorative nurse assistant Q (RNA Q) on 10/8/15 at 9:10 a.m., he stated he saw LVN P smack Resident 39's bottom and then move him away from the nursing station.During an interview with the administrator (ADM) on 10/8/15 at 9:30 a.m., he stated LVN P should not have hit any resident and LVN P was immediately suspended. Review of the facility's undated policy, "Preventing Resident Abuse", indicated the facility had a zero tolerance for abuse and its goal was to achieve and maintain an abuse free environment. It would not condone any forms of resident abuse and would continually monitor policies, procedures, training programs, and systems to assist in preventing resident abuse. The abuse intervention program included monitoring the staff on all shifts to identify inappropriate behavior toward the residents.The facility failed to provide an environment free from physical abuse as required.The above violation of the regulation presented a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000057 |
Herman Health Care Center |
070012376 |
A |
21-Jul-16 |
ZKGM11 |
6945 |
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 and prevent an accident and injuries for Resident 1 with a history of multiple falls. This failure resulted in Resident 1's hip fracture (broken hip), increased pain, hospitalization, and surgery. Resident 1's clinical record was reviewed and indicated he had diagnoses including glaucoma (eye disease causing poor vision), Alzheimer's disease, and dementia (a brain disease that affects a resident's ability to think and remember, influencing his daily functioning). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/4/16 indicated Resident 1's cognition and vision were moderately impaired. It further indicated Resident 1 had impaired balance and required the assistance of one person for walking, standing, and transferring from one surface to another, with or without an assistive device (walker or wheelchair). A review of Resident 1's fall risk assessment dated 4/18/16, indicated Resident 1 had a fall risk score of 17 (score of 10 or above indicated high risk for falls). A review of the nurses notes (NN) dated 4/16/16, at 3:30 p.m. indicated Resident 1 had a fall outside the building in the courtyard. A care plan dated 4/18/16 indicated the resident had an unwitnessed fall on 4/16/16. The interdisciplinary team (IDT, team members from different departments involved in a resident's care) Note dated 4/16/16, indicated staff would do "stand-by assist" when Resident 1 was walking and staff would monitor Resident 1's whereabouts. A review of NN dated 4/23/16, at 4 p.m., indicated Resident 1 had a fall in the courtyard with skin abrasions on his forehead and nose bridge. The IDT note dated 4/25/16, indicated staff would continue to monitor Resident 1's whereabouts because of his poor safety awareness. The care plan (CP), also dated 4/25/16, indicated staff should assist Resident 1 while he is walking. A review of NN dated 5/9/16, at 9:55 p.m., indicated Resident 1 had a fall in the dining room. The IDT note dated 5/10/16, indicated staff should remind Resident 1's family to notify them at the end of a visit. A review of NN dated 5/19/16 at 7:15 p.m., indicated Resident 1 had another fall outside of the building. A review of Resident 1's care plan dated 5/19/16 regarding the fall indicated it was an unwitnessed fall. During a telephone interview with the Activity Assistant (AA) on 6/14/16, at 2:35 p.m., she stated she heard a scream and found Resident 1 by himself, laying on the ground outside of the building, on 5/19/16 around 7 p.m. The AA stated staff sent Resident 1 to the hospital that evening. A review of Resident 1's Emergency Department (ED) progress notes from an acute care hospital, dated 5/19/16, indicated the resident was found laying down outside by the courtyard. It indicated the fall was unwitnessed. A review of Resident 1's hospital discharge instructions dated 5/19/16, indicated Resident 1's hip X-ray was negative for fracture and Resident 1 was transported back to the facility with a diagnosis of left hip contusion (injured tissue or skin, a bruise). A review of Resident 1's physician orders (PO) dated 5/20/16, at 12:15 a.m. indicated Resident 1 had multiple skin abrasions to his left forearm, right upper arm, left upper arm, left shoulder, and left elbow. The PO dated 5/20/16, at 8:53 a.m. indicated medication orders to start Tramadol (a pain medication to treat moderate to severe pain) and Norco (a Narcotic pain medication for severe pain). During an interview with registered nurse A (RN A) on 6/2/16, at 3:50 p.m., he stated staff should watch Resident 1 within 20 feet viewing distance. During an interview with registered nurse B (RN B) on 6/20/16 at 11 a.m., she stated Resident 1 began taking Norco on 5/20/16. RN B stated Resident 1 refused to get out of bed, was able to sleep, but when he was turned for toileting he would cry out in pain. RN B stated Resident 1 did not improve, was sent to the hospital emergency department on 5/24/16, and had surgery to repair the hip fracture that evening. During an interview with the primary care physician (PCP) on 6/21/16 at 3:30 p.m., she stated on 5/24/16, Resident 1's family member left her a telephone message about Resident 1's continued pain. The PCP stated she then asked an orthopedic physician to review Resident 1's 5/19/16 hip X-ray, and confirmed Resident 1 had a fracture in the left hip. The PCP then ordered Resident 1's return to the hospital for treatment on 5/24/16. A review of ED Provider Notes from an acute care hospital, dated 5/24/16, indicated Resident 1 was ambulatory prior to the fall and he was no longer ambulatory after the fall incident. The hospital discharge summary, dated 5/27/16 indicated Resident 1 underwent an interval left femur fracture fixation (surgery to repair the fractured hip) on 5/24/16. During an interview with CNA B on 6/2/16, at 4:05 p.m., he stated he was responsible for Resident 1 on 5/19/16 but he was supervising residents on a smoke break at the time Resident 1 fell. CNA B stated he knew Resident 1 needed supervision. During an interview with the director of nursing (DON) on 6/2/16 at 4:45 p.m., she stated the staff were responsible for Resident 1 and should be held accountable for his whereabouts, especially because Resident 1 was ambulatory and had a high risk for falls. During an interview with the family member (FM) on 6/14/16, at 4:05 p.m., she stated Resident 1 was never supposed to walk alone. During an interview with the minimum data set coordinator (MDSC) on 6/15/16 at 9:10 a.m., she stated Resident 1 had to be supervised at all times. The MDSC stated Resident 1 had fluctuating cognition and was not safe by himself. The facility's 2001 policy, "Falls and Fall Risk, Managing" indicated if a resident had multiple falls, staff would re-evaluate the situation and whether it is appropriate to continue or change current interventions. The facility's 2001 policy "Safety and Supervision of Resident" indicated the implementation of interventions to reduce accident risks and hazards should include communication of interventions to staff and assignment of responsibility to designated staff to carry out interventions. The policy indicated resident supervision should be a core component of the systems approach to safety: the type and frequency of resident supervision should be determined by the individual resident's assessed needs. Therefore, the facility failed to provide Resident 1 adequate supervision to prevent the fall incident. 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. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070012625 |
B |
10-Oct-16 |
MK0Y11 |
2228 |
F226--483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policy and procedure for Resident 31 when alleged abuse regarding missing or lost money was not reported to the law enforcement agency. This failure had the potential for continued abuse and harm to residents by a suspected abuser. Review of Resident 31's minimum data set (MDS, an assessment tool) dated 7/4/2016, indicated the resident was cognitively intact and had no problem in decision making. Review of Resident 31's nurses notes dated 8/21/16, indicated he lost his wallet and cash was missing. Review of the "Missing and loss log" dated 8/21/16, indicated Resident 31 lost his wallet, identification card and a cash amount of $520.00. During an interview with Resident 31 on 9/23/16 at 9:50 a.m., he stated he lost his money but he could not remember any other details. During an interview on 9/23/16 at 9:30 a.m., the social service director (SSD) confirmed Resident 31 lost his wallet, identification card and cash money of $520.00, and none of the items were found. During a telephone interview with the law enforcement officer (LEO) who investigated the case in the facility on 9/23/16 at 3:00 p.m., he stated there was an incident on 8/21/16 but not regarding Resident 31's missing money. During an interview with the administrator (ADM) on 9/23/16 at 4 p.m., he stated Resident 31's missing money should have been reported to the law enforcement agency. Review of the facility's undated policy, "Missing and Lost," indicated all items with a value of $100 or more believed to be stolen will be reported to the Sheriff and the ombudsman. Review of the facility's 12/2006 policy, "Reporting Abuse to Facility Management," indicated misappropriation of resident property is defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The above violation has a direct or immediate relationship to the health, safety, or security of residents. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070012626 |
B |
10-Oct-16 |
MK0Y11 |
3869 |
F281--482.20(k)(3)(i) SERVICES PROVIDED MEET PROFESSIONAL STANDARDS The services provided by the facility must meet professional standards of quality. The facility failed to follow their policy on medication administration when 15 residents (15, 19, 21, 41, 43, 44, 52, 53, 54, 56, 57, 58, 59, 60, and 61) did not receive their medications in a timely manner. Medications or treatments were not given or done as documented for two (11 and 12). These failures could potentially affect the quality of care provided to residents and the desired outcomes would not be achieved. During an observation on 9/23/16 at 10:20 a.m. in Station 3, licensed vocational nurse P (LVN P) stated he was almost done with the morning medication pass. During a review of the medication administration record (MAR), there were some missed 9 a.m. medications (unsigned) for Residents 52, 53, and 54. During an observation on 9/23/16 at 10:20 a.m. in Station 3, LVN P stated he was almost done with his morning medication pass. During a review of the medication administration record, there were some missed 9 a.m. medications (unsigned) for Residents 52, 53, and 54. A review of the facility's undated policy on "Medication Administration indicated," indicated the individual who administers the medication dose shall record the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the mediations shall review the MAR to ensure necessary doses were administered and documented. During an interview on 9/23/16, at 10:20 a.m., LVN P stated he could not finish his medication pass until 10:00 a.m. that morning. LVN P stated he was so busy that morning and he would run behind in his work. During a group meeting interview on 9/21/16 at 10:00 a.m., five residents (8, 13, 30, 42, and 70) complained their medications were not given on time and some medications were missed. Review on 9/21/16 of the monthly residents' council minutes from April to September 2016 indicated for the months of May, June, and August, there were issues with the nursing services regarding the passing of medications as being "very slow" and slow in answering call lights. During medication pass observation in Nursing Station 2A and interview with registered nurse E (RN E) on 9/23/16 at 10:15 a.m., RN E prepared the morning medications for Resident 44. RN E stated she was almost done but had not signed the medication administration record (MAR). She would let the surveyor know when she finished. During medication pass observation in Nursing Station 2B and interview with RN C on 9/23/16 at 10:40 a.m., RN C was not done passing her morning medications to Residents 19, 41, 42, 43, 44, 58, and 59. RN C acknowledged she was behind. She stated some residents refused their medications. During an observation on 9/23/16, at 10:20 a.m., in one nurse station hallway, RN A was passing the medications to the residents. During an interview with RN A on 9/23/16, at 10:22 a.m., he stated he "still" needed to pass the medications to eight residents. He stated he did not remember these eight residents' names. During another observation on 9/23/16, at 11 a.m., RN A was passing the medications to the residents. RN A stated he needed to give three more residents (21, 56 and 57) medications. He stated the residents' regular medication pass time was 8 a.m. to 10 a.m. RN A further stated he was late in giving the residents their medications. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should follow the physician orders for a medication regimen necessary to implement a treatment per the physician's order. These violations had a direct relationship to the health, safety and security of the residents. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070012627 |
B |
10-Oct-16 |
MK0Y11 |
2304 |
F458--483.70(d)(1)(ii) BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT Bedrooms must be at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. The following multi-resident rooms provided less than 80 square feet per resident, which had the potential to compromise the residents' care. Rooms 100, 102, 104, 106, 110, and 112 were measured by the maintenance supervisor (MS) on 9/21/16, at 9 a.m. For three residents residing in one room, each room measured 11 feet by 19.5 feet or 71.5 (sq. ft.) per resident. During the survey, Rooms 100, 102, 104, and 106 had three residents in each room. Room 110 was equipped for three residents but was empty at the time of the survey. Room 112 had three beds in the room but only two residents. During an interview on 9/21/16, at 11 a.m., with certified nurse assistant N (CNA N), he stated Rooms 100, 102, 104, 106, 110, and 112 were too small to provide adequate care for three residents because there was not enough room for the mechanical lifts and other necessary equipment. During an interview on 9/21/16, at 3:15 p.m., with the administrator (ADM), he stated the facility had room waivers for Rooms 101, 103, 105, 107, 109, 114, 116, and 119. He could not find any documentation indicating the facility had room waivers for Rooms 100, 102, 104, 106, 110, and 112. During an interview on 9/22/16, at 10:25 a.m., with certified nursing assistant O (CNA O), she stated Rooms 100, 102, 104, 106, 110, and 112 were too small to provide adequate care for three residents. She also stated she had worked at the facility for several years and the rooms never had three residents in a room until the new owners took over a few years ago. During an interview on 9/22/16, at 2 p.m., with Resident 31, a resident in one of the rooms with three residents, he stated the room was so crowded he was a foot away from his neighbor. He stated six people were using one bathroom, and he had to wait twenty minutes to use the bathroom so he used a urinal and his neighbor could hear him. He stated he complained to the director of nurses (DON) and the administrator (ADM) but he was told there were no other rooms available. These violations had direct relationship to the health, safety, or security of residents. |
| 070000057 |
Herman Health Care Center |
070012775 |
B |
28-Nov-16 |
LEIH11 |
3185 |
F223--483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to prevent abuse by a staff member against Resident 1. This failure had the potential to cause mental anguish as well as a decrease in self-esteem for Resident 1. Review of Resident 1's clinical record indicated diagnosis of paranoid schizophrenia (a disease of disordered thoughts causing someone to be unreasonably suspicious of other people) and dementia with behavior disturbances (a disease with impaired cognition and memory coupled with unpredictable behaviors or outbursts). Review of the nurse's notes written by the registered nurse unit manager (RNUM), dated 10/27/16, at 1:15 p.m. indicated certified nursing assistant A (CNA A) witnessed CNA B spit four times on Resident 1 when Resident 1 said to CNA B, "Nigger! Nigger! Go back to your own country." Review of the 10/27/16 investigation report "Interview Record," written on 10/27/16 at 1:15 p.m. indicated CNA A witnessed CNA B yelling at Resident 1 and spit on Resident 1's face four times when Resident 1 said to CNA B, "Nigger! Nigger! Go back to your own country." During a telephone interview with CNA A, on 11/4/16, at 4:30 p.m., she stated on the morning of 10/24/16 at around 4:30 a.m., she witnessed CNA B spit on Resident 1 four times after Resident 1 called CNA A "nigger." During an interview with Resident 1 on 11/4/16, at 4:15 p.m., when asked about the alleged abuse the morning of 10/24/16 involving CNA B, Resident 1 stated, "I spit on her first." During an interview with the RNUM on 11/4/16, at 1:45 p.m., she stated the above incident of verbal abuse occurred on 10/24/16 at around 4 a.m. per CNA A's report. During an interview with the director of staff development (DSD) on 11/17/16, at 8:25 a.m., she stated staff should not argue with a resident but should walk away from the situation per the training she provided to the staff. During an interview with the director of nursing (DON) on 11/16/16 at 8:30 a.m., she confirmed the above incident of verbal abuse was reported to her by CNA A the morning of 10/27/16. Review of the "Employee Personnel Action Form," dated 11/2/2016, indicated CNA B was terminated for "Violating Rights of Residents" and "Abuse." The facility's 2006 policy "Abuse Prevention Program" indicated residents had the right to be free from verbal abuse from the staff. It indicated the definition of verbal abuse was the used of oral or gestured language that willfully included disparaging and derogatory terms to the residents regardless of their age, ability to comprehend, or disability. The facility failed to prevent abuse by a staff member against Resident 1. This failure had the potential to cause mental anguish as well as a decrease in self-esteem for Resident 1. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000057 |
Herman Health Care Center |
070012776 |
B |
28-Nov-16 |
LEIH11 |
3995 |
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 report an abuse incident in a timely manner for Resident 1. The abuse incident regarding Resident 1 occurred on 10/24/16 by certified nursing assistant B (CNA B). CNA A was aware of the incident and did not report the incident to anyone until 10/27/16. The facility reported the incident to the ombudsman and the California Department of Public Health (CDPH) on 10/28/16. CNA B was not suspended until 10/27/16 and worked the night of 10/25/16. This failure to report had the potential for continued abuse and harm to residents by an unreported abuser. Review of Resident 1's clinical record indicated diagnosis of paranoid schizophrenia (a disease of disordered thoughts causing someone to be unreasonably suspicious of other people) and dementia with behavior disturbances (a disease with impaired cognition and memory coupled with unpredictable behaviors or outbursts). Review of the nurse's notes written by the registered nurse unit manager (RNUM), dated 10/27/16, at 1:15 p.m. indicated certified nursing assistant A (CNA A) witnessed CNA B spit four times on Resident 1 when Resident 1 said to CNA B, "Nigger! Nigger! Go back to your own country." Review of the facility's 11/27/16 investigation report "Interview Record," written on 10/27/16 at 1:15 p.m. indicated CNA A witnessed CNA B yelling at Resident 1 and spit on Resident 1's face four times when Resident 1 said to CNA B, "Nigger! Nigger! Go back to your own country." During an interview with Resident 1 on 11/4/16, at 4:15 p.m., when asked about the alleged abuse the morning of 10/24/16 involving CNA B, Resident 1 stated, "I spit on her first." During a telephone interview with CNA A, on 11/4/16, at 4:30 p.m., she stated the morning of 10/24/16 at around 4:30 a.m., she witnessed CNA B spit on Resident 1 four times after he called her "nigger." CNA A stated she did not report the above incident to anyone until the morning of 10/27/16 when she informed the director of staff development (DSD) by telephone. During an interview with the RNUM on 11/4/16, at 1:45 p.m., she stated she was informed of the above verbal abuse incident on 10/27/16 and started the investigation on the same day. The RNUM stated CNA A should have reported the abuse incident when it occurred to protect the residents from further abuse. Review of CNA B's time card indicated CNA B worked the night of 10/25/16, after the incident of resident abuse had occurred. Review of CNA B's "Employee Counseling Form" indicated CNA B was suspended from working on 10/27/16. During an interview with the director of nursing (DON) on 11/16/16 at 8:30 a.m., she confirmed the above incident of verbal abuse was reported to her the morning of 10/27/16. The facility's 2006 policy, "Abuse Prevention Program," indicated residents had the right to be free from verbal abuse from the staff. It indicated the definition of verbal abuse was the use of oral or gestured language that willfully included disparaging and derogatory terms to the residents regardless of their age, ability to comprehend, or disability. The facility's 2014 policy, "Reporting Abuse," indicated it was the responsibility of the staff to immediately report, or cause a report to be made of, the mistreatment or offense of a resident. If the suspected abuse does not result in serious bodily injury, the mandated reporter must report the incident to the local ombudsman, the CDPH, and the local law enforcement agency within 24 hours. The facility failed to report an abuse incident in a timely manner for Resident 1. This failure to report had the potential for continued abuse and harm to residents by an unreported abuser. This violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070012804 |
B |
9-Dec-16 |
U3PO11 |
1785 |
F241 - 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. The facility failed to ensure Resident 1 was treated with respect and dignity when certified nurse assistant A (CNA A) told Resident 1 "you're so bossy". This resulted in emotional distress for Resident 1. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/1/16, indicated Resident 1 was cognitively intact, required assistance with bathing, dressing, hygiene and transfer. During an interview on 11/16/16 at 11:30 a.m., Resident 1 stated on 11/8/16 after receiving a shower from CNA A she told CNA A to turn off the running faucet. Per Resident 1, CNA A stated "he cannot handle me because I'm bossy". CNA A left her alone in the room with no clothes on and a different CNA came to help her. Resident 1 stated after the incident she was scared when CNA A was around her. During an interview with the administrator (ADM) on 11/16/16 at 11:40 a.m., he stated he was aware Resident 1 felt offended by the actions of CNA A. During an interview with CNA A on 11/16/16 at 1:45 p.m., he confirmed he told Resident 1 she was too bossy. CNA A stated he knew Resident 1 was offended by his action. Review of the facility's 10/2009 policy, "Quality of Life-Dignity", indicated residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000059 |
HILLVIEW CONVALESCENT HOSPITAL |
070012823 |
B |
20-Dec-16 |
KM4811 |
7001 |
F221 - 483.10(e)(1), 483.12(a)(a) 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 ?482.12, 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. The facility failed to ensure Resident 2 was free from physical restraints and failed to determine the appropriateness of the restraint, when there was no physician's order for the use of a seat belt. The resident did not have an assessment and care plan for the use of the restraint. These failures could have contributed to Resident 2's fall with injuries. Review of Resident 2's clinical record on 12/1/16 indicated Resident 2 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions), depression (a mood disorder causing a feeling of sadness and loss of interest), anxiety disorder (a feeling of worry, nervousness), and metabolic encephalopathy (chemical disorder that affects brain function). Review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated on 6/20/16 indicated the brief interview for mental status (BIMS) was not rated due to her severely impaired cognitive status. Resident 2 required minimal assistance with ambulation and to move about her room and other areas of the facility. During the initial tour with registered nurse D (RN D) on 11/28/16 at 7:35 a.m., Resident 2 was observed in her room sitting on her wheelchair with a seat belt. RN D stated Resident 2 was confused and the seat belt was used to prevent the resident from falling. During an interview with certified nursing assistant E (CNA E) on 11/29/16 at 11:55 a.m. in Resident 2's room, she stated the "seat belt" was to prevent the resident from sliding off the chair. She stated the resident would not be able to release the seat belt by herself. Resident 2 was then asked to release the belt but she could not do it. The resident was calm. CNA E acknowledged it would be considered a restraint if the resident could not self-release it and a physician order would then be needed. Record review with the director of staff development (DSD) on 11/29/16 at 12:10 p.m. indicated there were no physician's order and no informed consent for the seat belt. There was no assessment and care plan done for the use of a seat belt. The DSD stated there should be an order for the seat belt, and an assessment and care plan addressing the seat belt use should have been done. She confirmed there were none found. Review of Resident 2's clinical record indicated she had an unwitnessed fall on 7/20/16 at about 8 a.m. The nurse's notes indicated a certified nursing assistant (CNA) found the resident at the foot of the bed lying on her left side, Resident 2 had sustained injuries to right forearm, chin, and contusion to the right temple. Resident 2 was sent to the hospital for evaluation. Review of Resident 2's initial fall assessment dated 6/7/16 indicated a score of 14, indicating a high risk for fall. Resident 2's clinical record also indicated episodes of restlessness. During an interview with CNA B on 12/1/16 at 1:40 p.m., she stated at 7 a.m., Resident 2 was at the nursing station in a wheelchair wearing a lap belt. The nurse instructed her to take the resident back to her room. CNA B stated Resident 2 was not restless at that time and she felt it was safe to leave her so she could finish her rounds. She stated another CNA alerted her about the fall. CNA B stated she found the resident face down with the wheelchair on top of the resident with the seat belt still on. CNA B stated the resident was probably trying to remove her seat belt and fell forward with the wheelchair on top of her. She stated Resident 2 would not be able to remove her lap belt. She also stated the resident could walk prior to the fall. During an interview with licensed vocational nurse A (LVN A) on 12/1/16 at 3 p.m., she stated CNA B reported the fall to her but was not aware Resident 2 fell forward with the wheelchair and seat belt still on. Review of the Enabler Assessment form dated 6/26/16 did not indicate an assessment was done for a self-release belt. Review of the Fall Risk Care Plan did not include use of a seat belt. Review of the order summary report did not include an order for the use of a seat belt. Review of the physician progress notes did not indicate presence of a specific medical reason that would require the use of the restraint. A review of the Journal of the American Geriatric Society (5/01) "Fall Prevention, Guideline for the prevention of falls in older persons", indicated there was no evidence the use of physical restraints, including but not limited to side rails, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries, e.g., strangulation, entrapment. A review of the facility's undated policy on lap belts indicated the alarm should be on and the resident should not be left unattended unless the resident understands purpose for the belt and how to remove the lap belt. A review of the facility's undated policy on "Fall Prevention Program" indicated a care plan will be implemented to reduce falls and prevent injury. The policy also indicated the facility recognizes the residents' rights to be free from restraints and they will only be utilized per state and federal regulations regarding their use and to treat a medical condition. A copy of the hospital emergency room record indicated the resident was evaluated on 7/20/16 for an unwitnessed fall. Resident 2 had small chin laceration (a deep cut or tear in the skin) and right forearm abrasions (a scrape on the skin). A computerized tomography (CT scan, a series of X-ray images taken from different angles) of the head, indicated mild left frontal scalp soft tissue swelling. The CT of the facial bones indicated questionable subtle nondisplaced fracture of the anterior left nasal bone. This failure had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000068 |
Hearts & Hands, Post Acute Care & Rehab Center |
070013053 |
B |
5-Apr-17 |
WGO111 |
7414 |
F323 -- 483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to provide supervision and adequate assistance to prevent an unavoidable accident when Resident 1 exited from the facility and wheeled himself into an unsafe and unsupervised area. The facility staff failed to call for immediate assistance when Resident 1 did not respond to redirection, enabling Resident 1 to be out of range for visual supervision. These failures resulted in a fall with laceration to the left temple.
Review of the facility's investigation report dated 2/7/17, indicated Resident 1 exited the facility to sit outside and sustained a fall on 2/4/17 at 12:55 p.m. The alarm went off and receptionist L (RC L) followed the resident in an attempt to bring him back into the facility. Resident 1 got agitated and refused to go back into the facility. RC L went back to the facility and left Resident 1 unsupervised outside.
Review of Resident 1's clinical record on 2/24/17, indicated Resident 1 was admitted on XXXXXXX10 with diagnoses including cerebral infarction (an area of brain tissue damage due to a blockage or narrowing of the arteries supplying blood and oxygen to the brain); hemiplegia (loss of the ability to move, affecting one side of the body); anxiety disorder (feelings of worry, fear); depression (feelings of sadness, despair, hopelessness) and cataracts (clouding of the eye).
Review of minimum data set (MDS, an assessment tool) dated 1/30/17, indicated the resident had impaired cognition (mental process) but was able to understand and express his needs. It also indicated Resident 1 had impaired vision, required one-person assistance for bed mobility, transfers, and required no physical assistance for locomotion on and off the unit. Resident 1 was able to propel himself around the unit with his manual wheelchair.
Review of Resident 1's Fall Risk Assessment dated 1/24/17, indicated the resident had a score of 10. A score of 10 and above indicated high risk for fall.
Review of Resident 1's Elopement Assessment dated 1/24/17, indicated the resident had moderate risk for elopement with a score of 14.
Review of Resident 1's care plan for elopement risk initiated on 4/14/16, indicated frequent check for whereabouts as one of the interventions. There was no indication of a process in place as to how the resident was frequently checked.
Review of Resident 1's situation background assessment recommendation (SBAR, a tool technique used to facilitate prompt and appropriate communication) dated 2/4/27, indicated the resident refused to return to the facility and became physically aggressive with staff and attempted to hit staff. The resident had a fall with injury and was sent to the hospital for evaluation.
Review of the acute care emergency department notes dated 2/4/17 under History and Physical Information, indicated "Per EMS (emergency medical responder), one of the wheels on his wheelchair went off the curb, causing patient to fall on to his left side. Patient had laceration to his left temple." Discharge Diagnosis indicated facial laceration.
During an observation of Resident 1 on 2/24/17 at 11 a.m., the resident was sitting in the activity room. The wheelchair had a left arm and left foot rest, and a battery operated door monitor alarm attached to the back of the wheelchair.
During a concurrent interview with Resident 1, he stated he did not remember when the fall incident happened, but he stated he wanted to go home. Resident 1 stated he went to the lobby, pushed the door opener for the disabled, and wheeled himself out. He stated no one was with him at that time. Resident 1 stated he wheeled himself to the sidewalk and his wheelchair hit the "gutter" and it flipped over, causing him to fall and hit his head on the ground next to a parked car.
Review of Resident 1's interdisciplinary team care conference (IDT, team members from different departments involved in a resident's care) Fall Investigation and Intervention dated 2/5/17, under "new or revised interventions," indicated it will refer resident to rehabilitation department (rehab) for rehab screening, to determine if an evaluation was required.
During an interview with the dietary aide A (DA A) on 2/24/17 at 11:55 a.m., she stated she was in the kitchen and heard staff talking about a resident's fall outside the facility. She went out to check as she was the manager of the day (MOD). She saw Resident 1 lying on the ground on his left side and several staff were attending to the resident.
She stated Resident 1 fell on the sidewalk in an area visible from the dining/activity area. The area was approximately 250 feet (ft., unit of measure) from the facility entrance door.
During an interview with Licensed Vocational Nurse B (LVN B) on 2/24/17 at 12:20 p.m., she stated on 2/4/17, someone from the dining area informed her of Resident's 1 fall. LVN B stated she and LVN C went out to assess the resident. She found the resident on the ground next to a parked car and noted an abrasion with bleeding on his left forehead. They attended to the resident until the paramedics came and the resident was transferred to the hospital for evaluation. LVN B also stated she did not hear RC L's overhead page. She stated it was customary for a receptionist to page overhead when a resident's door monitor alarm sounds off, a signal alerting a resident was attempting to leave the facility. LVN B stated she did not observe the resident display any aggressive behavior.
During an interview with RCC (Resident Care Coordinator) on 2/24/17 at 2:20 p.m., she stated the facility does not prohibit residents to go sit outside including residents who are cognitively impaired. The RCC acknowledged there was no staff assigned to visually supervise cognitively impaired residents who would like to go outside of the facility.
A review of the facility's revised policy dated 12/07, "Elopements," indicated, if an employee observes a resident leaving the premises, he/she should: attempt to prevent the departure in a courteous manner; get help from other staff members in the vicinity, if necessary; and instruct another staff member to inform the charge nurse or the director of nursing that a resident has left the premises.
Therefore, the facility failed to provide supervision and adequate assistance to prevent an avoidable accident when Resident 1 exited from the facility and wheeled himself into an unsafe and unsupervised area.
These failures had a direct relationship to the health, safety, or security of residents. |
| 070000057 |
Herman Health Care Center |
070013101 |
B |
11-Apr-17 |
RRC911 |
3642 |
483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES
483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to implement their policy and procedure in reporting an injury of unknown origin when Resident 14 had a purplish-green discoloration on his right eye. Resident 14's skin discoloration of unknown origin was not reported to the Ombudsman.
Resident 14's clinical record was reviewed. The resident was admitted to the facility on XXXXXXX15 with a diagnosis of Alzheimer's disease (a progressive, degenerative disorder that attacks the brain, resulting in loss of memory, thinking and language skills, behavioral changes, and affecting a person's daily functioning).
Review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 1/23/17, indicated his cognition was severely impaired.
Review of Resident 14's Progress Notes dated 3/24/17 at 12:12 a.m., indicated Resident 14 was found with skin discoloration on his right eye measuring four by two centimeters. There was no documented evidence the cause of the skin discoloration.
During an observation on 3/27/17 at 3:00 p.m., Resident 14 had purplish-green discoloration on his right eye.
During an interview with the certified nursing assistant J (CNA J) on 3/29/17 at 2:00 p.m., he stated, on 3/24/17 at 11:45 p.m., Resident 14 was in the dining room when he observed the resident had a purple discoloration on his right eye. The CNA stated they did not know where the resident received the bruise.
During an interview with the licensed vocational nurse I (LVN I), on 3/28/17, at 3:00 p.m., she stated on 3/24/27, Resident 14 was found with purple discoloration on right eye from unknown origin.
During an interview the director of nursing (DON), on 3/29/17, at 4:10 p.m., she acknowledged the incident was not reported to the Ombudsman. The DON stated Resident 14's injury of unknown origin should be reported to the ombudsman and California Department of Public Health (CDPH).
The facility policy "Abuse Investigations" dated 7/2014, indicated the individual in charge of the abuse investigation will notify the Ombudsman that an abuse investigation is being conducted.
The facility policy "Investigating Unexplained Injuries" dated 4/2011, indicated the investigation will follow the protocols set forth in the facility's abuse investigation guidelines.
Therefore, the facility failed to implement their policy and procedure in reporting an injury of unknown origin when Resident 14 had a purple discoloration on his right eye. Resident 14's skin discoloration of unknown origin was not reported to the Ombudsman.
The violation of this regulation had a direct or immediate relationship to the health, safety, or security of the patients. |
| 070000057 |
Herman Health Care Center |
070013325 |
B |
11-Jul-17 |
4GG811 |
6641 |
F323--483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to provide supervision and a safe environment for one of three residents (Resident 1) when staff did not supervise Resident 1 while she was sitting upright in a wheelchair without footrests. This resulted in a fall with injury (forehead lacerations and rib fractures).
Review of Resident 1's admission record indicated Resident 1 was admitted with diagnoses including dementia (a progressive and sometimes chronic brain condition that causes problems with thinking, behavior, and memory), dementia with Lewy bodies (Lewy bodies are clumps of protein that can form in the brain and cause problems with the way the brain works, including memory, movement, thinking skills, mood, and behavior), major depressive disorder (low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause), and anxiety disorders (restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping).
Review of the Minimum Data Set (MDS, an assessment tool) dated 4/18/17 indicated Resident 1 was total dependent for all activities of daily living (ADL's).
Review of Resident 1's Morse Fall Scale (a method of assessing a patient's likelihood of falling) dated 4/18/17 indicated she was a high risk for falls.
During an interview with the director of nursing (DON) on 6/14/17 at 1:15 p.m., she stated Resident 1 was assessed by the occupational therapist (OT, a person who helps people to fully engage in their daily lives, from their work and recreation to activities of daily living like getting dressed, cooking, eating and driving) to have poor trunk control. The DON also stated, as per OT's assessment Resident 1 required a Tilt-in-Space wheelchair (a wheelchair that reduces the risk of slumping and sliding for people who are at risk of falling out of a wheelchair) for safety.
During an interview with certified nursing assistant A (CNA A), on 6/26/17, at 10:20 a.m., she stated after lunch she prepared to transfer Resident 1 from wheelchair to bed. She set the wheelchair to upright position and removed the footrests. While waiting at the room door for CNA B to come and help her with the transfer, she saw CNA C helped a resident who almost fell. She then went to help CNA C. While helping CNA C, CNA B came and told her Resident 1 fell. She came to the room and saw Resident 1 with her face turned to her side and her head was lying on a bloody floor.
During an interview with CNA B, on 6/14/17, at 2:10 p.m., she went in to Resident 1's room to help CNA A with the transfer and saw Resident 1 lying chest down on the floor. Her head turned to the side, and was lying on a bloody floor. CNA A was not in the room.
During an interview with CNA C, on 6/14/17, at 4:20 p.m., she stated CNA A came to help her with a resident who almost fell from the hallway bathroom back to her room. While in the room she heard someone asked someone to call 911 for Resident 1. She came to Resident 1's room and saw her on the floor lying on her chest, her face turned to the side and her head lying on a bloody floor. Resident 1's wheelchair was in upright position and had no footrests on.
During an observation on 6/14/17, at 1:45 p.m., Resident 1 was lying in bed with her eyes opened. There was 1.5 x 1.5 centimeters (cm. - unit of measurement) dry reddish brown scab on the right side of her forehead. The area was slightly swollen.
Review of Resident 1's Interdisciplinary Meeting notes indicated Resident 1 sustained a laceration on right side of forehead and fractures on second to fourth ribs because of the fall.
During an interview with licensed vocational nurse D (LVN D), on 6/16/17, at 3:45 p.m., she stated she had been working with Resident 1 since her admission. When Resident 1 was in the wheelchair, she needed to have the footrests and the wheelchair should be tilted back. Otherwise, she would fall because she had tendency to lean forward.
During an interview with the director of staff development (DSD), on 6/22/17, at 11:55 a.m., she stated for Resident 1's safety she could not be left alone while she was in the wheelchair in upright position and the footrests were off. Even if the wheelchair was in the tilted back position and the footrests were on, Resident 1 could be left alone only for a short time.
Review of Resident 1's OT Progress & Discharge Summary dated 4/24/13 indicated, "The patient tolerates upright sitting in chair/wheelchair maintaining proper postural alignment for 1 minute. Patient demonstrates continuous non purposeful motor movements... The patient did not make significant progress toward goals. Standard manual wheelchair not appropriate for this patient due to motor movements. Requested Broda chair (tilt and recline positioning chair) from medical group... Precautions Fall risk... "
The facility policy and procedure titled "Safe Lifting and Movement of Residents" revision dated 12/2013, indicated "In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents... Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents."
The facility failed to provide supervision and a safe environment for one of three residents (Resident 1) when staff did not supervise Resident 1 while she was sitting upright in a wheelchair without footrests. This resulted in a fall with injury (forehead lacerations and rib fractures).
This violation had direct or immediate relationship to the health, safety, or security of patients. |
| 110000702 |
HEALDSBURG DISTRICT HOSPITAL D/P SNF |
110009753 |
AA |
24-Jan-14 |
IB9G11 |
15753 |
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 ensure that, Resident 9 (one of the three abbreviated survey sample), who was fed by a gastric tube (G tube: a tube inserted directly into the stomach through an abdominal incision for the administration of food, fluids, and medications), received appropriate treatment and services to prevent gastric tube replacement complications; failed to identify signs and symptoms of sepsis (sepsis is a serious medical condition caused by an overwhelming immune response to infection); and failed to ensure that all staff were trained to replace feeding tubes. This presented imminent danger to Resident 9, as a result of the misplacement of the gastric tube outside of the stomach, which led to sepsis, kidney failure and death. During a review of the clinical record, on 8/3/12 at 11 a.m., Resident 9 was admitted to the facility on 6/25/09 with diagnoses that included persistent vegetative state due to a stroke with brain hemorrhage, high blood pressure, and a seizure disorder. Resident 9 had a gastric tube for feeding, fluids, and medications.Resident 9's Minimum Data Set (MDS), an evaluation tool, revealed that Resident 9 could not understand others or be understood and was totally dependent for all activities of daily living. (Merck Manual - persistent vegetative state is a chronic condition that preserves the ability to maintain blood pressure, respiration, and cardiac function, but not cognitive function. The patient has no awareness of self and interacts with the environment only via reflexes and cannot interact with people. Purposeful responses to external stimuli are absent, as are language comprehension and expression. Treatment is supportive only). Nurses notes, dated 6/8/12, as a late entry for 6/5/12, revealed that at 10 a.m., Licensed Nurse (LN) D went into Resident 9's room to turn on the tube feeding after it had been turned off for one hour after medication was administered. The gastric tube was lying on Resident 9's stomach with the balloon deflated. A moist Q-tip was inserted to keep the tract open and another gastric tube was inserted, with some difficulty. Placement was checked by injecting air into the gastric tube and listening for air. The notes indicated that air was heard to the left of the gastric tube insertion site, and that there was no residual fluid, as the tube feeding had been off for one hour following a medication. A second nurse checked placement. Further record review revealed that there were no notations on the care plan about the reinsertion. During an interview, on 8/7/12 at 11:30 a.m., when asked to explain the note of passing the gastric tube with difficulty, LN D stated that she could not get it to, "follow the line," and tried three or four attempts to get it in, then finally felt a pop as the gastric tube was placed and felt that the pop meant that it was in the tract of the stomach.LN D did inject air into the tube to listen for air in the stomach and heard it to the left, not where it had normally been heard before (on the right). LN D asked another nurse to check placement but was not in the room when this occurred.LN D stated that the second nurse, who checked placement, reported that Resident 9's color was gray two hours after the gastric tube was replaced. Resident 9 was suctioned through the tracheostomy, and there was no sputum, and it was decided to just continue monitoring. LN D stated that this resident could not tell you what was wrong, so observation skills were critical. LN D stated that the physician was not notified at the time, as she felt the tube pop into the tract. LN D also stated that an X-ray should have been done, to check placement, after the difficult placement and that it was standard orders when something did not seem right.During an interview, on 8/7/12 at 11 a.m., LN H stated that LN D had requested that he check placement of the gastric tube after it was reinserted. LN H was not in the room when LN D reinserted the tube. LN H stated that the tube feeding had been held for one hour after medication so there was only a small amount of residual fluid in the tube when checked for fluid, and that air was heard on the left side and none on the right side, where it had been previously heard. LN H stated that he had not attended any in-services for gastric tubes. During an interview, on 8/7/12 at 10:20 a.m., LN G, the nurse who cared for Resident 9 during the evening (3 p.m. to 11 p.m.) shift, was asked if gastric tube residual and placement had been verified. LN G stated that it had been reported that the gastric tube was replaced, but the report had not indicated that it was a difficult replacement. LN G did state that air was heard when the gastric tube placement was checked. When asked if there was residual fluid, and where the residual was recorded, LN G stated that residuals were not recorded, and could not remember if there was any residual fluid in the tube or stomach, and that residuals were never recorded.LN G stated that as the evening progressed Resident 9's condition worsened. The nursing assistants had reported that Resident 9 was very diaphoretic (profuse sweating) while sitting up in a chair. LN G asked the nursing assistants to put Resident 9 back to bed and turn on a fan. Later the nursing assistants reported that Resident 9 was again very diaphoretic and asked LN G to re-evaluate.LN G stated that Resident 9's blood pressure was low, and it seemed like something was going on, and thought that Resident 9 was possibly getting a urinary tract infection. Resident 9's temperature and pulse were not taken. When asked what the policy was for reporting a low blood pressure or for required nursing documentation, LN G did not know, and stated that the policy manuals that were at the nursing station, and were not very user friendly, so they were not used very often. LN G also stated that the above findings were not recorded in the record, but should have been.Record review, on 8/4/12 at 11 a.m., revealed nurses notes for the night shift (11 p.m. to 7 a.m.), with a time recorded as 3 a.m., that Resident 9's blood pressure was 89/52: "Gave patient rest of water via G tube, stopped feeding for 30 minutes, re-checked BP (blood pressure), it had gone up to 90/54, restarted feeding." A second note, timed also as 3 a.m., indicated, "Second time BP was checked, it was 75/47. After giving rest of water and elevating feet re-checked, it was 90/54."During an interview, on 8/7/12 at 11:35 a.m., LN I stated that the concern on the night shift was the low blood pressure. LN I also stated that sometime during the night Resident 9 was shaking, so a warm blanket was applied. When asked what the pulse was when the blood pressure was checked, LN I did not know. When asked if a temperature was taken when Resident 9 was shaking, LN I replied, "no." LN I stated that the other Licensed Nurse on that night (LN P) and she had been concerned with the low blood pressure. LN I did check gastric tube placement, but did not recall if there was any residual, did hear air, but was not sure which side it was heard. When asked about the no urine output for the entire night shift, LN I responded that sometimes the residents did not have urine output on the night shift and would make up for it on the day shift. When asked to list the symptoms of sepsis, LN I did not know them.During an interview, on 9/4/12 at 11 a.m.., when asked what the signs and symptoms of sepsis were, LN P, the second nurse on the night shift caring for Resident 9, indicated she did not know them that night. (Sepsis Fact Sheet - National Institute of General Medical Sciences: Common symptoms of sepsis are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation. Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. This results in impaired blood flow, which damages the body's organs by depriving them of nutrients and blood.In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs - lungs, kidneys, liver - may quickly fail and the patient can die. Sepsis does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen or other part of the body.)Record review, on 8/3/12 at 10 a.m., of the 6/6/12, day shift nurses notes (7 a.m. to 3 p.m.), revealed that at 8 a.m. the vital signs were: Temperature 38.2 axillary, Pulse 132, Respirations 43, Blood Pressure 122/82. Resident 9 was diaphoretic and cold, his toes and feet were gray, his hands were cold, and he was cyanotic (a bluish discoloration of the skin and mucous membranes; a sign that oxygen in the blood is dangerously diminished). The notes indicated that the physician was notified immediately, and laboratory studies, EKG and chest x-ray were ordered. At 9 a.m. Resident 9's heart rate was in the 40's, his blood pressure was 81/56, his oxygen saturations were in the 70's (normal = 96-99), and the hospital Rapid Response Team was called.During an interview, on 8/10/12 at 3:15 p.m., LN E, the hospital intensive care nurse who responded to the rapid response team page, stated that Resident 9's abdomen was very distended, his color was gray, his skin was cold, and that it was obvious that Resident 9 was in full-blown septic shock. LN E stated that the rapid response team should have been called much earlier. Resident 9 was transferred to the hospital intensive care unit with a diagnosis of septic shock.Record review, on 8/3/12 at 10 a.m., revealed a CT scan of the abdomen/pelvis, dated 6/8/12, with the conclusion: "The gastrostomy tube is outside the stomach. Fluid and air are present in the abdominal wall."Resident 9 was transferred to another local hospital intensive care unit on 6/9/12, for consideration of dialysis (process of cleansing the blood by passing it through a special machine. Dialysis is necessary when the kidneys are not able to filter the blood) due to renal insufficiency (kidney function failure) with anuria (failure of the kidneys to produce urine). A CT scan of the abdomen/pelvis, dated 6/11/12, was done with the impression: Feeding tube in musculature of the left abdominal wall, air in the left anterior abdominal wall crossing the midline to the right, intra-abdominal air also present, primarily against the left anterior abdominal wall, with associated fluid. Resident 9 died on 6/17/12, with final discharge diagnosis that included septic shock secondary to intra-abdominal (inside abdominal cavity) sepsis, and acute kidney injury.Review, on 8/3/12 at 1 p.m., of the facility policy titled: Gastrostomy Tube Changing or Reinsertion of (excluding Jejunostomy tubes), dated 7/11, included the policy statement: "...if a gastrostomy tube falls out, a replacement tube should be inserted as soon as possible, within a few minutes at most..." Documentation required: "1. 24 hour nursing assessment notes, 2. Nurse's progress notes, 3. Kardex, and 4. Care Plan."Review of the facility policy titled: Notification of Resident Changes, dated 7/11, included: "Procedure: The physician shall be notified promptly of: a. Any sudden and marked change in signs, symptoms or behavior exhibited by a resident, b. Any unusual occurrence involving a resident,... d. Any untoward response or reaction by a resident to a medication or treatment..." During a review, on 8/14/12 at 5 p.m., the facility policy Titled: Contacting the physician for changes in patient's condition, revised 1/11, included: "1. The nurse will notify the attending physician when the following circumstances arise, unless otherwise modified by the physician: a. Systolic B/P below 80 or above 180 mm Mercury - new onset, b. Pulse below 50 or above 110, new onset....2. When any of the above conditions occur, the Lead Nurse or Staff nurse will: 1. Contact the physician by office phone, Tiger Text or overhead paging if in the hospital. B. Contact the ICU for possible admission to that unit (consider calling a Rapid Response Team to evaluate the patient) ..." During a review, on 1/24/13 at 11 a.m., the manufacturer instructions (BARD) for the gastric tube, included in Warnings "...Be certain that the balloon has passed through the fistulous tract and is completely in the stomach prior to inflation of the balloon. Placement or slippage of the device into the peritoneal cavity will result in serious consequences including peritonitis, sepsis and potentially, death..." During an interview, on 8/3/12 at 10 a.m., when asked about the specific staff training for gastric tubes, Administrative Staff C stated that there was no formal training. Nursing staff, who had previous experience, trained new staff who, after inserting a G tube, could then train the next nurse. There were no skills competency evaluations, and the yearly Licensed Nurse performance evaluations were not specific to skills with gastric tubes. Administrative Staff C stated that all 13 residents in the distinct part skilled nursing unit had gastric tubes, and that all residents had traumatic brain injuries requiring feeding, fluids, and medications through gastric tubes. During a review, on 8/3/12 at 11 a.m., the performance evaluation for LN D indicated that all criteria were met, but that there was a need to strengthen critical thinking skills. The licensed nurse performance evaluation did not include an evaluation of skills with gastric tubes. Safe Practices in Patient Care: Enteral Nutrition and Hydration in Long-Term Care (Continuing Education for Nurses), indicated...Tube Displacement...The auscultation method of listening for insufflative air over the epigastrium to check for tube placement is not always reliable...If there is any question of tube migration or displacement or if the nurse is unable to determine tube placement, an X-ray should be requested..." http://emedicene.medscape.com/article/14589-overview: G-tube replacements:..."If G-tube replacement does not occur easily, abort the procedure and contact the provider who placed the tube..." American Society for Parenteral and Enteral Nutrition (ASPEN) Standards of Practice: Standard 11: 11.1 Appropriate access devices (tubes placed for the delivery of nutrients or drugs) shall be placed by or under the supervision of a physician, nurse or specially trained healthcare professional who is competent and knowledgeable in recognizing and managing complications associated with the placement and management of the device...11.3 Proper placement of vascular (into a blood vessel) and enteral devices (into the gastrointestinal tract) shall be appropriately confirmed and documented before use...11.4 complications related to an access device and outcome of actions to manage the complication shall be clearly documented in the medical record. The facility violated the regulation by failing to ensure that all staff were trained and competent to replace gastrostomy tubes, failed to obtain an x-ray to check placement of the gastric tube after difficulty in passing the tube, and failed to recognize signs and symptoms of sepsis.These failures resulted in Resident 9's gastric tube placement outside of the stomach which resulted in septic shock with kidney failure and was the direct proximate cause of death. The above violation presented an imminent danger to the patient and was a direct proximate cause of the death of the patient. |
| 010000029 |
Healdsburg Senior Living Community |
110011937 |
B |
05-Feb-16 |
07UM11 |
9288 |
1418.21(a)(1)(A) 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: (A) An area accessible and visible to members of the public. 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(a)(1)(C) 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: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. 1418.21(a)(2)(A) 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: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (A) The full name of the facility, in a clear and easily readable font of at least 28 point. 1418.21(a)(2)(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: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (B) The full address of the facility in a clear and easily readable font of at least 20 point. 1418.21(a)(2)(C) 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: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from the CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by the CMS. The number shall be in a clear and easily readable font of at least two inches print. 1418.21(a)(2)(D) 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: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (D) Directly below the star symbols shall be the following text in a clear and easily readable font of at least 28 point: "The above number is out of 5 stars." 1418.21(a)(2)(E) 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: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (E) Directly below the text described in subparagraph (D) shall be the following text in a clear and easily readable font of at least 14 point: "This facility is reviewed annually and has been licensed by the State of California and certified by the federal Centers for Medicare and Medicaid Services (CMS). CMS rates facilities that are certified to accept Medicare or Medicaid. CMS gave the above rating to this facility. A detailed explanation of this rating is maintained at this facility and will be made available upon request. This information can also be accessed online at the Nursing Home Compare Internet Web site at. Like any information, the Five-Star Quality Rating System has strengths and limits. The criteria upon which the rating is determined may not represent all of the aspects of care that may be important to you. You are encouraged to discuss the rating with facility staff. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions. Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating posted here." 1418.21(a)(2)(F) 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: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (F) Directly below the text described in subparagraph (E), the following text shall appear in a clear and easily readable font of at least 14 point: "State licensing information on skilled nursing facilities is available on the State Department of Public Health's Internet Web site at: www.cdph.ca.gov, under Programs, Licensing and Certification, Health Facilities Consumer Information System." 1418.21(a)(3) 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: (3) For the purposes of this section, "a detailed explanation of this rating" shall include, but shall not be limited to, a printout of the information explaining the Five-Star Quality Rating System that is available on the CMS Nursing Home Compare Internet Web site. This information shall be maintained at the facility and shall be made available upon request. 1418.21(a)(4) 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: (4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements. 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. Based on observation and interview, the facility failed to post the overall facility rating ("star rating") determined by the Federal Centers for Medicare and Medicaid Services, as required. This failure had the potential to prevent residents, staff, and visitors from comparing the overall quality of the facility with other skilled nursing facilities.Findings: During multiple observations and interviews between 12/14/15 and 12/18/15, the survey period, the Centers for Medicare and Medicaid Services,"star rating" was not observed anywhere in the skilled nursing facility. During an observation on 12/14/15 at 10:15 a.m., no postings were noticed in the staff lounge/break room.During an interview on 12/15/15 at 11:16 a.m., regarding required postings, Administrative Staff B stated she would check with Administrative Staff A.During a follow-up interview on 12/15/15 at 4:10 p.m., Administrative Staff B stated the facility had painted and had, "removed postings."During an interview on 12/18/15 at 10:47 a.m., Administrative Staff A stated the 5-star rating postings had been, "pulled off" when the facility had been, "painted."This had a direct relationship to the health, safety, or security of patients. |
| 010000029 |
Healdsburg Senior Living Community |
110013071 |
A |
30-Mar-17 |
GYFL11 |
17456 |
F323 ?463.25(d)(1)(2)(n)(1)-(3)- Free of Accident Hazards/supervision/devices
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to: 1) Provide adequate supervision for Resident 1, when Resident 1, who required two-person assist and extensive assistance for toileting, was left sitting on a toilet seat unattended. She stood and attempted to walk out of the Shower room/Bathroom door and fell, resulting in a fractured hip; and 2) Provide adequate supervision for Resident 6, when Resident 6, who required one-person extensive physical assistance for transfer to and from the wheelchair, had multiple falls, two of which resulted in lacerations to Resident 6's forehead above the right eye.
1) During Resident 1's clinical record review on 1/24/17, the record indicated that Resident 1 was admitted to the facility on XXXXXXX 16 for rehabilitation due to a stress fracture (fracture of bone caused by repeated mechanical stress) to the pelvis. Resident 1 was 77 years of age, alert and oriented. The resident had conditions listed in the resident's diagnoses to include difficulty in walking, abnormal posture, need for assistance with personal care.
1st fall:
On 7/8/16 at 11:30 PM Resident 1's Nurse Progress Note indicated "At about 8:15 PM, resident was found on the floor with blood near her head. Upon assessment, there is a gash on the right brow (1.3 cm) [centimeter, one hundredth of a meter] with hematoma [swelling of clotted blood in the tissues] and bruising on the area ..."
2nd fall:
On 8/13/16 at 1:30 a.m., the record indicated that while at the facility, Resident 1 fell coming out of the shower room/bathroom, where she was left unattended sitting on the shower/bathroom toilet. She was sent to the local acute care hospital's emergency Department (ED). Resident 1 refused an x-ray and was sent back to the facility. She continued to experience pain and on 8/15/16, she was transferred back to the local acute care facility for a physician ordered x-ray. The x-ray indicated that the resident sustained an acute right intertrochanteric (thighbone connected to hip) fracture with fragment.
On 1/24/17, Resident 1's clinical record included the initial Minimum Data Set (MDS-a resident assessment tool) dated 6/21/16, which indicated Resident 1 required 2 persons assist for transfers with toilet use. The MDS indicated the resident was coded an 8/8 under the heading of "C. Walk in room - how resident walks between location in his/her room." Coding 8/8 indicated that activity did not occur for any part of the 7 days prior to coding the MDS.
During an interview on 1/25/17 at 3:10 pm, Unlicensed Staff I stated the practice in the facility for 2 person extensive assist with toilet use was that 2 Certified Nursing Assistants (CNA) would help a resident stand on his or her feet and one CNA would stay in the bathroom with the resident sitting on the toilet seat. When the resident was ready to come off of the toilet seat, the CNA would pull the call light or wait for the 2nd CNA to come back to help the other CNA assist the resident back on to the wheelchair.
During an interview on 1/25/17 at 3:30 PM, Unlicensed Staff J stated that Resident 1 could walk if holding on to a bar before the August fall. She stated Resident 1 would stand and tried to be independent which is why she would not leave her alone.
During an interview on 1/25/17 at 3:40 PM, Family Member K stated the facility notified the family about the fall on 8/13/16, when a nurse took Resident 1 to the bathroom, the nurse turned around and fixed the bed, Resident 1 stood and fell. Family member K stated that Resident 1 came to the facility for rehabilitation due to falls and now the fall of 8/2016 broke her hip and was "irreparable."
During an interview on 1/26/17 at 2:36 p.m., Licensed Staff L stated that Resident 1 was taken to the toilet in the shower room. Licensed Staff L stated Resident 1 did not like staff to stay with her. Licensed Staff L stated the CNA, (Unlicensed Staff M) who assisted Resident 1 in the toilet went to help another resident. Licensed Staff L stated Resident 1 was told to use the call light when done. Licensed Staff L stated she heard the door of the shower room open and saw Resident 1 come out of the shower room and started to fall. Licensed Staff L stated that Resident 1 should not have been left in the room by herself and stated "Had I known 2 CNAs were busy, I could have help." Licensed Staff L stated the CNA did not tell Licensed Staff L that resident 1 was left alone. "Usually they [CNA] try to stay by the door...."
On 1/26/17, Review of Resident 1's clinical Nursing Notes indicated Late entry note Text: "Resident at 0130 [1:30 a.m.] was taken to the shower room/bathroom to be toileted by [Unlicensed Staff M]. The CNA left her after telling her to pull the call light when she was done. Instead of pulling the call light for help when she was done, she got up and walked out of the shower room/bathroom; as she was coming out of the door the nurse noticed she was unattended and tried to help stabilize her at which time the resident lost her balance and fell in the hallway. Nurse asked if she hit her head and she stated "no, I think I broke something." A Nurse called the physician on call and Resident 1 was transferred to the local acute hospital for observations. Due to Resident 1's refusal of an X-ray, the resident was transferred back to the facility. She continued to experience pain and on 8/15/16, she had X-rays per physician order. The X-ray indicated "Acute right intertrochanteric fracture which is fragmented. Partially displaced with varus [bone bent inward] deformity." Right hip fracture was noted.
On 1/26/17, review of the Facility policy and procedure titled Fall Risk Assessment dated 12/07 indicated "The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable."
Review of the Falls and Fall Risk, Managing Policy, dated 12/07 indicated "If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified."
2) During review of Resident 6's clinical record on 1/23/17, the resident's record indicated resident 6 was admitted on XXXXXXX12 with diagnoses and conditions that included difficulty walking, generalized muscle weakness, Alzheimer's Disease, and dementia. Resident 6 also had a total of three of four falls with injury in 2016 (1/30/16, 5/26/16, 7/1/16, and 8/27/16), and one fall in 1/4/17, without injury.
The annual MDS assessment on 6/23/16, indicated Resident 6 had one fall since admission without injury and required one person extensive physical assistance for transfers to and from the wheelchair.
During a concurrent interview and record review on 1/30/17, at 2:05 p.m., the nursing note, dated 1/30/16, for Resident 6 indicated the resident fell and acquired a 1.5 cm (centimeters) bleeding open gash above his right eye that dripped blood on the floor. Resident 6's nursing note also indicated his wife expressed concern and stated the falls from the wheelchair happened before and asked why he did not have the self-releasing belt to keep him from falling. Resident 6's wife stated, "Well he needs it back, I want him to have it." The nursing note indicated the nurse would talk to the doctor and Administrative Staff B. Administrative Staff B stated the facility had discussed the self-releasing belt and did not record Interdisciplinary Team (IDT) notes, (a management team that implemented comprehensive resident care plans, that included measurable objectives and timeframe's to meet a resident's medical needs that are identified in the comprehensive assessment) that discussed the 1/30/16 through 1/4/17 falls for Resident 6. The IDT note for Resident 6, dated 7/14/16, indicated goal met and resident has not had further incidents. No additional IDT notes were for Resident 6 were located by Administrative Staff B.
During a concurrent interview and record review on 1/30/17, at 2:10 p.m., Resident 6's nursing notes, dated 5/26/16 through 1/4/17, indicated on 5/26/16, Resident 6 had a fall that was witnessed by the nursing assistant. The resident fell from his wheelchair to his knees. On 7/1/16, Resident 6 was found on the floor next to his bed and had a bleeding gash above his right eye; three staff assisted Resident 6 to his bed. On 8/27/16, Resident 6 leaned forward and fell from his wheelchair witnessed by staff and sustained a 1 cm laceration to his right eyebrow. On 1/4/17, Resident 6 had a fall to the floor during a transfer to the wheelchair with one staff member. When asked how Resident 6's care prevented further falls after the fall on 1/30/16, Administrative Staff B stated that the nurse performed and documented Fall Risk Evaluations and initiated care plans with updated interventions after each fall. Administrative Staff B agreed the Fall Risk Evaluation form for Resident 6's fall on 1/30/16, dated 2/1/16, was inaccurate and indicated no history of falls in past 3 months was inaccurate. Administrative Staff B also stated the Fall Risk Evaluations for Resident 6's falls on 7/1/16 and 8/27/16, were not documented and should have been completed by the nurse.
Care plans and interventions for Resident 6 included:
a) Care plan initiated on 10/28/15, revised 2/1/16, the resident has limited physical mobility r/t (related to) gen (generalized) weakness, on 1/30/16, resident apparently fell out of his wheelchair; sustained a 1.5 cm cut above R (right) eye. Interventions included verbal reminders on safety with proper position while up in wheelchair (initiated 2/1/16). Redirect and ask if needing assistance with something when resident noted to lean forward in chair (initiated 2/1/16). The resident is weight-bearing (initiated 10/28/15). Locomotion, resident uses wheelchair for locomotion. Clean (per schedule cleaning and prn [as needed] soilage) (initiated and revised 11/29/15).
b) Care plan initiated on 10/28/15, revised 1/10/17, the resident has limited physical mobility r/t (related to) general weakness, interventions initiated on 2/1/16, included verbal reminders on safety with proper position while up in wheelchair. Redirect and ask if needing assistance with something when resident noted to lean forward in chair (initiated 2/1/16).
c) Care plan initiated 4/15/16, revised 11/29/16, the resident is moderate risk for falls r/t weakness and history of falls. 8/27/16: Resident had witnessed fall from wheelchair to ground as he was trying to reach towards the ground and hit his head with minor skin tear. Interventions included anticipate and meet the resident's needs (initiated 4/15/16). Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (initiated 8/29/16). Ensure the resident is wearing appropriate footwear (non-skid socks) when mobilizing in w/c [wheel chair] (initiated 8/29/16, revised 11/29/16). Follow facility fall protocol (initiated 4/15/16). The resident uses (chair and bed) electronic alarm. Ensure the alarm is in place as ordered (initiated 8/29/16, revised 11/29/16). The resident uses fall prevention device: tab alarm. Ensure the device is in place as ordered (initiated 4/15/16, revised 4/15/16).
d) Care plan initiated 4/15/16, revised 1/10/17, the resident is moderate risk for falls r/t weakness and history of falls. Interventions included, anticipate and meet the resident's needs (initiated 4/15/16), be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (initiated 8/29/16). The resident needs prompt response to all requests for assistance (initiated 8/29/16). Ensure resident is wearing appropriate footwear (non-skid socks) when mobilizing in w/c (wheelchair) (initiated 8/29/16, revision 11/29/16). Follow facility fall protocol (initiated 4/15/16). The resident needs a safe environment with: (a working and reachable call light, the bed in low position at night; Slide fails [sic] as ordered, personal items within reach) (initiated 8/29/16, revision 11/29/16). The resident uses (chair and bed) electronic alarm. Ensure the alarm is in place as ordered (initiated 8/29/16, revised 11/29/16). The resident uses fall prevention device: tab alarm. Ensure the device is in place as ordered (initiated 4/15/16, revised 4/15/16).
During a concurrent interview and record review of Resident 6's care plans on 1/31/17, at 8:25 a.m., when asked what fall prevention interventions were put in place to prevent Resident 6 from repeated falls, Administrative Staff B stated the fall committee and IDT meetings discussed further interventions. Administrative Staff B also stated the Fall Committee started October 2016, and no documentation existed from the Fall Committee for Resident 6. Administrative Staff B stated she recalled the IDT determined Resident 6 was no longer able to release his self-releasing lap belt and it was discontinued. Administrative Staff B could not locate the documentation regarding the discontinued self-releasing lap belt in Resident 6's clinical record. Administrative Staff B also stated Resident 6 did not have the cognition (lacks ability to reason, perceive, and conceive knowledge) to use his call bell independently. IDT note on 7/14/16, indicated Resident 6 sustained a fall without a date, no injury, the goal met and resident has not had further incidents. Administrative Staff B concurred care plans were not initiated nor updated to include falls that occurred on 5/26/16 and 7/1/16.
During an interview on 1/31/17, at 9:00 a.m., when asked what Administrative Staff B expected from nursing when Resident 6 had repeated falls, Administrative Staff B stated she expected nursing staff to document all falls in the care plan and progress notes, perform a full assessment, and a fall risk evaluation. Administrative Staff B also stated Resident 6's repeated falls were discussed at the IDT meetings and fall committee to re-evaluate interventions and discuss further interventions. When asked how the chair alarm initiated on 4/15/16, prevented Resident 6's repeated falls from the wheelchair, Administrative Staff B stated the chair alarm alerted staff when Resident 6 was falling from the wheelchair. When asked who performed the root cause analysis (investigation to determine reason of fall) after a fall, Administrative Staff B stated the facility did not perform a root cause analysis for any of Resident 6's falls.
The facility policy and procedure titled "Falls and Fall Risk, Managing, dated 2001, revised December 2007, pages 5 & 6, no revision date, indicated Monitoring Subsequent Falls and Fall Risk, item 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. Item 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.
The facility document titled "Falls - Clinical Protocol", dated 2001, revised September 2012, page 3, indicated Monitoring and Follow-up, item 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.
Therefore, the facility failed to: 1) Provide adequate supervision for Resident 1, when Resident 1, who required two-person assist and extensive assistance for toileting, was left sitting on a toilet seat unattended, stood and attempted to walk out of the Shower room/Bathroom door and fell, resulting in a fractured hip; and 2) Provide adequate supervision for Resident 6, when Resident 6, who required one-person extensive physical assistance for transfer to and from the wheelchair, had multiple falls, two of which resulted in lacerations to Resident 8's forehead above the right eye.
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. |
| 120000331 |
Height Street Skilled Care |
120010212 |
B |
23-Oct-13 |
8NSR11 |
2846 |
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 10/3/13 at 1:50 PM, an unannounced visit was made to the facility to investigate a complaint regarding facility not reporting injuries of unknown origin.Based on observation, interview, and record review, the facility failed to report an allegation of resident to resident abuse within the required time frame. During a concurrent observation and interview with Resident 1, on 10/3/13, at 5:01 PM, in the smoking area. She stated yesterday (10/2/13) around 4 PM, there was a confused resident (Resident 2) who grabbed her left wrist in the hallway and it was so hard that she thought her wrist would be fractured. Licensed Vocational Nurse (LVN) 1 and CNA 1 came to help and removed Resident 2's hand from her. Resident 1 stated she was so mad with the LVN to make her felt it was her fault.During a review of the clinical record for Resident 1, on 10/3/13, at 5:15 PM, there was no documentation found regarding the incident. During an interview with the LVN 1, on 10/3/13, at 5:25 PM, she stated Resident 1 came out of her room and Resident 2 was in the hallway. She also stated Resident 2 suddenly grabbed Resident 1's left wrist in the hallway. She and another staff (CNA) 1 came to help by removing Resident 2's hand from Resident 1's wrist. She also stated she did not document the incident or make an incident report because Resident 1 said she was okay, and thought it was settled. LVN 1 denied yelling at the resident. During an interview with CNA 1, on 10/4/13, at 3:05 PM, she stated Resident 2 was more confused and when the incident happened she told Resident 2 "Don't do that," while removing Resident 2's hand from Resident 1's wrist. She then pushed Resident 2 back to his room. CNA 1 also stated she did not document the incident.During an interview with the Registered Nurse Supervisor (RNS), on 10/9/13, at 3:20 PM, she stated she was there and heard the resident to resident altercation but she did not documented or report the incident because Resident 1 said "She's OK. During an interview with Resident 1, on 10/7/13, at 1:25 PM, she stated the confused resident (Resident 2) tried to grab her arm again in the hallway on Saturday 10/5/13, two days after the first incident. Since the yelling and two incidents of the confused resident trying to grab her, she stated she became sick and kept herself in the room.The undated facility policy and procedure titled "ABUSE POLICY AND PROCEDURE" indicated under "G. REPORTING 8. The Administrator or designee and Director of Nursing, or Nursing Supervisor shall report all incidents of alleged abuse or suspected abuse to Department of Public Health within 24 hours." |
| 120000331 |
Height Street Skilled Care |
120010559 |
A |
01-Apr-14 |
535P11 |
8577 |
72311Nursing 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... (3)Notifying the attending physician promptly of... (B)Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On September 18, 2012 at 2:45 PM, an unannounced visit was made to the facility to investigate a family complaint regarding quality of care.Based on interview and record review, the facility failed to accurately assess the severity of one patient's (Patient A) change in condition when she was noted to have increased edema (swelling) to her entire body and failed to notify the attending physician of the change in condition for the patient. Patient A subsequently died.Patient A was a 54 year old , ventilator dependent (a device for giving artificial respirations for patients who cannot breathe on their own) female admitted to the facility on August 9, 2012 with the diagnoses of respiratory failure, tracheostomy (a surgical opening made in the neck/throat for the insertion of a tube to facilitate breathing), G-tube feedings (tube inserted through the abdomen into the stomach used to feed liquid nourishments), diabetes, chronic obstructive pulmonary disease, chronic Hepatitis C (disease of the liver), liver cirrhosis (when the cells become scared preventing the liver from functioning), and chronic renal failure (kidney no longer function to purify the blood). Patient A was non-verbal and made her needs known through facial expression, pointing, and grunting.During a review of the clinical record for Patient A the "Intake Output Record" dated 8/9/12 through 8/13/12 indicated Patient A received 1280 ml on 8/9/12, 4500 ml on 8/10/12, 4700 ml on 8/11/12, 4810 ml on 8/12/12, and 1790 ml on 8/13/12 before being transferred to the emergency department of a local acute care hospital at 5:45 AM. There was no output amounts documented on the form only the number of times Patient A voided. The "Physician's Orders" dated 8/9/12 included "record the intake and output each shift." Although requested, the facility failed to provide their policy and procedure for monitoring Intake and Output.During an interview with Certified Nursing Assistant (CNA 1) on 9/28/12 at 9:30 AM, she stated "I started noticing changes (in Patient A) like swelling, slept more, and moaned less about 2 AM on 8/13/12. CNA 1 stated she informed RT 1 and RN 1 and RT 1 talked to RN 1 about sending the patient out (to the hospital). RT 1 asked about her urine output and CNA 1 informed him she was unable to measure it due to the patient had no Foley catheter (tube inserted into the bladder for drainage of urine). CNA 1 stated RT 1 gave breathing treatments and he kept asking RN 1 if she was sure she didn't want to send the patient out, "he asked her this several times." "(RN 1) kept saying she only needs suctioned." CNA 1 stated RN 1 continued to ignore RT 1's request to send the patient out to the emergency room. CNA 1 described entering Patient A's room about 5 AM (on 8/13/12) and found her eyes swollen shut and tongue swollen and she was not breathing. CNA 1 then went to get RT 1. RN 1 entered the room at the same time and informed RT 1, the patient needed to be suctioned again. CNA 1 stated when RT 1 entered Patient A's room he said "she doesn't need suctioned she is suffocating." The "Respiratory Notes" dated 8/13/12 and signed by the Respiratory Therapist (RT 1), indicated he was called into Patient A's room by Registered Nurse (RN 1) at 5:15 AM. RT 1 described walking into the room and observed the patient as "extremely swollen," she had a palpable pulse with a slow heart rate and advised RN 1 to call 911. RT 1 described the trach collar (used to secure the tracheostomy tube) was cutting into the neck and could not loosen it so he cut it off. When Patient A was being transferred from the bed to the gurney for transport the trach tube came out and they were unable to re-insert it; therefore, losing the air-way. RT 1 indicated Patient A's gown was so tight on her that it had to be cut off before chest compressions could be started.During an interview with RT 1 on 9/28/12, at 8:50 AM, he described during his rounds on 8/13/12 he noted Patient A had "puffy cheeks" and completed an assessment. He alerted RN 1 of his findings and told her he suspected it was possible fluid overload and the patient should be watched closely due to her history of congestive heart failure and being prone to retaining fluids. RT 1 stated RN 1 called him into Patient A's room to be suctioned and when he entered the room the patient was "3 times her normal size". RT 1 told RN 1 "she didn't need suctioned but had fluid overload, then RN 1 asked what to do." RT 1 instructed her to call 911 and he began setting up to provide oxygen. After an assessment he began bagging (providing oxygen by using a bag you squeeze air into the trach). RT 1 described meeting resistance with bagging due to the swelling in Patient A's airway. RT 1 stated he cut off the gown due to constriction around the chest and the neck, but did not remember cutting off the trach collar, but he said "if I charted it, I did it." RT 1 stated the Ambulance and Fire Department personnel arrived and took over the code. During an interview with RN 1 on 9/28/12, at 9:15 AM, she indicated during her rounds she found Patient A lying in bed moaning and experiencing increased agitation. RN 1 stated she checked the tubing for secretions and attempted to suction Patient A two times before calling for RT 1, whom also suctioned the patient. RN 1 stated Patient A "kept blowing up like a balloon, she kept getting bigger and bigger and was having difficulty breathing." RN 1 stated she noticed the trach collar getting tighter and told RT 1 who then "cut it off." RN 1 stated she began CPR and RT 1 began bagging the Patient.During an interview and record review with the Minimum Data Set Nurse Coordinator (MDSC), on 3/20/14, at 2:20 PM, after reviewing the record of Patient A, she stated she did not know why the patient did not have a Foley catheter inserted or why no physician's order was obtained to insert a Foley catheter. No further information was provided.The Licensed nurse progress notes were reviewed. On 8/12/12, at 10:40 PM, the licensed nurse documented the patient's oxygen saturation ([O2 sat] the amount of oxygen in the blood with normal range 95%-100%) was 97%. On 8/13/12, at 4 AM, the licensed nurse documented the oxygen saturation was 95%. At 5:17 AM, the licensed nurse documented, "...assessed the resident since sign of SOB (shortness of breath) is noted. Took O2 Sat, 71%. Called up RT to suction, despite such effort O2 Sat is decreasing. Condition worsens. Ambu bag (and) CPR done...Code blue (a medical emergency when medical personnel attempt to resuscitate a patient)." At 5:21 AM, the licensed nurse documented 911 was called. At 5:28 AM, the licensed nurse documented 911 personnel arrived. At 5:45 AM, the licensed nurse documented, the 911 personnel left the building. At 7:15 AM, the patient's sister informed the facility the patient had expired. At 7:40 AM, the Coroner's office called to ask what "transpired..." From 8/12/12 at 10:40 PM through 8/13/12 at 7:40 AM, there was no assessment by the licensed nurse (RN 1) of the severity of Patient A's edema. There was also no documentation, until the code blue was called, any attempts to notify the attending physician of the patient's change in her physical condition.The Care Plan for "Renal Failure/insufficiency dated 8/9/12 was reviewed. The approaches included, "Observe feet and hands for edema...Notify PMD (Primary Medical Doctor) if edema...or shortness of breath occurs...Monitor intake and output as indicated and any other fluid restrictions as ordered..."The approaches for the care plan titled, "Risk of Dehydration," dated 8/10/12, included, to monitor skin turgor, complete labs and medications as ordered, and monitor for edema and report any abnormal condition to MD (physician).Therefore the facility failed to properly assess a change in condition in Patient A and failed to notify the physician of the change in condition when the patient was observed to have edema throughout her body, which had a substantial probability to have contributed to her death. |
| 120000331 |
Height Street Skilled Care |
120010870 |
A |
04-Aug-14 |
R3QR11 |
10509 |
F314 - Treatment/services to Prevent/heal Pressure sores - 483.25(c) Based on the comprehensive assessment of a resident, the facility must ensure that resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.On 3/20/14, at 1:35 PM, an unannounced visit was made to the facility to investigate a complaint about the development of a pressure ulcer.Based on interview and record review, the facility failed to ensure one of one sampled resident (1) did not develop an avoidable pressure ulcer (according to the National Pressure Ulcer Advisory Panel [NPUAP] a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with a shear), when the facility failed to:a. develop a care plan to address the resident's noncompliance with floating her heels, b. accurately assess the right heel pressure ulcer to ensure proper treatment, c. ensure showers were provided, d. perform skin assessments, e. ensure the Interdisciplinary Team (IDT) reviewed Resident 1's pressure ulcer per the facility's policy and procedure, f. develop a policy and procedure for Deep Tissue Injury (according to the NPUAP suspected [DTI] is purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue...Evolution may be rapid exposing additional layers of tissue...) treatment.These failures resulted in the development and progression of Resident 1's pressure ulcer.Findings:Resident 1 is a 77 year old female admitted on 1/17/14, with diagnoses of left knee periprosthetic fracture (a fracture around a join replacement prosthetic or implant), muscle weakness and Diabetes Mellitus (a disease characterized by hyperglycemia [elevated blood glucose levels] resulting from defects in insulin secretion, insulin action or both). A review of the clinical record was conducted. The admission document, "NURSES ADMISSION AND ASSESSMENT RECORD", indicated Resident 1 had no pressure ulcer upon admission.The "Pressure Ulcer/Skin Integrity" care plan, dated 1/17/14, indicated Resident 1 had poor bed mobility with thin and fragile skin. The Minimum Data Set (MDS-a comprehensive assessment tool), dated 1/29/14, indicated Resident 1 required extensive one person assist with bed mobility. The Braden Scale (a tool used to assess a patient's risk for skin breakdown) for 1/17/14, 1/24/14, 1/31/14, and 2/7/14, indicated a score of 14 (moderate risk). On 2/23/14, the "Licensed Nurses Progress Notes" indicated Resident 1 had redness on the right heel. A physician's order, dated 2/23/14, indicated to "monitor (right) heel redness QD (every day) x 14 (days)". On 2/28/14, the document "WEEKLY LICENSED DOCUMENTATION" indicated Resident 1's right heel was "red/purple intact" measuring 1 x 1 centimeters (cm).a. During an interview and record review with Licensed Nurse (LN) 1, on 3/20/14, at 2:20 PM, she stated Resident 1 developed a pressure ulcer on her right heel because Resident 1 was not compliant with floating her heels and kept rubbing her heels on the bed; however, there was no care plan noted in the clinical record to address the resident's noncompliance with floating her heels and to address the resident's rubbing her heels on the bed. LN 1 confirmed and acknowledged there should have been a care plan for the LNs to implement approaches to address the problem.The undated facility policy and procedure titled, "CARE PLANNING", indicated under PROCEDURE: "4. Identify the problems or needs. After information has been gathered, the data is analyzed to determine when problems and needs exist...5. Select actions/approaches.When selecting appropriate actions or approaches toward resolving the resident's problems, ...Although specific actions are performed by the individual responsible discipline, the interdisciplinary team's collective actions provide the most effective effort toward resolution of the resident's problems..."The undated facility policy and procedure titled, "PRESSURE ULCER" indicated under the PURPOSE subheading, "A program of preventative, care, and treatment of pressure ulcers is carried out for all residents to prevent skin breakdown and promote healing." Under the POLICY subheading it indicated, "...Nursing judgment may be used to determine what preventive measures are to be used for each resident. These measures are included in the Resident Care Plan..."b. During a concurrent interview and review of the clinical record for Resident 1, on 3/20/14, at 2:26 PM, LN 1 was asked the stage of the pressure ulcer Resident 1 developed on her right heel. On 2/23/14, the "Licensed Nurses Progress Notes" indicated Resident 1 had redness on the right heel. On 2/28/14, the document "WEEKLY LICENSED DOCUMENTATION" indicated Resident 1 had a stage I (according to the NPUAP, a stage I is intact skin with non-blanchable redness of a localized area) pressure ulcer which was "red/purple intact" measuring 1 x 1 centimeters to the right heel. On 3/6/14, the document "WEEKLY LICENSED DOCUMENTATION" indicated Resident 1 had a stage I pressure ulcer measuring 1 x 1 cm to the right heel that was "red/purple". After reviewing the clinical record, LN 1 indicated if the color of the right heel was "red/purple", as indicated on 2/28/14 and 3/6/14, the wound should have been categorized as a DTI. No further information was provided.c. During an interview with LN 2, on 6/2/14, at 4:20 PM, she stated Resident 1's shower schedule was Tuesday, Thursday, and Saturday Morning shift.During a review of the clinical record for Resident 1, the document "RESIDENT DAILY CARE FLOW SHEET" indicated, from 1/28/14 to 3/6/14, Resident 1 should have received a total of 16 showers. There was no documentation from, 1/28/14 to 3/6/14, on the "RESIDENT DAILY CARE FLOW SHEET" Resident 1 received any shower and there was no documented evidence Resident 1 had refused showers during that timeframe.During an interview with LN 2, on 6/2/14, at 4:25 PM, after reviewing the clinical record of Resident 1 she confirmed there was no documentation the resident received a shower as scheduled and stated she would check the Certified Nursing Assistant (CNA) shower skin assessment (a document used by CNAs to document skin issues on the days the resident is showered) to find out if there was any documentation the resident may have refused showers.No further information was provided that Resident 1 had refused showers or any documentation the resident was showered as scheduled.During an interview with CNA 1, on 6/2/14, at 4:25 PM, she stated there were no shower skin assessments because the resident did not receive any shower, only sponge baths. No further information was provided.The undated facility policy and procedure titled, "BATHING A RESIDENT", indicated under the PROCEDURE subheading, "...16. Record in the medical record the procedure, results and observation." Under the "REPORTING AND DOCUMENTATION", subheading it read in part, "If the resident refused...note the reason(s) why on the CNA Progress Notes."d. During an interview with LN 2, on 6/2/14, at 4:30 PM, after reviewing the clinical record of Resident 1, she was unable to find documentation the CNAs performed skin assessments on the resident's shower days from 1/28/14 to 3/6/14 since no showers were given. No further information was provided.The undated, facility policy and procedure titled, "BATHING A RESIDENT" indicated under the "REPORTING AND DOCUMENTATION subheading, "The following information should be reported to the staff/charge nurse and documented in the resident's medical record...Report, to the staff/charge nurse, any skin issues observed during the procedure." Indicated under the PROCEDURE subheading, "3. Observe the resident's skin for any redness, rashes, broken skin, tender areas, irritation, reddish or blue-gray area over a pressure point, blisters or skin breakdown..."e. During a concurrent interview and review of the clinical record for Resident 1 with LN 2, on 6/2/14, at 4:38 PM, although the Interdisciplinary Team (IDT) should have reviewed Resident 1's pressure ulcer when it developed, she was unable to find documented evidence the IDT reviewed Resident 1's pressure ulcer. LN 2 indicated an incident report should have been completed and then once the IDT receives the incident report, IDT would review the clinical record and document in the clinical record. No documentation could be found in the resident's clinical record, the IDT reviewed Resident 1's pressure ulcer.The undated policy and procedure titled, "CARE PLAN CONFERENCE" which LN 2 provided indicated under the "RESPONSIBLE DISCIPLINE" included, "The Interdisciplinary Team is composed of the Physician if available, director of Nursing...Charge Nurse and/or Licensed Nurse who provides care...representative from disciplines, including...Dietary, Physical and Occupational Therapies...and the resident/the resident's family..." Under the POLICY subheading, "Each resident will have an Interdisciplinary Team Conference during the initial admission period, quarterly and on as needed basis." Under the PURPOSE subheading it reads, "3. To develop, review and update the resident's plan of care...4. To reassess those residents who experience a significant change in status. 5. To document a summary of the resident's plan of care and progress..."f. During a concurrent interview and review of the undated facility policy and procedure titled, "PRESSURE ULCER", with LN 2, on 6/2/14, at 4:50 PM, although different stages of pressure ulcers require different treatment options, the policy and procedure did not address the treatment options for a pressure ulcer that is categorized as a DTI; therefore, the policy and procedure did not provide guidance to licensed nurses through the assessment and treatment phase of Resident 1's DTI. LN 2 verified the findings. No further information was provided.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. |
| 120000331 |
Height Street Skilled Care |
120011359 |
A |
06-Apr-15 |
XCF911 |
14804 |
?483.13(b) Abuse (F223) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On October 20, 2014 at 11:10 AM, an unannounced visit was made to the facility to conduct a relicensing and recertification survey.Based on interview, observation, and record review, the facility failed to provide adequate supervision for one of 27 sampled patients (17) which placed 108 patients, including Confidential Patient C, at risk for potential harm from verbal and physical abuse, as well as actual harm for Random Patient 33, Sampled Patient 4, and Confidential Patients A and B.1. For Random Patient 33, the facility failed to protect her from verbal abuse, and her family from physical abuse, by Patient 17 which resulted in Patient 33 fearing for her life.2. For Sampled Patient 4, the facility failed to protect her from verbal and physical abuse by Patient 17, which resulted in an unsafe living environment. 3. For Confidential Patients A and B, the facility failed to protect them from verbal and physical abuse which resulted in them not feeling safe in the facility.Findings:1. During an interview with Patient 33, on 10/20/14, at 11:20 AM, she stated Patient 17 was her roommate. Patient 33 stated Patient 17 had threatened to "...slice my throat open with a knife while I slept." She had told her daughters this information, was afraid of Patient 17, and did not feel safe in her room. Patient 33 stated her daughters had spoken to the Administrator recently about this, and demanded Patient 17 be moved out of her mother's room, but this request had been denied. Patient 33 stated she believed Patient 17 was dangerous, "very abusive", swears at her and her family, rams her wheelchair into her family members during visits, and "She's got some kind of mental illness, and she's just not safe here around all these old people. She belongs in a psych hospital [psychiatric hospital is a facility that specializes in the treatment of those with mental illnesses]."During an interview with the Administrator on 10/22/14, at 12:20 PM, he recalled talking with Patient 33's daughters on 10/18/14. They discussed how Patient 33 did not feel safe with Patient 17. The Administrator stated Patient 17 did not want to move to a different room and that "she has rights too." The Administrator stated that since Patient 17 did not want to move, he would provide her with a "sitter", explaining that this would be an employee who would sit with, and monitor, Patient 17's behaviors for 24 hours. The Administrator was then asked for a list of staff who providing this "sitting" duty.However, during an interview with the Administrator on 10/22/14, at 3:50 PM, he stated "We didn't actually have a sitter" for Patient 17 when she was in her room with Patient 33. The Administrator stated that despite what he told Patient 33's family, he had later "conferred with the nursing staff", and determined a sitter was not required.During an interview with Patient 33's daughter, FM 1, on 10/22/14, at 4:50 PM, she stated she and her family had requested Patient 17 be removed from her mother's room because "She was destructive and mean." Family Member (FM) 1 stated Patient 17 "rams her wheelchair into us during our visits." FM 1 stated Patient 33 told her Patient 17 had threatened to "slice her throat open while she slept." FM 1 stated the facility "needs to observe [Patient 17] 24 hours a day, 7 days a week." FM 1 further stated she had seen Patient 17 ram her wheelchair into other patients'. FM 1 stated she and her sister requested Patient 17 be moved to another room because she was violent, and feared for their mother's safety. FM 1 stated she and her sister expressed this to the Administrator a few days earlier in a meeting with him. FM 1 indicated the Administrator stated he could not do that because he had no empty beds available for her. FM 1 also stated she had also informed the Social Services Designee (SS) 1 of these concerns.2. During an interview with Certified Nursing Assistant (CNA) 1 on 10/22/14, at 9:40 AM, she indicated she was very familiar with Patient 17, and had just given her a shower. CNA 1 stated Patient 17 gets "aggressive sometimes. She wants to fight the other patients. We never say anything. She tries to hit other nearby patients, the old ladies." When asked if she thought other patients were safe around Patient 17, CNA 1 answered "No." CNA 1 stated Patient 17 was recently assigned to a different room, and she had a roommate there [Patient 4] who could not walk, and Patient 17 would get angry at that patient, and "I don't think [Patient 4] was safe, we can't watch [Patient 17] 24 hours a day. So we moved [Patient 17 to another room, with Patient 33]."During an interview with Licensed Vocational Nurse (LVN) 4 on 10/23/14, at 4:10 PM, she stated she was familiar with Patient 17, and gives her medications in the evenings. LVN 4 stated trying to talk and calm down Patient 17 often does not work because "the more you talk to her, the more agitated she gets." LVN 4 stated Patient 17 had two room changes recently due to "roommate incompatibility." LVN 4 stated Patient 17 is not always confined to her wheelchair, and can get up and walk about freely if she wishes. LVN 4 was asked if other patients in the facility are safe around Patient 17, and she answered "No, probably not." LVN 4 further stated it would be beneficial to have a dedicated staff person assigned only to care for Patient 17.During an interview with Patient 4, on 10/23/14, at 4:30 PM, she stated Patient 17 used to be her roommate. Patient 4 stated "I've been kicked, hit, pinched, bit on the hand, and screamed at" by Patient 17. Patient 4 stated she had told staff of these events, and mentioned LVN 4 specifically. Patient 4 stated Patient 17 "is a big devil."3. During a confidential group interview on 10/21/14, at 3:30 PM, Confidential Patient A stated Patient 17 had rammed her wheelchair into her, swore at her, and therefore had complained to staff, but "They don't do anything." Confidential Patient B stated Patient 17 "Hit me with her wheelchair on my shin," and swore at her. Confidential Patient C indicated Patient 17 was dangerous in the facility, and believed she was going to seriously injure another patient, stating "She's going to take someone to the cleaners." Confidential Patients A, B, and C all stated they did not feel the facility provided a safe environment for the patients, and did not appropriately address Patient 17's physical and verbal violence towards the other patients.During an interview with LVN 1 on 10/22/14, at 9:50 AM, she stated she was familiar with Patient 17 and gives her medication daily. LVN 1 stated Patient 17 "Gets mad, with aggressive behavior." LVN 1 also stated Patient 17 visits the main dining room for "mostly all meals" daily, which is also visited by dozens of other patients. LVN 1 indicated Patient 17 will often yell and swear profanities at the dozens of other patients during their meals. LVN 1 indicated Patient 17 is loud and can hear her do this from the other end of the building. LVN 1 stated if Patient 17 "targets a patient, we move that patient away from her, and tell her 'that isn't very nice.' This occurs daily. If she's in a bad mood, other patients are not safe around her."During an observation of Patient 17 on 10/22/14, at 12:30 PM, she was noted screaming and crying, in the lobby of the facility, stating "No! I hate her guts!" loudly toward another patient. Then, she wheeled herself in her wheelchair along one hallway rapidly. When she approached two slow moving patients blocking her path by Room 104, she yelled "Move!" and rammed her wheelchair into the back of one. Nearby staff intervened, separated the patients, and escorted Patient 17 away.During an interview with Patient 17 on 10/23/14, at 3:20 PM, she stated she liked it at the facility, but sometimes gets sad. When asked 'What happens when you're sad?', Patient 17 stated "I want to kill everyone." When asked "Do you ever get mad' Patient 17 stated "Yes. At my roommate. She's elderly."During a review of the clinical record for Patient 17, the documents titled "Minimum Data Set [a standardized, comprehensive assessment tool]", dated 10/8/14, indicated she was admitted to the facility in 2013, with diagnoses that included schizophrenia and bipolar disorder, both serious psychological diseases that can cause significant behavior issues. [From the National Institute of Mental Health, at "www.nimh.nih.gov": Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history. People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated. 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. Symptoms of bipolar disorder are severe.]The document titled "Nurse's Notes" dated 10/18/14, at 7 AM, read Patient 17 was "...now yelling and screaming and cursing to staff and other patients... throwing things across the room such as hairbrush and cups." The document read at 8 AM, the local police department was called, and after arriving at 8:30 AM, police officers took Patient 17 to a local psychiatric facility on a "5150 [Section 5150 is a section of the California Welfare and Institutions Code which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him or her a danger to themselves, a danger to others, and/or gravely disabled]" for "anger outbursts, throwing things, and danger to herself." The "Nurses' Notes" indicated Patient 17 returned to the facility later that day at 11:30 AM.The facility documents titled "[Patients] known to have Contacts with [Patient 17]", dated 10/24/14, were reviewed. The documents contained interviews with patients regarding their experiences with Patient 17 and read in part (each entry is from a different patient):-- "...had seen [Patient 17] outside in the hallway yelling and cussing others..."-- "...yells and curse others..."-- "...heard [Patient 17's] yelling in the hallway."-- "...doesn't like it when other patients yell or scream."-- "...don't like it when other patients yell or scream."-- "...always hears [Patient 17] in the hallways... cursing at everyone."-- "...witnessed [Patient 17] continuously cursing at... other patients... using explicit language."-- "... witnessed [Patient 17] always cussing everyone out... very disruptive and that it's more peaceful in the building now that she has been relocated."-- "...witnessed [Patient 17] being verbally aggressive with other patients using cuss words and being very 'unpleasant'... she was always cussing and being rude."-- "...was very 'mean' by always using cuss words and raising her middle finger at her... avoided her when she could."During an interview with the Administrator on 10/27/14, at 10:05 AM, he stated Patient 17 had been transferred out of the facility on 10/24/14, to a psychiatric facility. The Administrator stated Patient 17 was not exhibiting any "behaviors." When asked why was she sent to a psychiatric facility, i.e., what was she doing that warranted such a transfer, the Administrator answered "Nothing." The Administrator indicated the facility held an interdisciplinary team meeting, and the team determined Patient 17 "should be at a lower level of care, or at a psychiatric hospital, a more appropriate setting. Her attending physician (Medical Doctor [MD] Z) transferred her. She has been there ever since."However, during an interview with the Registered Nurse Supervisor (RNS) on 10/27/14, at 2:55 PM, she stated she was on duty and caring for Patient 17 when she was transferred out to the psychiatric hospital. The RNS stated Patient 17 was in the hallway, screaming, crying, and kicking another staff member. The RNS stated this behavior started at approximately at 1 PM on 10/24/14. The RNS stated because of her combative behavior, she called Patient 17's attending physician personally, who ordered her to be sent to a psychiatric hospital.The facility policy and procedure titled "Abuse Prevention, Recognition, and Reporting", dated 10/2013, read in part:"Abuse... will not be tolerated in this facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from verbal, sexual, physical, and mental abuse... Residents must not be subjected to abuse by anyone, including, but not limited to... other residents... Abuse means the willful infliction of injury... intimidation... pain or mental anguish.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. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.Facility will identify, correct and intervene in situations in which abuse... are more likely to occur (i.e., physical environment that may make abuse and/or neglect more likely to occur, deployment of staff on each shift in sufficient number to meet the needs of the residents, supervision of staff to identify inappropriate behaviors and assessment, care planning and monitor of residents with needs and behaviors which might lead to conflict or neglect).If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps: Provide a safe environment for resident(s) as indicated by the situation: a) if the suspected perpetrator is another resident: separate the residents so they do not interact with each other until circumstances of the reported incident can be determined; if a room change is appropriate, advise resident's families of the change in room location."Therefore, the facility failed to protect as many as 108 patients from the potential for physical from Patient 17; as well as actual harm for Random Patient 33, Sampled Patient 4, and Confidential Patients A and B. This presented imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result, to as many as 108 patients. |
| 120000331 |
Height Street Skilled Care |
120011468 |
A |
02-Jun-15 |
XCF913 |
8887 |
F223-42CFR 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On February 24, 2015, at 9:30 AM, an unannounced visit was made to the facility for a third revisit from a recertification survey. The facility failed to follow it's abuse policy and procedure when four staff (Director Of Nursing (DON), Social Services Assistant (SS) 1, Licensed Nurse (LN) 1, LN 3, were made aware of an allegation of abuse by one of 14 sampled residents (66) and the allegation of abuse was not investigated, not reported, and the resident was not kept safe. This failure resulted in Resident 66 suffering in physical pain when pain medications were withheld, and mental anguish when the licensed nurse (LN 5) accused of abusing her, continued to be assigned to her and also had the potential to affect other residents.Resident 66 was a 58 year old woman. She had a tracheostomy (an opening through the neck into the windpipe through which a tube is placed to provide an airway and to remove secretions from the lungs) connected to her, as well as a gastrostomy tube (nutrition provided through a tube which is surgically inserted into the stomach). Because of the tracheostomy, Resident 66 was only able to speak in a whisper, however she is able to communicate. Resident 66 had a medical history of Acute Respiratory Failure, Encephalopathy (infection of the brain), and generalized muscle weakness. During an interview with Resident 66 on 2/24/15, at 10:25 AM, she stated she had submitted a grievance to SS 1 regarding an incident with LN 5. Resident 66 presented a copy of the "Resident Grievance/Concern Form", dated 2/17/15, which indicated "The pm nurse is so mean to me. I'm asking my 9:00 pm medication [sic] and he yelled at me...." Resident 66 further stated the incident occurred on 2/16/15, and LN 5 refused to give her the scheduled medications after she (Resident 66) complained about him.During a review of the clinical record for Resident 66, the "Admission Record" dated 1/23/15, indicated Resident 66 was her own responsible party. The "History and Physical" dated 10/26/14 and 2/10/15, indicated Resident 66 "Has the capacity to understand and make decisions."During a review of the facility "Grievance Log" for 2/2015, there was no documentation of the grievance submitted by Resident 66 on 2/17/15.During an interview with Resident 66 on 2/26/15, at 3 PM, she began to cry and stated she was scared and upset..."I'm afraid he (LN 5) will retaliate against me again when he finds out I talked to you. He is still my nurse sometimes, even though I asked to have a different nurse." She stated on 2/16/15, when LN 5 did not give her the scheduled medications, LN 5 stated to her, 'I don't care about you, stop asking me (about the pain medications), because you won't get them (pain medications).' "I cried...I was so upset... I was in pain without my medication." Resident 66 further stated her pain level on 2/16/15 was a "9" (on a pain scale ranging from 0 to 10, 0 meaning no pain, 10 meaning a severe amount of pain) and was "...so bad I was shaking and crying." Resident 66 stated LN 3 was aware of the incident because "LN 3 was the other nurse on. She came in (Resident 66's room) an hour later and saw me crying and shaking. She gave me my medications after I told her what had happened with LN 5."During an interview with SS 1, on 2/26/15, at 3:55 PM, she was asked if Resident 66 submitted any grievances. SS 1 stated, "No, none that I know of." SS 1 was shown a copy of Resident 66's grievance, and SS 1 stated "Oh yea, that is my handwriting...I gave the copy to the resident...she wanted a copy." SS 1 was asked what was done to protect Resident 66. SS 1 stated "The nurse is not assigned to her." When asked if she knew who the licensed nurse was, she stated "I don't know...I would ask the charge nurse who is assigned." She was then asked if she would know if it was the same licensed nurse from the grievance, and SS 1 stated, "I don't know." SS 1 then stated that she had not reported the allegation, she did not document in the social service notes, she did not a form to report adult/elder abuse, and a care plan had not been completed.During an interview with both the Administrator and the Assistant Administrator on 2/27/15, at 11 AM, the Administrator stated he was not aware of the abuse allegation Resident 66 made against LN 5 ten days earlier, "...There wasn't anything in the 'Grievance Log'." He further stated he spoke with Resident 66 earlier in the morning and Resident 66 "...was very upset...crying and crying... she said the way LN 5 treated her was abuse and she wanted something done about it... she said she didn't want LN 5 to take care of her anymore..." The Administrator also admitted the resident was not kept safe since LN 5 had been assigned to care for Resident 66 since the allegation was initially made, and an investigation had not been done. The Assistant Administrator also stated he was unaware of the abuse allegation and he agreed it should have been reported and investigated.During a review of the clinical record for Resident 66, the Medication Administration Record for the month of 2/2015 indicated LN 5 cared for Resident 66 on 2/20/15 and 2/25/15 (after the resident requested to not have him care for her).During an interview with the DON, on 3/2/15, at 3:15 PM, she reviewed the "Grievance Log" and was unable to find documentation of the "Resident Grievance/Concern Form" submitted by Resident 66. She stated if any grievance involves nursing care or nursing staff, Social Services (SS) is to inform the DON and the Administrator.She further stated she was aware of the grievance, it was not documented in the grievance log, it was not investigated, it was not reported, there was no document of an assessment of Resident 66 after the incident, there was no monitoring of Resident 66 after the incident and there was no corrective action taken against LN 5. The DON verified, besides SS and herself, LN 1 and LN 3 were also aware of the allegation. "I didn't treat it as abuse...everyone should've been investigating...We didn't...I made a mistake."During an interview with LN 3, on 3/2/15, at 5:50 PM, she stated she was aware of Resident 66's grievance with LN 5..."(Resident 66) didn't want to see LN 5 anymore...she was teary eyed... I had to give her her medicine..." She verified she did not document the incident.During an interview with LN 1, on 3/3/15, at 10:50 AM, he stated "I was told LN 5 yelled at Resident 66... I told LN 3 what happened... I told SS about the incident...the DON knew about the incident..."During an interview with SS 1, on 3/4/15, at 8:15 AM, she stated "The DON said not to document anything (referring to the grievance)...that's why the grievance was not put in the book. She (DON) told me not to, and to give it (the grievance) to her (DON), She (DON) had it."The facility policy and procedure titled "Abuse Prevention, Recognition and Reporting" dated 10/13, indicated in part, "...Each resident has the right to be free from verbal...abuse...Residents must not be subjected to abuse by anyone, including...facility staff...'Verbal Abuse' is defined as the use of oral...language that willfully includes disparaging and derogatory terms to the resident...Facility will identify, correct and intervene in situation in which abuse...are more likely to occur...If a resident incident is reported...the facility will take the following steps:..If the suspected perpetrator is an employee: Remove employee immediately from the care of the resident; Suspend employee during the investigation...All incidents of suspected or alleged abuse will be investigated... Any mandated reporter who has knowledge of an incident...shall report the...abuse...immediately... The report shall be made to the local ombudsman or the local law enforcement agency...and the Licensing and Certification (L&C) Program...the Director of Nursing will complete an Incident Report and initiate an abuse investigation...A physical assessment of the resident(s) involved will be completed..."Therefore, the facility failed to follow it's abuse policy and procedure when four staff (Director Of Nursing (DON), Social Services Assistant (SS) 1, Licensed Nurse (LN) 1, LN 3) were made aware of an allegation of abuse by one of 14 sampled residents (66) and the allegation of abuse was not investigated, not reported, and the resident was not kept safe. This violation resulted in Resident 66 suffering in physical pain when pain medications were withheld, and mental anguish when the licensed nurse (LN 5) accused of abusing her, continued to be assigned to her and also had the potential to affect other residents. This violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 120001037 |
Higher Ground Homes, Inc. #2 |
120012857 |
B |
10-Jan-17 |
JUGI11 |
4044 |
76345 (a) (2) Health Support Services - Nursing Services Facilities shall provide nursing services in accordance with the needs of the clients for the purpose of: Assistance in achieving and maintaining optimal health. On 11/21/16, an unannounced visit was made to the facility to investigate an entity reported incident regarding Client 1 not provided proper nursing services. Based on interview and record review, the facility failed to: 1. Ensure proper nursing service was provided to Client 1 which resulted in the delayed treatment of Client 1's muscle spasms and exacerbation of her health status. 2. Ensure a health care plan was developed for identified medical problem for Client 1 which resulted in the inappropriate treatment of her health condition. Findings: 1. During a review of the clinical record for Client 1, the progress note dated 11/12/16, at 3:50 PM, indicated "(DSP 1) called stating (Client 1's) pump was needing to be refilled, but doctor's office did not have Baclofen (medication used to treat muscle symptoms like spasms, stiffness) med (medication) and pump (a device consists of delivering a liquid form of Baclofen into the spinal fluid) has been beeping ever since. This occurred on Thursday 11/10/16, that she's been needing Baclofen refill. Today, (Client 1) does "not look right" according to staff...but (Client 1) has been having spasms and a low grade fever...Got to the facility approximately 3:30 PM and (Client 1) did show spasms to hands and arms. Bringing her left arm up to cover her whole face, which is unusual for her behavior." During an interview with the Registered Nurse (RN), on 11/22/16, at 12:25 PM, she stated "The HS (House Supervisor) called me that (Client 1) did not look right...She actually behaved very differently from what she usually does. She was red. Her arms were very tensed. She's not usually like that...Yes, I know she has a Baclofen pump. I know she was needing a refill during that week...It should not be abruptly stopped." During an interview with the HS, on 11/22/16, at 4:10 PM, she stated "I was informed that (Client 1) was having spasms. When I came back over here, it was unusual to see her with movements like that. She was also sweating a lot, having a temperature. I let her (Qualified Intellectual Disability Professional-QIDP) know that the pump was already beeping. It started beeping like by the 28th of October. It was reported to the nurse at (Dr. XXX 1) office that the pump was beeping. I started calling them the 24th of October, every day except Saturday and Sunday. The RN knows that her (Client 1) Baclofen needs to be refilled. (Dr. XXX 2) was not notified. Not to my knowledge." During an interview with the Manager at Dr. XXX 1's clinic, on 12/20/16, at 2:45 PM, she stated "...They used to go to (XXX) hospital for Baclofen refill but we learned lately that it no longer accepts Baclofen administration." 2. During a review of the clinical record for Client 1, the follow up report of the QIDP to an incident dated 11/14/16, indicated "...She (Client 1) is noted to have a lot of muscle spasms and we are thinking this is the result of her Baclofen pump." During a concurrent clinical record review for Client 1 and interview with the RN, on 11/22/16, at 1 PM, she was informed there was no health care plan developed for muscle spasms/spasticity to include the Baclofen pump use. She confirmed the findings and no further information was provided. The facility policy and procedure titled "Health Care Plans" undated indicated "Facility shall establish a formal Health Care plan for each medical condition/medication. Within the plan, devised by the RN, the method of care for the client shall be included as well as any medications with which they are to receive. The Plans shall be client specific and designed to meet each individual client need." Therefore the above violation presented a substantial probability that a serious medical condition adversely affected Client 1's well-being would result and constitute a "Class B" citation. |
| 240000925 |
Hi-Desert Medical Center D/P SNF |
240008914 |
B |
17-Jan-12 |
7ZX711 |
11073 |
REGULATION VIOLATION: Title 22 72315 Nursing Services-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. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (m) Patient call signals shall be answered promptly.The facility failed to ensure that Patient A was free from verbal and mental abuse by staff and failed to ensure Patient A was consistently treated with dignity and respect. The facility failed to ensure Patient A's skin was clean and free from feces. The facility failed to ensure Patient A's linens and clothing were free from feces. The facility failed to promptly answer Patient A's call light. As a result, Patient A was incontinent of a bowel movement and subsequently lay in bed while waiting for staff to provide personal hygiene care.On October 13, 2010, Patient A's medical record was reviewed. Patient A was 62 year old female who was admitted to the facility on September 24, 2009. Patient A's diagnoses included dysfunctional uterus, (Abnormal vaginal bleeding usually resulting from a hormonal imbalance), hypertension, (high blood pressure), diabetes, (high glucose level in the blood) and morbid obesity, (refers to patients who are 50 - 100%, or 100 pounds above their ideal body weight).The Minimum Data Set (MDS, a comprehensive assessment of the resident) dated June 17, 2010, described Patient A as independent with cognitive skills for daily decision making, without memory problems and continent of bladder and bowel; Patient A was totally dependent on staff for transfers. On October 13, 2010 at 9:45 AM an interview was conducted with Patient A. Patient A was awake, lying in bed, and responded appropriately to questions. Patient A stated that on the date of the incident, she put her call light on because she needed to use the bedpan. Patient A stated that she waited a few minutes and when no staff came in to assist her, she yelled for help. Patient A stated that no staff responded to her call light and she "pooped" in the bed. Patient A stated that she was very upset because she lay in her "poop", while she waited for a staff to assist her. Patient A stated that it was approximately 45 minutes before CNA 1 responded to her call light. CNA 1 was assigned to Patient A for the day shift (7:00 AM to 7:00 PM). Patient A stated that she asked CNA 1, "Where have you been?" CNA 1 responded, "I was assisting another patient". Patient A stated, "Bull shit, not with a patient that long, you were probably with your friend". CNA 1 yelled, "F... it, I'm leaving". Patient A stated that CNA 1 left the room without assisting her. Patient A stated that she put her call light on again and waited another 20 minutes before CNA 1 returned. Patient A stated to CNA 1, "You cannot do anything without your buddy". Patient A stated that CNA 1 responded, "I'm not putting up with this shit", threw the wash cloth or towel on the bed and walked out of the room without assisting her.Patient A stated that she waited for about 2 hours before CNA 2 came in and "cleaned her up from the poop and changed her soiled linen". Patient A stated, "I was extremely angry, uncomfortable, helpless, felt unwanted, no one wanted to take care of you. I don't poop in my bed, I use the bedpan." Patient A was asked the average waiting time for assistance on each shift. Patient A responded that the average waiting time was between 15-20 minutes on the day shift. Patient A stated that after Registered Nurse (RN) 1, came and talked to her, "You felt like I was the problem." On October 13, 2010 at 10:05 AM, an interview was conducted with RN 1. RN 1 stated that CNA 1 reported that she could not go back into Patient A's room because the patient had "cursed her out". RN 1 stated that she observed Patient A crying. Patient A told her that she had waited for a long time for help and did not know what was going on with CNA 1. RN 1 stated that she told Patient A that she would assign a different staff to care for her. RN 1 stated that later that shift, CNA 2 reported that she observed Patient A lying in bed with one end of attached wall drape/blind cord around the patient's neck. RN 1 stated that when she entered Patient A's room, she did not observe the cord around Patient A's neck. RN 1 stated that she assigned a staff just to sit and care for Patient A for a couple of days since the patient was so upset.RN 1 was asked the facility's protocol for staff to answer patient's call light. RN 1 stated that the charge nurses or the RN will respond to call lights when the CNAs were busy. RN 1 stated that she could not recall call lights being left unanswered at the time of the incident. Review of the licensed nurses progress notes dated July 10, 2010 at 5:00 PM included the following: "Resident found to have put the chain from the window blind around her neck, stating that she just want to end it all. Earlier, resident had an outburst toward a CNA; this writer and the TL (team leader) went to room to speak to resident, however resident feels staff is always defended and we don't believe her when states something about the staff. The DON (Director of Nursing) was called and message left; crisis response called and message left; physician called and message left. Awaiting return calls." On October 13, 2010 at 10:20 AM, an interview was conducted with CNA 2. CNA 2 was assigned to provide care to Patient A following the incident with CNA 1 on July 10, 2010. CNA 2 stated that Patient A told her that she was upset because she waited an hour before her call light was answered. CNA 2 stated that she provided care to Patient A, talked with the patient and she [Patient A] "calmed down." CNA 2 stated that when she entered Patient A's room at about 5:00 PM with the patient's dinner tray, she observed, "[Patient A] hands up under her chin, the patient was holding onto the draw string from the window blinds; it appeared like the patient was trying to put her head through the draw string." Patient A stated, "I just want to kill myself." CNA 2 stated that she took the cord away from Patient A and immediately notified RN 1. Patient A was assigned a staff to sit with her.On October 13, 2010 at 10:30 AM, a second interview was conducted with Patient A. Patient A stated, "I had been extremely depressed for couple of weeks prior to this incident. I lost my father and was having other family problems. This incident put me over the edge." "No one wanted to care for me, like it was my fault, I don't care anymore. So, I pulled the cord, (metal type) from the wall drape and tried to put it around my neck and strangle myself."On October 13, 2010 at 10:45 AM, an interview was conducted with the DON. The DON stated that she was aware that Patient A had been depressed due to family issues. The DON stated, "CNA 1's behavior was unprofessional but did not rise to the level of abuse." The DON stated that Patient A cursed at CNA 1.The DON was asked what was the acceptable waiting time was for a resident needing to use the bedpan. The DON confirmed that a wait time of 45 minutes was too long. The DON was asked if the facility had thoroughly investigated why it took staff 45 minutes to respond to Patient A's call light and how the facility was addressing this problem. The DON stated that the facility had been monitoring calls lights since the last State survey. The DON stated that for the past 3 months, there was only one time when a call light was on for 21 minutes and this was during an emergency involving another patient. The DON stated that the facility's policy was that any staff, who observed a light, answered the light. The facility's policies on abuse, call light answering and staff burnout were requested. The policy, "Abuse prevention reporting" revised February 2010, included: "Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability."On October 13, 2010 at 10:55 AM, an interview was conducted with the Administrator. CNA 1's personnel file was requested. The administrator stated that CNA 1 was suspended for 2 days during the investigation. CNA 1 was given a final written warning for violating organization rules and unsatisfactory customer service. CNA 1's corrective action plan, dated July 15, 2010, showed, "Problem: Unprofessional behavior with difficult resident; engaged in argument with inappropriate language." The administrator stated that CNA 1 had been working at the facility for 8 years and this was the first time this type of incident had occurred. On October 15, 2010 at 11:45 AM, a telephone interview was conducted with CNA 1. CNA 1 stated that at the time of the incident, several patient lights were on. CNA 1 stated that she answered other patient's lights before responding to Patient A's light. CNA 1 stated that when she entered Patient A's room, the patient started yelling and cursing at her. CNA 1 stated that she turned around and walked out of Patient's A room and went and answered other patient's lights. CNA 1 stated that when she returned to Patient A's room, the patient started yelling and cursing at her again. CNA 1 stated to Patient A, "I don't have to take this shit" and walked out of the room. CNA 1 stated that she went to the charge nurse and requested that another CNA care for Patient A. CNA 1 stated, "I know what I said was wrong, I know what I said was not right but I was overwhelmed by the situation". CNA 1 was asked if she was aware why Patient A was upset. CNA 1 responded that Patient A stated that because she [CNA 1] did not respond to her call light, she "shit all over herself". CNA 1 stated that she told Patient A that she was not her only patient and that she had been busy answering other patient call lights. CNA 1 stated that the regular assignment for the day shift was 10 patients and 11-12 patients per staff when short staff.CNA 1 stated that when she was in a patient's room, she could not tell/or hear when another call light was on. CNA 1 stated, "You had to come out of the room and go into the hallway to see the lights." CNA 1 stated that sometimes the CNAs would be paged to respond to call lights. CNA 1 stated if the nurses were busy, it was up to the CNAs to respond to the call lights.The facility failed to protect Patient A from verbal and mental abuse from staff, respond to Patient A's call for assistance in a timely manner which resulted in Patient A having a bowel movement in the bed, and failed to ensure the patient's linen as well as skin were consistently clean, dry and free of feces. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000925 |
Hi-Desert Medical Center D/P SNF |
240009101 |
B |
12-Mar-12 |
2VJ511 |
8684 |
REGULATION VIOLATION: Title 22 72311 Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. And (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 ensure that staff provided ongoing assessments when Patient 1 began to exhibit early signs of a change in condition, manifested by a low blood pressure (B/P) of 98/50 on March 22, 2010 at 6:30 PM.The facility failed to notify the physician when Patient 1 began to exhibit early signs of a change in condition, manifested by a low blood pressure (B/P) of 98/50 on March 22, 2010 at 6:30 PM. Family Member A reported that Patient 1 fell out of the wheelchair and broke her hip on March 24, 2010, and during the family visit on March 26, 2010 Patient 1 did not recognize the family members, and appeared "dehydrated." Patient 1's medical record, reviewed on April 21, 2010, showed that Patient 1 was a 63 year old female, admitted to the skilled nursing facility on March 19, 2010 with diagnoses that included hyponatremia (Deficiency of sodium in the blood), hypertension (Elevated blood pressure above normal parameters), Moyamoya disease (Cerebral ischemia due to occlusion and small hemorrhages from rupture of an abnormal network of vessels at the base of the brain, causing progressive neurologic disability), Raynaud's disease [A condition in which small arteries (Arterioles), usually in the fingers and toes, go into spasm, causing the skin to become pale or a patchy red to blue], and congestive heart failure (A condition in which the quantity of blood pumped by the heart each minute is insufficient to meet the body's normal requirements for oxygen and nutrients). Patient 1's past medical history included chronic obstructive pulmonary disease, arteriosclerotic heart disease, severe emphysema, left tibia and fibular fracture, status post ORIF (Open reduction internal fixation), history of fall, multiple CVA (Cerebrovascular accident) and hypercoagulation state. Review of the nursing notes revealed the following: (Baseline blood pressure from March 19, 2010 at 6 PM thru March 22, 2010 at 6 AM ranges: systolic B/P = 101 - 129, diastolic B/P = 68 - 78). March 22, 2010 at 6:30 PM - B/P = 98/50, Pulse (P) = 80 beats per minute (BPM), Respiration (R) = 16 breaths per minute (RPM) and temperature (T) = 97.8 degrees Fahrenheit. There was no documented evidence that the vital signs were re-checked in view that the B/P was low and that the patient had fallen from the wheelchair.There was no documented evidence that the physician was notified of the low blood pressure. March 23, 2010 at 6 AM - B/P = 98/60, P = 82 BPM, R = 20 RPM, T = 98.4 degrees Fahrenheit. There was no documented evidence that the vital signs were re-checked until 6 PM. In addition, there was no documented evidence that the physician was notified of the low blood pressure. March 23, 2010 at 6 PM - B/P = 102/60, P = 66 BPM, R = 20 RPM, T = 97.6 degrees Fahrenheit. March 24, 2010 at 6 AM - B/P = 90/50, P = 90 BPM, R = 18 RPM, T = 97.2 degrees Fahrenheit. There was no documented evidence that the vital signs were re-checked until 6:45 PM.There was no documented evidence that the physician was notified of the low blood pressure. March 24, 2010 at 6:45 PM - B/P = 129/78, P = 82 BPM, R = 18 RPM, T = 97.7 degrees Fahrenheit. Documentation indicated Patient 1 was, "Alert but still very confused." There was no documented evidence that the physician was notified of Patient 1's current mental status. March 25, 2010 at 6 AM - B/P = 121/72, P = 82 BPM, R = 18 RPM, T = 98.3 degrees Fahrenheit. Documentation indicated Patient 1was, "Alert, confusion noted." March 25, 2010 at 6 PM - B/P = 122/80, P = 74 BPM, R = 18 RPM, T = 98 degrees Fahrenheit. Documentation indicated Patient 1 was, "Very confused." March 26, 2010 at 6 AM - B/P = 102/62, P = 74 BPM, R = 20 RPM, T = 98 degrees Fahrenheit. Documentation indicated Patient 1 was, "Very confused." March 26, 2010 at 6 PM - B/P = 102/67, P = 94 BPM, R = 20 RPM, T = 97.6 degrees Fahrenheit.March 27, 2010 at 6 AM - B/P = 99/60, P = 56 BPM, R = 20 RPM, T = 98.9 degrees Fahrenheit. Documentation indicated Patient 1 was, "Chatting with invisible friend...speech slurred, difficult to communicate needs." There was no documented evidence that the vital signs were re-checked until 6 PM.In addition, there was no documented evidence that the physician was notified of the patient's low blood pressure and current mental status. March 27, 2010 at 6 PM - B/P = 94/64, P = 80 BPM, R = 18 RPM, T = 97.3 degrees Fahrenheit. The following was documented, "All meds held due to low B/P after numerous attempts and different nurses trying to get a B/P reading. Faint B/P reading of 94/64 was obtained." There was no documented evidence that the vital signs were re-assessed and the physician was notified of current patient's change of condition and that all medications were held due to low blood pressure. March 28, 2010 at 6 AM- B/P = 120/70, P = 59 BPM, R = 20 RPM, T = 95.3 degrees Fahrenheit. Documentation indicated Patient 1 was, "Agitated for an hour ... moaning and guarding." when the Certified Nurse Assistant (CNA) changed her brief.There was no documented evidence that a repeat check of body temperature was done to ensure Patient 1 was not hypothermic (Abnormally low body temperature). March 28, 2010 at 6 PM- B/P = 134/76, P = 68 BPM, R = 20 RPM, T = 97.4 degrees Fahrenheit. Patient 1 was described as, "Confused, mumbling words and talking to self." March 29, 2010 at 6 AM- B/P =92/51, P = 102 BPM, R = 24 RPM, T = 97.6 degrees Fahrenheit. Documentation indicated the following, "[Patient 1] still restless during night." However, there was no documented evidence that the vital signs were re-assessed and the physician was notified of fluctuating blood pressures. March 29, 2010 at 6 PM- B/P =85/66, P = 105 BPM, R = 22 RPM, T = 95.9 degrees Fahrenheit, per axilla. Documentation indicated, "All meds held due to low B/P. There was no documented evidence that Patient 1 was reassessed by a licensed nurse in view of low blood pressure until at approximately 9:21 PM when the CNA reported that she was unable to get a B/P reading with the machine. The documentation also indicated the B/P was done manually by Charge Nurse A. The vital signs revealed a B/P 68/44, P = 104 BPM, R = 20 RPM, oxygen saturation of 86% at room air. Patient 1 required an oxygen administration of 2 liters/nasal cannula to raise oxygen saturation to 94%. The note further indicated, "Resident nauseated, reddened 96, cold to touch."On March 29, 2010 at 9:20 PM, the physician was notified and orders were obtained to send the patient to an acute care hospital for further evaluation and treatment. Review of the "Patient transfer and referral record" signed and dated March 29, 2010 indicated the reason for transfer was low blood pressure, shallow breathing, nausea and vomiting, and low oxygen saturation. Review of the acute care hospital History and Physical (H&P) dated March 30, 2010,showed that Patient 1 was transferred and admitted for low blood pressure and change of mental status. The admitting diagnoses included acute renal failure, polycythemia, severe leukocytosis, hyponatremia, hypercalcemia (An excess of calcium in the blood, manifestations include fatigability, muscle weakness, depression, anorexia, nausea, and constipation), chronic obstructive pulmonary disease, and status post multiple cerebral infarctions. Patient 1 was documented as a "no code (no CPR) status." The facility failed to ensure that staff provided ongoing assessments and notified the physician promptly when Patient 1 exhibited early signs of a change of condition. These failures resulted in a delay in treatment when the patient was later found in severe hypotension, and in respiratory distress requiring oxygen treatment. Patient 1 was transferred to the acute care hospital with a diagnosis of acute renal failure.These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000068 |
Highland Palms Healthcare Center |
240009306 |
B |
15-May-12 |
YZGC11 |
10414 |
REGULATION VIOLATION: Title 22 72311 Nursing Service - General and 72315 - Nursing Service - Patient Care.72311 (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. And 72315 (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by physician's orders.The facility failed to develop and implement a specific care plan on how to assist the patient with activities of daily living (ADL) following her post lumbar laminectomy. This resulted in an unplanned second surgery for, "Repositioning of interbody graft." The facility failed to ensure that Patient A achieved and maintained her highest level of self-care and independence. The failure of staff to keep the patient's back brace on at all times, per the physician's orders, resulted in Patient A undergoing a second back surgery to repair the damage caused by facility staff. Therefore, Patient A was unable to proceed with therapy, as planned, following the first back surgery.Patient A stipulated in her letter to the Department that on January 14, 2010, two CNAs (Certified Nurse assistant) removed the back brace that she was supposed to wear at all times when they gave her a shower. The letter also indicated that one CNA lifted her from the front while holding her under her arms and the other CNA lifted her legs then put her on a shower chair to give her a bath. Patient A stated, "Almost immediately I felt pain in my lower back to the same area where I had the surgery."Further documentation showed that Patient A related that the pain continued to get worse. On January 27, 2010 a CT scan was done and revealed that the previous surgery had been compromised. Therefore, Patient A had to go for another surgery to repair the damage. An unannounced visit to the facility was conducted on March 2, 2011 and record review was conducted. Subsequent visits were made on March 7, 2011, October 4, 2011 and October 6, 2011.Review of Patient A's medical record showed that Patient A was admitted to the facility on January 8, 2010 for "Aftercare status post (s/p) lumbar laminectomy L5-S1" and was re-admitted to an acute care hospital on January 29, 2010 for a second "Back Surgery." Review of the Minimum Data Set (MDS) dated January 14, 2010 showed that Patient A had no short term and long term memory deficit, and was able to make herself understood and understands others. However Patient A required extensive to total assistance with her activities of daily living (ADL). Review of the physician's orders dated January 8, 2010 included an order for, "TLSO (Thoracolumbosacralorthoses) needed when patient get up - continuous." Review of the Physical Therapy (PT) evaluation dated January 11, 2010 included documentation that was given to the nursing staff which included: "Fall risk, TLSO when OOB (Out of bed), blind...provide assistance with all functional mobility."Review of the PT notes dated January 14, 2010 at 11:37 AM showed, "Patient c/o (Complained of) increased numbness on LLE (Left lower extremity), mild numbness on RLE (Right lower extremity), and pinching/spasm and shooting pain on L (Left) buttock going up the spine. Patient also demonstrated increased weakness on BLE (Bilateral lower extremities) with BLE dragging ... with posterior and lateral trunk sway, both sides during gait training with FWW (Forward wheel walker) today ..." Review of the nurse's progress note dated January 15, 2010 at 15:52 PM indicated that Patient A had the following change of condition, "Decrease strength in her lower extremities, increased muscle spasm, legs shake more and has left foot drop, resident not ambulating as she should per therapist." Review of the PT progress note dated January 28, 2010 at 1:11 PM indicated Patient A "continued to c/o (Complain of) back and left calf spasm and demonstrate BLE dragging during gait training." Review of the PT weekly progress report dated February 1, 2010 at 7:34 AM indicated Patient A had "Decreased sensation to light touch/proprioception bilateral (B) lower leg and ankle (LR, left more than right). Patient continues to c/o pinching, shooting pain on left buttock radiating up towards her head."Review of the Occupational Therapy (OT) evaluation January 10, 2010 at 16:00 PM stipulated, "TLSO on when OOB (Out of bed)."Review of the OT progress notes dated January 26, 2010 at 4:40 PM, indicated, "Resident had again limited gains due greatly in part to pain/spasms ..." Review of the OT weekly progress report dated February 1, 2010 at 8:18 PM stipulated, "TLSO when OOB" and need a "Shower chair level, d/t (due to) decreased coordination, strength, endurance, increased pain; requires long handled sponge" with moderate assist for lower body bathing.Review of the "CT Scan of the Lumbar Spine" obtained on January 27, 2010, showed the following results: "Postoperative changes incident to pedicle screw and plate fixation at L5-S1." "There is a disc expander in place at L5-S1 which appears extruded into the spinal canal from its expected location in the disc space and protrudes approximately 14 mm into the canal and likely produces thecal sac/nerve root impingement, though this is difficult to evaluate because of the postoperative metallic artifact. CT myelography might be advised." "Mild disc protrusion L4-5 extending slightly to the right without central canal or foraminal stenosis." "Mild disc protrusion L3-4 extending to the right without significant stenosis."Review of the acute care hospital Admitting History and Physical report dated January 29, 2010, showed that Patient A presented with a chief complaint of back pain with a pain score of 9 out of 10 (pain scale of 1 as mild and 10 as most severe), " due to lumbar instability post lumbar surgery." Review of the acute care hospital discharge summary dated February 3, 2010, revealed that Patient A, "Returned to surgery for repositioning of interbody graft. The workup CT scan revealed an "Injected graft." Patient A had an operative repair which was completed without complication. After the surgery Patient A's pain was well-controlled and she was subsequently discharged to rehab." During an interview with PT 1 on March 2, 2011 at 3:44 PM, PT 1confirmed that Patient A developed increased muscle spasm, decreased leg strength and had a foot drop.PT 1 also stated that Patient A had back brace with back precaution, which included log roll, no bending and twisting; back brace while out of bed, stand and pivot with back brace at all time, and once patient was seated on the chair, back brace can be removed for cleaning (Can not bend the back) then dry the skin and then put back the brace. Review of the care plans for the following problems: "Risk for fall" and "Deterioration in ADL" did not include specific approaches for providing care to patients with TLSO/back precautions. Review of the care plan dated January 11, 2010 for a problem related to impaired mobility, decreased strength and endurance, decreased balance and coordination, joint mobility limitation with back precautions s/p L5/S1 laminectomy, included, "... TLSO when OOB..."During an interview with PT 2 on October 4, 2011 at 2:45 PM, PT 2 confirmed that on January 14, 2010 she provided care to Patient A, per the plan of care. PT 2 stated that during the treatment, Patient A complained of increased numbness to her lower extremities and pinching/spasm and shooting pain on left buttock going up to the spine and was observed with increased weakness on both lower extremities with dragging, and posterior and lateral trunk sway during gait training. PT 2 stated she reported the findings to the nurse. PT 2 stated that there was no formal or informal in-service given to the CNAs regarding caring for patients with TLSO (Thoracolumbosacralorthoses).During an interview with Occupational Therapist 1 (OT) on October 6, 2011 at 11:10 AM, OT 1 confirmed that she did recall helping the assigned CNA lift Patient A's leg on January 14, 2010. OT 1 also stated that the "Education/Training with Patient/Family/Caregiver" referred to in the progress reports, which included bathroom/functional mobility training, functional transfers, and precautions were referred to the caregiver that will take care of Patient A after discharge from the facility and not to the CNA/nursing staff at the facility.During an interview with CNA1 on October 6, 2011 at 10:25 AM, CNA1 stated that she was the assigned CNA for Patient A on January 14, 2010. CNA1 stated that it was her first time to care for Patient A. CNA1 further stated that the charge nurse "Gave me information about the patient but not give me details on how to do it." CNA1 also stated that she didn't recall getting an in-service pertaining to caring for patients with TLSO. CNA1 stated that she gave the shower to Patient A by herself. CNA1 stated that she took off the brace before she gave the patient the shower and after Patient A was dried she applied the back brace and wheeled the patient back to the room. While in the room and while the patient was still seated on the shower chair, she put a shirt on Patient A then applied back the brace. CNA1 also stated that she asked Patient A to lift her leg one at a time to slide the pants on each leg, she then lifted the patient from the front while holding her under the arm and OT 1 held the other arm. CNA 1 stated she and OT 1 pulled the patient up together to pull the diaper and pants up; they then pivoted her from the chair to the wheelchair. CNA1 stated that while in the room, Patient A complained of "pain on the back of her neck." CNA 1 stated she notified the nurse as soon as she left the patient's room. Based on the information obtained, the facility failed to develop and implement a specific care plan which would include instructions on the care of a patient with status post lumbar laminectomy, which would ensure that Patient A achieved and maintained her highest level of self-care and independence. These facility failures had a direct or immediate relationship to the health, safety, or security, or security of long-term health care facility patients or residents. |
| 240000066 |
Hillcrest Nursing Home |
240009385 |
B |
05-Jul-12 |
L4YO11 |
6975 |
REGULATION VIOLATION: Title 22 72311 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 ensure that staff consistently implemented Patient A's plan of care that pertained to supervision with dressing. On September 2, 2011, Patient A placed both legs inside her pant leg. Patient A fell and sustained a fracture (broken bone) to the left hip which required surgical intervention and hospitalization. On September 14, 2011, Patient A's medical record was reviewed. Patient A was admitted to the facility on May 24, 2011, with diagnoses that included dementia (deterioration of intellectual faculties, such as memory, concentration, and judgment), diabetes mellitus (elevated blood glucose) and hypertension (elevated blood pressure). The Minimum Data Set (MDS, a comprehensive assessment of the patient) dated June 6, 2011, indicated that the patient usually understood and was usually understood by others. The patient was independent with ambulation but required supervision and set up help for dressing (including how patient puts on, fastens and takes off all items of clothing), personal hygiene (including combing hair, brushing teeth, washing and drying face and hands) and bathing.A review of the licensed nurses' progress notes (LNPN) dated September 2, 2011 at 6:50 AM, showed that the patient fell in her room while attempting to walk with two legs in one pant leg. The patient complained of left hip pain and the physician was notified.A review of the LNPN dated September 2, 2011 at 7:50 AM, indicated that the patient was sent out to the acute care hospital for evaluation. A review of the LNPN dated September 2, 2011 at 2:20 PM showed that the patient was diagnosed with a left hip fracture. On September 14, 2011 at approximately 10:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when he arrived in Patient A's room after the fall, the patient was sitting on the bed. The DON stated that he saw that the patient was hurting; therefore, the patient was sent out for an evaluation. On September 22, 2011 at approximately 4:03 PM, an interview was conducted with CNA 1 via the telephone. CNA 1 stated that she worked the day shift (6:30 AM -3:00 PM. CNA 1 stated that when she walked pass Patient A's room, she observed the patient falling over to the floor. CNA 1 stated that she called the licensed nurse who was in the hallway outside of the patient's room for assistance. The patient told staff that her head and hip hurt. CNA 1 stated that after the nurse assessed the patient for injuries, CNA 1 and the night CNA assisted the nurse in picking the patient up off of the floor and placed the patient on the bed.On September 23, 2011 at approximately 8:30 AM, an interview was conducted via the telephone with Licensed Vocational Nurse (LVN) 1 who was responsible for Patient A at the time of the fall. LVN 1 stated that the patient was sitting on her bed when he went into the room and asked the patient if she wanted her medication. LVN 1 stated that he went out of the room and was preparing the medication when he heard a "thump." LVN 1 further stated he thought that the patient was trying to walk towards the door to get her medication when she fell over. The patient was observed with both legs in one pant leg. LVN 1 stated that the patient complained that his hip and head hurt.A review of the Interdisciplinary Team (IDT) dated September 2, 2011 indicated that Patient A fell while getting dressed.A review of the care plan titled "Activities of Daily Living (ADL) preference" dated June 3, 2011, included "dressing with intervention for supervision with limited assist." On September 29, 2011, a review of the "Nurse's Aides Notes" that documented the patient's care needs, including meals for the CNA's to follow, did not have any documentation/instruction on dressing. There was no documentation instructing the CNA staff that Patient A required supervision and limited assist with dressing as per the plan of care. On October 3, 2011 at 10:50 AM, an interview was conducted with CNA 2, who was working the day shift (6:30 AM to 3:00 PM). CNA 2 stated that she had been working at the facility for about a month. CNA 2 stated that the night shift CNAs' usually assisted the patients with dressings and that there might be a few patients left over that needed help with dressing on the day shift. CNA 2 was asked where she obtained information on what care her assigned patients required. CNA 2 stated that she would look on the CNA's flow sheet and ask other CNAs that she received report from the previous shift. CNA 2 could not locate documentation on the CNA flow sheet that addressed the patient's dressing needs. On October 3, 2011 at 10:55 AM, an interview was conducted with CNA 3, who was working the day shift. CNA 3 stated that he had been working at the facility for 4 years. CNA 3 confirmed that the night shift staff usually assisted the patients with dressing. CNA 3 stated that other staff assisted patients with dressings, especially during bath and shower times. CNA 3 stated that he knew the patients and how much assistance they needed.On October 3, 2011 at 11:00 AM, an interview was conducted with the Director of Staff Development (DSD). Patient A's nurses' aide notes were reviewed. The DSD could not find documented evidence in the nurse's aide notes for all three shifts that addressed Patient A's dressing needs. There was no documentation of dressing on the nurses' aide flow sheet. The DSD stated, "Oh, dressing is not on the nurses' aide notes." Patient A's ADL care plan was reviewed with the DSD. The DSD was asked how the dressing interventions were communicated to the CNA's. The DSD responded, "The CNA's who work with the patients knows their needs."As of October 12, 2011, CNA 4 who was assigned to provide care for Patient A at the time of the incident had not returned any of my calls in order to conduct an interview. On October 12, 2011, a review of the facility policy titled," Resident care plan," undated, included the following: "Purpose: To assist nursing and other disciplines in administering comprehensive resident care plan and to provide a means of communication to those persons responsible for giving care on an individual basis." "Objectives: To identify the problems and needs of the resident and the special care required to rehabilitate and restore to the maximum potential." The facility failed to implement the plan of care that pertained to supervision with dressing. As a result, Patient A dressed herself, placed both legs in her pant leg and fell, sustaining a fracture to the left hip. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240001081 |
HERITAGE PARK NURSING CENTER |
240009558 |
B |
18-Oct-12 |
T0UH11 |
6106 |
REGULATION VIOLATION: Title 22, 72311 Nursing Service - General and 72523 Patient Care Policies and Procedures. 72311 (a) 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. AND 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The facility failed to develop a specific care plan which would direct staff on assisting the patient with activities of daily living (ADL), such as transferring to and from the toilet. This resulted in the patient sustaining and fall and fracturing her left ankle, on March 31, 2012.The facility failed to ensure that the established policies and procedures were implemented to prevent Patient A's fall with an injury.An unannounced visit with medical record review and interviews was conducted on April 12, 2012. A subsequent visit was conducted on May 7, 2012. Review of Patient A's medical record showed that Patient A was admitted to the facility on March 27, 2012 for therapy, sent to an acute care hospital on March 31, 2012 for further evaluation of left ankle fracture, and was re-admitted to the facility on April 1, 2012 for aftercare healing trauma fracture to left ankle. Patient A was a 75 year old female with a history of diabetes mellitus, hypertension and recent CVA (Cerebrovascular accident) with a left-sided facial droop and weakness. Review of the Minimum Data Set (MDS) dated March 31, 2012 showed that Patient A had no short term and long term memory deficit, and was able to make herself understood and usually understood others. Documentation showed that Patient A required extensive assistance with her activities of daily living (ADL) with two + (Plus) persons physical assist with toilet use. Review of the "Admission Nursing Assessment" signed and dated March 27, 2012, under the heading "Functional status," showed that Patient A required 2 staff caregiver assistance with transfers and ambulation.Review of the Physical Therapy (PT) evaluation dated March 28, 2012, included documentation of functional mobility which indicated that Patient A needed maximum assist with 2 person physical assist with toilet transfers.In addition, review of the Occupational Therapy (OT) evaluation dated March 29, 2012, showed that Patient A needed total assistance with toilet transfers/toileting.During a simultaneous interview with PT 1 and the Rehabilitation Director on April 12, 2012 at approximately 3:04 PM, both confirmed and stated that Patient A needed maximum assistance of at least 2 persons for toilet transfers. Review of the care plans for the following problems: "Self-care deficit", "Impaired physical function" and "At risk for fall" related to late effects of CVA with left hemiparesis; however, did not include specific approaches for providing care to patients requiring assistance with ADLs. There was no directive on how to assist patients with ADL care. During an interview of Patient A on April 12, 2012 at approximately 1:35 PM, the patient was asked how she sustained the fracture to her left ankle. Patient A stated, "I fell here in the restroom." Patient A further stated that the CNA left her alone in the wheelchair inside the restroom when she went to get another staff to assist her to transfer the patient from the wheelchair to the toilet. On observation, it was noted that Patient A's left foot was on cast and was elevated on a pillow. Review of the nurse's note dated March 31, 2012 at 4:30 PM revealed that Patient A was left in a wheelchair by CNA 1 after Patient A told CNA 1, "I'm too heavy, ask for help ..." The note further indicated, "When the 2 CNAs went to the restroom to transfer resident (Patient A) to toilet, they found her right knee kneeling on the floor with right hand holding onto side rail."Documentation further indicated, Patient A told staff, "My foot hurts." Patient A was re-assessed by the licensed nurse at 4:50 PM; the nurse noted that the left ankle was swollen. A STAT (Immediate) x-ray was ordered and the result revealed a left ankle fracture. Patient A was sent to an acute care hospital for further evaluation and treatment of her left ankle fracture. Review of the left ankle x-ray result done on March 31, 2012 revealed, "Fracture involving the medial malleolus with mild displacement. A very subtle distal fibular fracture is also suggested ... there is associated soft tissue swelling ... osteoporosis is present." "Conclusion: Acute ankle fractures." Review of the facility's policy regarding "Standards of Conduct" Rule # 1 Safety Rules, and Rule # 3 Negligence/Carelessness revealed: Rule #1 - Safety Rules: "Willful violation of security or safety rules or failure to observe the Facility's safety rules or practices. Carelessness or misconduct resulting in injury to residents ...including disregard of safety rules relating to patient assists and transfers ..." Rule #3 - Negligence/Carelessness: "Negligence or any careless action which endangers the health, life, or safety of a resident, guest, or employee." Based on the information obtained, the facility failed to develop and implement a specific care plan which would include instructions on the care of a patient with self-care deficit, impaired physical function requiring assistance with ADLs and at risk for fall, related to late effect of CVA with left hemiparesis (Muscular weakness or partial paralysis affecting one side of the body) which would ensure that Patient A achieved and maintained her highest level of self-care and independence. The facility failed to ensure CNA 1 adhered to facility's policy regarding safety practices in assisting the patient to the bathroom. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000925 |
Hi-Desert Medical Center D/P SNF |
240011213 |
B |
09-Jan-15 |
9J0311 |
7547 |
REGULATION VIOLATION: Title 22 72311 Nursing Service - General. (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following:(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, or more often if there is a change in the patient's condition. On September 12, 2014, at 2:05 PM, an unannounced visit was conducted to investigate an entity reported incident regarding an accident involving a patient (Patient A). Based on interview and record review, the facility interdisciplinary team (IDT- includes the RN, physical therapist, direct care staff such as a certified nurse assistant {CNA}, social service designee, and the physician) failed to ensure Patient A's comprehensive plan of care that addressed the patient's current physical mobility and functioning to include safe toileting and transfers was reviewed, revised and updated. This failure resulted in a fall and injury (of non-displaced right pubic ramus {bone in the inner lower buttock area} fracture) of Patient A due to the lack of structured plan of care and safety care interventions in place for staff members to follow when providing toileting care with the use of a bedside commode.On September 12, 2014, a review of the facility's investigation report summary written and dated August 22, 2014 by the Director of Nursing (DON) showed that "on August 5, 2014, at 9:45 AM, the patient (Patient A) was attempting to transfer from bedside commode back to bed which she had been cleared to do independently by the Physical Therapist (PT). Patient A was hopping on her good right leg but her left leg did not follow causing her to fall to her left side." A review of the incident report written and dated August 15, 2014 by the RN charge nurse indicated that Patient A "fell due to non-compliance with call system" (activating the call light when needing help by pressing a call button at bedside) on August 5, 2014. The x-ray results on August 15, 2014 showed that Patient A sustained a trauma-fracture of the right pubic ramus. On September 12, 2014, at 2:20 PM, an interview with Certified Nursing Assistant (CNA) 1 was conducted regarding Patient A's incident of fall on August 5, 2014. CNA 1 stated he was helping Patient A with toileting when the incident of fall happened. CNA 1 explained that Patient A fell when she (Patient A) attempted to get up from the commode and go back to bed by herself without calling for help. When asked regarding the patient's toileting plan of care, whether Patient A was independent or needed supervision with toileting and transfer, CNA 1 did not give an answer. CNA 1 stated he had to step outside the resident room by the door and wait until Patient A was done (toileting) and call for the CNA. CNA 1 explained that Patient A did not call for assistance and attempted to get up and transfer from the bedside commode back to bed by herself and fell.On September 12, 2014, a review of Patient A's medical record was conducted. Patient A was 74 years of age, admitted to the facility on July 23, 2014 with diagnoses that included osteopenia (bone mineral volume significantly reduced making the bone weak), history of falls, and status- post surgery of left leg due to a fracture. Patient A had a non-weight bearing (NWB- could not put weight or pressure) status on the left leg and had been wearing a left leg immobilizer (a type of a brace). The nurses notes dated August 2014 indicated that Patient A was alert and oriented x4 (oriented to person, time, place and situation) and able to understand and follow instructions. A review of Patient A's physical therapy treatment discharge summary dated and signed July 23, 2014 by the Physical Therapist (PT) 1, showed that Patient A was discharged from physical therapy treatment on July 21, 2014, and had met her (Patient A) functional therapy goals which included the following:"Patient (Patient A) able to transfer Supervised on bed< bedside commode (bed to bedside commode and vice-versa); moderate assistance (MOD A) to transfer on low surfaces (such as toilet seat and standard chair)." The PT discharge summary on the patient's functional outcomes dated July 23, 2014 further showed that Patient A had to be supervised (by facility staff) during toileting with the use of bedside commode, and had not been cleared by the PT to transfer self independently from bed to commode and vice-versa (as the investigation summary claimed).A review of Patient A's comprehensive care plans for "Fall risk/Potential for Injury"; "Self care deficit related to post-left knee surgery" and "Impaired mobility" dated July 23, 2014 and July 31, 2014, respectively, noted the fall prevention interventions included the following: 1. Place call light, bedside table and comfort items in reach while in bed or sitting at bedside. 2. Encourage to use call light system. 3. Answer call light promptly. 4. Assist with wheelchair mobility per resident (patient) request. There was no written evidence that the IDT such as the PT and the RN had revised and updated the plan of care to prevent fall and injury after the patient's discharge from physical therapy (on July 23, 2014). The care plan did not reflect the level of staff assistance needed in order to safely transfer from the bed to the bedside commode, or whether supervision was necessary during toileting to prevent falls. Patient A had been discharged from the facility and was no longer available for interview. The violation of the above regulations had a direct or immediate relationship to the patient's health, safety, or security.During a concurrent interview with the Physical Therapist (PT) and the DON on September 12, 2014 at 3:45 PM, the PT was asked regarding Patient A's current functional status (after being discharged from physical therapy) with toileting and transfer from bed to commode and vise-versa. The PT stated that Patient A had met her goals of modified independence (MOD I) with toileting transfer from bed to commode and vice-versa. When asked, what modified independence means, and if Patient A needed supervision during toileting, transfers from bed to commode and vise-versa, the PT did not give an answer.On September 12, 2014, at 3:45 PM, during the interview with the PT, the DON stated, "She (Patient A) needed to be supervised (by staff during toileting), and staff had to be there present (with the patient) when using the commode." The DON acknowledged that based on the PT's discharge assessment, Patient A had to be supervised during transfer from bed to commode and vice-versa and should have not been left alone by herself in the room while the patient was using the commode.The facility failed to ensure that the comprehensive plan of care that addressed Patient A's physical mobility and functioning was reviewed and revised to reflect the patient's current physical functioning of supervised transfer with the use of a bedside commode. This failure resulted in a fall and injury (of non-displaced right pubic ramus {bone in the inner lower buttock area} fracture) of Patient A due to the lack of a structured care plan and safety care interventions in place for staff members to follow when providing care during transfers and toileting of the patient.The facility's failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients. |
| 240000018 |
Healthcare Center of Bella VIsta |
240011979 |
B |
22-Jan-16 |
6EZV11 |
7930 |
REGULATION VIOLATION: Title 22 72315 Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures or deformities. The facility failed to ensure Patient 1 did not develop pressure sores (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), when Patient 1's removable brace (a device used for support) for the right lower leg was not removed and the skin under the brace was not assessed for 2 (two) days. Patient 1 sustained 2 (two) DTI (deep tissue injury-a unique form of pressure ulcer; pressure-related injury to subcutaneous tissues under intact skin) pressure sores on the right leg due to the facility staff's failure to assess Patient 1's skin under the brace. Patient 1 was admitted to the facility on June 18, 2014, with diagnoses that included: aftercare of traumatic fracture of the hip (a break in the upper quarter of the femur (thigh) bone) and a history of falls.A review of the physician's order from the sub-acute hospital, dated June 17, 2014, revealed the Physical Therapist (PT) was to have the orthotist (a medical person who designs medical supportive devices and measures and fits patients for them) provide a right femur (upper leg bone) fracture brace for Patient 1.A review of the transfer record from the sub-acute hospital for Patient 1, dated June 18, 2014, reflected Patient 1's brace had been ordered by the sub-acute hospital staff. During a wound care observation of the LVN (Licensed Vocational Nurse) treatment nurse in Patient 1's room on September 19, 2014 at 9:40 AM, Patient 1 was in bed and was observed to have wound dressings to right lateral knee and right ankle.During an interview with the Director of Rehab (DOR) on October 30, 2014 at 3:15 PM, she confirmed, she was notified by physical therapy from the subacute hospital, the right leg brace had been ordered for Patient 1. When asked about the type of brace, the DOR stated it was a "customized brace, a static brace (a brace that limits or controls motion around the hip) to support the fracture, due to (Patient 1) not having surgery." The DOR stated Patient 1 did not have any brace for the right leg at the time of admission on June 18, 2014. The DOR was asked what the facility had done to stabilize Patient 1's fracture until the brace was delivered, she stated, "We positioned the resident (Patient 1) in bed and the resident was not to get out of bed. The resident had an abductor pillow (a pillow placed between the legs to maintain the legs alignment) for support." The DOR was asked when was the brace to be delivered to Patient 1. She stated the orthotist had come to the facility on Friday, June 20, 2014. The orthotist had brought the custom-molded plastic brace that was fitted to Patient 1. The DOR stated the brace did not fit right on Patient 1's right leg. She further stated the orthotist took the brace home with him on Friday June 20, 2014 and was to make the adjustments and bring the brace back. On Saturday, June 21, 2014, the orthotist reapplied the brace to Patient 1's right leg. The DOR stated she assessed Patient 1's right leg on June 20, 2014, and confirmed there was no skin breakdown on the patient's right leg. The DOR also stated that only she and the orthotist were trained to don (to put on) and doff (take off) Patient 1's brace. The brace was a removable brace. A review of the "Physical Therapy Treatment Record," dated June 23, 2014, reflected the following documentation by the DOR, "Leg brace and sock taken off to check skin integrity...for pressure sores. Noted an open sore on the lateral (side) aspect of fibular head (upper part of the femur bone) and the medial (middle) aspect of the knee joint noted redness." There was no documentation of wound measurements done by the DOR. A review of the clinical nursing notes showed on June 23, 2014 at 11:41 AM, LVN 1 documented, "...Resident noted w/DTI to (R) lateral aspect of leg w/100% purple wound bed, also w/DTI to (R) medial aspect of leg w/100% purple wound bed." A review of the treatment record dated June 23, 2014, indicated an order for wound care to the right lateral leg DTI -"Cleanse (R) (right) lateral leg....apply proderm (wound care product)... secondary to leg brace. For the right medial DTI "Cleanse (L) (left) leg...apply proderm...secondary to leg brace." During an interview with LVN 2, on September 19, 2014 at 9:40 AM, she stated Patient 1 had DTI's on the right leg that resulted from the brace. A review of the nurse's notes for Patient 1 indicated documented entries for the following dates: On June 21, 2014 at 10:45 AM, Patient 1 had a brace on the right leg. There was no documentation to show the licensed nurse had monitored the skin under the brace.On June 21, 2014 at 7:14 PM, Patient 1 had a brace on the right leg. There was no documentation to show the licensed nurse had monitored the skin under the brace.On June 22, 2014 at 11:07 AM, Patient 1 had a brace on the right leg. There was no documentation to show the licensed nurse had monitored the skin under the brace.On June 23, 2014 at 11:19 AM, Patient 1 found with 2 DTI's to right lateral leg and right medial leg. A review of the clinical record showed Patient 1's brace was not removed and the skin under the brace was not assessed for 2 days, from the application of the brace on June 21, 2014 through June 23, 2014, when the brace was removed by the orthotist.Review of clinical nursing notes showed, from June 24, 2014 through July 24, 2014, the nursing documentation indicated the wounds as; (2) DTI's to the right lateral leg and right medial leg. Further review of the clinical notes, showed on August 4, 2014 at 2:25 PM, the LVN treatment nurse documented that there was a new classification of the wound and a new order, "Purple eschar (dead tissue) has fallen off to R lateral leg leaving site with 70% slough (yellow, tan dead tissue), 30 % red granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process), 1.5 CM (centimeter(length) x 1.5 CM (width) x 0.2 CM (depth), no drainage, no foul odor noted... Resp. party (self), made aware of reclassification from DTI to pressure ulcer Stage IV and new orders." The facility policy and procedure titled, "Immobilizer Care Guideline" dated August 12, 2008, indicated, under "Procedure 4"; "If the immobilizer is removable, the licensed nurse will remove the immobilizer at a minimum every shift...The licensed nurse will assess the following possible complications; a. skin condition; for signs and symptoms of infection or irritation and or any tissue injury..." The facility policy and procedure titled, "Pressure Ulcer and Wound Management" with a revised date of September 20, 2010, indicated under "Policy Statement"; "...to ensure that residents skin status is assessed and appropriate interventions are developed and implemented to maintain skin integrity, assist in wound healing and or prevent avoidable skin breakdown..." During an interview with LVN 1 on October 30, 2014 at 3:50 PM, she confirmed that the licensed nurses did not monitor or assess Patient 1's skin under the brace from June 21, 2014 through June 23, 2014. The facility failed to ensure Patient 1 did not develop pressure sores (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), when Patient 1's removable brace (a device used for support) for the right lower leg was not removed and the skin under the brace was not assessed for 2 (two) days. Patient 1 sustained 2 (two) DTI (deep tissue injury-a unique form of pressure ulcer; pressure-related injury to subcutaneous tissues under intact skin) pressure sores on the right leg due to the facility staff's failure to assess Patient 1's skin under the brace. These violations had a direct relationship to the health, safety or security of the patients. |
| 240000925 |
Hi-Desert Medical Center D/P SNF |
240012166 |
B |
06-Apr-16 |
6SOL11 |
11073 |
Title 22 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients have the right: (10) To be free from mental and physical abuse. The facility failed to ensure one of twenty-two sampled patients (Patient 2) was free from verbal/physical/mental abuse.This failure resulted in Patient 2's withdrawal from group activity participation by isolating herself in her room and her avoidance of Employee 1 in the patient care area. During an initial tour observation on August 3, 2015 at 11:25 AM, Patient 2 sat in her bed watching television. During subsequent observations: From August 3-August 5, 2015, Patient 2 did not attend any group activities or eat in the dining room. During a breakfast meal observation and interview on August 5, 2015 at 7:20 AM, Patient 2 stated, "Three weeks ago while playing Bingo, Employee 1 cussed at me, I can't remember the words." A review of Patient 2's clinical record documented Patient 2 was admitted to the facility on December 16, 2014 with diagnoses which include anxiety (an uneasy feeling of discomfort or dread), and depression (one of several mood disorders marked by loss of interest or pleasure in living). During a family interview with Patient 2's family member (FM), on August 5, 2015 at 12:30 PM, the FM stated, "Usually she (Patient 2) goes down to the dining room and plays Bingo but she has not gone to play or eat in the dining room for several weeks and I do not know why." During an interview with Patient 2, on August 5, 2015 at 12:45 PM, Patient 2 stated, "Since the thing with [Employee 1], I do not go [to activities]." During an interview conducted on August 4, 2015 at 10:00 AM, after the group interview (August 3, 2015), Patient 19 stated he need to talk about his concerns about ... and an incident he witnessed a couple of weeks ago.During an interview with Patient 19, on August 5, 2015 at 1:30 PM, Patient 19 stated he heard and observed what Employee 1 said and did to Patient 2 a couple of weeks ago. Patient 19 heard Employee 1 making statements to Patient 2, "You should not be saying anything about Keno (a game similar to bingo)...I'm not really interested in your opinion since you never attend functions ...You should not be here. You should go back to your room." Patient 19 stated he observed Employee 1 grabbing Patient 2's wheelchair and pulling it back quickly causing Patient 2 to shift forward and backward in the seat of the wheelchair.During further interview Patient 19 stated Employee 1's tone of voice to Patient 2 was "very stern and very direct - short spoken like a drill sergeant." Patient 19 stated he saw Employee 1 quickly pushing Patient 2 in her wheelchair down the hallway against Patient 2's objection, not wanting to go back to her room. Patient 19 stated Patient 2 became upset because "it was Employee 1's tone of voice and how Employee 1 handled Patient 2 in her wheelchair." Patient 19 stated Employee 2 witnessed the incident and Patient 19 reported the incident to Employee 3 on the same date of the incident. Patient 19 recalled the incident occurred, "About two weeks ago on a Wednesday or Thursday at 2:30 PM." During an interview with Employee 1, on August 5, 2015 at 3:23 PM, Employee 1 stated, Patient 2 claimed I was rude to her. Employee 1 stated he was counseled after the incident occurred. During an interview with Employee 2, on August 5, 2015 at 4:02 PM, Employee 2 stated she saw and heard a portion of the incident between Employee 1 and Patient 2. Employee 2 stated Employee 1 and she were standing next to a table and Patient 2 and Patient 19 were present. Patient 2 complained about not having either Keno or Pokeno (a game similar to the poker card game and keno combined) and Employee 1 stated there would be something else later. Patient 2 stated she wanted to stay [in the dining room].During further interview Employee 2 stated she observed Employee 1 grab the back of Patient 2's wheelchair and pull it out abruptly causing Patient 2 to shift forward and backward in the seat of her wheelchair. Employee 2 heard Employee 1 stating to Patient 2, "I will take you back to your room." Employee 2 heard Patient 2 stating she did not want to go back to her room several times. Employee 2 stated she then walked away from the situation. Employee 2 stated she reported the incident to Employee 3 on July 16, 2015, the date of the incident. During an interview with Employee 3, on August 5, 2015 at 5:00 PM, Employee 3 stated he received a verbal report from Patient 19 around 4:45 PM on July 16, 2015. Employee 3 stated Patient 19 reported Employee 1 being rude to Patient 2 and Employee 1 made Patient 2 go back to her room even though she wanted to stay in the dining room. Employee 3 acknowledged Patient 2 was upset from the incident. Employee 3 acknowledged Employee 2 reported Employee 1 was "very rude" to Patient 2. During the same interview on August 5, 2015 at 5:00 PM, Employee 3 stated he did not report the incident to the abuse coordinator until the following Monday, July 20, 2015 (4 days after the incident occurred). Employee 3 confirmed Employee 1 worked on Friday, July 17, 2015. Employee 3 stated he did not speak to Employee 1 regarding the incident. Employee 3 acknowledged Employee 1 was not removed from the resident care area during the pending investigation.During a concurrent interview with the Abuse Coordinator, she stated Employee 3 should have reported to her when he had the knowledge of the incident. She further stated the facility's policy stipulated allegation of abuse must be reported immediately to the abuse coordinator and involved staff would be removed from resident care. During an interview with Employee 2, on August 6, 2015 at 11:00 AM, Employee 2 stated Patient 2's level of participation in group activities had decreased. Patient 2 did not attend activities she enjoyed such as games, buffets, poetry and literature club and special events like she used to. During an interview with Patient 2, on August 6, 2015 at 12:55 PM, Patient 2 stated her feelings about the incident and said, "I was wondering if [Employee 1] thought I was a f...b (cuss words) and wondered what I did to be treated like that." During a phone interview with a certified nursing assistant (CNA 3), on August 6, 2015 at 1:45 PM, CNA 3 stated she remembered the incident and Patient 2 said Employee 1 was upset at her. CNA 3 stated Patient 2 told her about "not wanting to go back down to the dining room because of the way [Employee 1] is." During a record review on August 6, 2015 at 8:35 AM, the annual Resident Assessment Instrument (RAI) (a comprehensive resident assessment tool) dated December 23, 2014, noted the following activities as being very important to Patient 2: "Keeping up with the news, doing things with groups of people, doing her favorite activities, going outside for fresh air during good weather and attending religious services." During a record review on August 6, 2015, Patient 2's activity care plan dated, December 23, 2014, indicated a goal of attending/participating in activities three to five times per week. Specific interventions for the activity care plan included ... inviting the resident to scheduled activities ... modify daily schedule and treatment plan to accommodate activity participation, resident preferred activities- , [name of game], TV, reading newspapers and family visits. A record review of Patient 2's Activity Readmission Review dated June 16, 2015, indicated preferred activities of TV, music, Bingo, Keno, religious services, desire to participate in group activities, desire to talk 1:1 with staff, engage in independent activities e.g. reading and puzzles. Patient 2's assessment did not indicate any cognitive, communication, or hearing deficits but Patient 2 required staff assistance to attend activities. During a record review on August 6, 2015 at 8:35 AM, Patient 2's Activity Quarterly Assessment dated June 18, 2015 indicated: attends two to four times per week with a positive response, enjoys TV, reading, Bingo, Keno, and buffets.A record review of the facility's activity calendars for the month of July and August 2015 indicated on Monday, Wednesday, Thursday, and Saturday each week when games of Bingo or Keno occur for each month. A record review of the facility's "Daily Work Sheet -Activities" dated from April 1, 2015 until June 30, 2015 indicated Patient 2's participation in activities ranged from 20-27 activities per month, and three to five times per week. During July 1-31, 2015, Patient 2 participated in ten activities for the month and averaging two times per week. Continued review reflects Patient 2 participated in group activities on July 16, 18, 23 and 24. There was no documentation to show Patient 2 participated in group activities after July 24. During the week of August 1-5, 2015, Patient 2's participation was zero for all group activities scheduled on the activity calendar for the week.During an interview with Employee 2, on August 6, 2015 at 11:00 AM, Employee 2 stated Patient 2's level of participation in group activities had decreased since the incident with Employee 1. Patient 2 did not attend activities she enjoyed such as games, buffets, poetry and literature club and special events like she used to. A record review of Employee 1's training records indicated Employee 1 received annual abuse training related to mandated reporting on June 26, 2014. A review of the facilities In-Service Lesson Plan titled, Resident Rights-Abuse, dated July 13, 2015, reflects Employee 1 attended the In-service training.A review of the facility policy and procedure titled, Reporting of Abuse, dated April, 1995 with a revised date of June 2013, reflects under Procedure: 5. Reporting of abuse is required when: b. For Dependent Adult/Elder, i. Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment has observed, suspects or has knowledge of an incident that reasonably appears to be physical abuse......shall report the known or suspected instance of abuse by telephone immediately or as soon as practically possible, and by written report sent within two working days to the appropriate agency. Under section J. Definitions, "Abuse of an elder or a dependent adult" means physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering, or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering [Welfare and Institutions Code Section 15610.07]. The above violation had a direct or immediate relationship to the health, safety, or security of the patient. |
| 240000068 |
Highland Palms Healthcare Center |
240012845 |
A |
27-Dec-16 |
7C6L11 |
9031 |
REGULATION VIOLATION: 72311(a)(1)(B) Nursing Services-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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 ensure adequate supervision was provided for Patient 1 by failing to develop a care plan to prevent repeat elopement for Patient 1 after he was found on July 27, 2014 in the facility back parking lot. Consequently, on July 29, 2014, Patient 1 eloped from the facility again and was found by the paramedics approximately a mile away from the facility. This failure resulted in Patient 1 experiencing a significant medical change of condition with an altered mental status (an abnormal change in responsiveness and awareness) and syncope (temporary loss of consciousness caused by a fall in blood pressure), and a transfer to the acute hospital for medical treatment which included IV (intravenous) fluids. A review of the clinical record for Patient 1, indicated Patient 1 was admitted to the facility on xxxxxxx with diagnoses which included hypotension (low blood pressure), muscle weakness, obesity, diabetes mellitus (abnormal blood sugar) and backache. A review of Patient 1's history and physical report dated July 1, 2014, reflected the physician documented Patient 1 was alert, oriented x 2 (Person and place), and with a history of falls at home. On July 31, 2014 at 12 noon, Patient 1 was observed sitting on the edge of his bed with his family surrounding him. He was alert and verbally responsive. A review of the clinical record for Patient 1 showed an event report dated July 27, 2014 at 7:48 PM, which documented the patient was found at the facility back parking lot trying to elope. A review of the Event Details Elopement, dated July 27, 2014, indicated: " Elopement-Occurs when a resident leaves the facility premises or safe area without authorization and/or any necessary supervision to do so...with no order for discharge or leave of absence." A review of the clinical record for Patient 1, reflected a progress note dated July 27, 2014, at 8:23 PM, which documented: "resident (Patient 1) was found by the back of the facility trying to elope. Resident said my wife is not picking my call I have to go home. Resident was assist back to the facility ...will continue to monitor for elopement." Review of the nurse?s progress notes for Patient 1 dated July 27, 2014, at 3:24 AM, documented: "resident alert with periods of confusion and forgetfulness at times." A review of the Interdisciplinary Team notes for Patient 1, dated July 28, 2014, documented an interview with Patient 1: ?he stated that his wife is not responding to all of his calls, that's why he wanted to go home.? Further review of the clinical record for Patient 1 demonstrated there was no care plan developed to implement interventions to prevent a repeat elopement, after the elopement episode identified on July 27, 2014. The medical record designee (MRD) verified there was no elopement assessment, care plan and monitoring system provided to Patient 1 after the elopement episode identified on July 27, 2014. This finding was verified by the MRD at the time of record review on July 31, 2014 at 12:25 PM. An interview was conducted with the Director of Nursing (DON) on October 27, 2014, at 4:40 PM, whereupon she stated the care plan is updated as needed and quarterly and / or when there is a change in the patient?s condition. A review of the nurse's progress notes dated July 29, 2014 at 1 PM, documented Patient 1 left the facility. A review of the care plan dated July 29, 2014 documented: "Resident left facility without signing out." During an interview with the DON on July 31, 2014 at 12:30 PM, the DON was asked if Patient 1 had an authorization to leave the facility on pass on July 29, 2014, and the DON responded, "No." When asked if the facility knew where the patient was, the DON stated, "No." The DON stated Patient 1 had eloped from the facility on July 29, 2014. She stated the charge nurse had sent Restorative Nursing Assistant (RNA) 1 to look for Patient 1. The DON stated, Patient 1 was transferred to the acute hospital on July 29, 2014, straight from the location, where the paramedic found Patient 1. During an interview with Registered Nurse (RN) 1 on August 5, 2014 at 4:10 PM, she stated Patient 1 had episodes of forgetfulness and confusion. On July 29, 2014 at approximately 12 PM, Licensed Vocational Nurse (LVN) 1 reported to her that Patient 1 was missing. RN 1 stated she received a phone call from the paramedic around lunch time, informing her that Patient 1 was found, approximately a mile away from the facility. The facility then sent Restorative Nursing Assistant (RNA) 1 and the maintenance supervisor (MS) to pick Patient 1 up. Review of the nurses progress notes for Patient 1 dated July 29, 2014 at 6:22 AM, documented "res (resident)...noted to have episodes of forgetfulness/confusion at times.? During an interview with RNA 1 on July 31, 2014 at 12:40 PM, he stated on July 29, 2014, he and the MS were asked by the licensed nurse to pick up Patient 1 on the corner of the street, approximately a half to one mile away from the facility. RNA 1 stated when they had arrived on the location; Patient 1 was being treated by the paramedics and was already loaded into the ambulance. RNA 1 stated the paramedic had already called the facility to let the facility know they had found him. A review of the paramedic report for Patient 1, dated July 29, 2014 at 1:00 PM, showed the following: "AOS (arrived on scene) to find 74 YOM (year old male) in care of ME541 (Paramedics) on street in wheelchair with C/C (change of condition) of ALOC (altered level of consciousness). Per ME541 Captain, Pt. is a resident of (name of facility). ME541 contacted (name of facility) and spoke to staff whom per ME541 Captain would not disclose the time that patient was last seen at their facility. Pt (Patient 1)'s skin are dry and flushed and hot to touch, oral temperature (measured body temperature using a thermometer in the mouth) 103.3 (Normal body temperature 98.6 degrees Fahrenheit)) ...blood pressure (BP) at 1:30 PM was 94/33 mmHg (Normal BP is 120/80 mmHg ), received oxygen (Oxygen is widely used for emergency medicine) at 15 liters (high flow oxygen is definitively indicated for use in hypoxemia-abnormal low level of oxygen in the blood) per minute (LPM)." Patient 1's pulses; at 1:10 PM pulse was 129, at 1:13 PM pulse was 126, at 1:18 PM pulse was 122, at 1:20 PM pulse was 123. The pulses indicated rapid and abnormal. (Normal pulse for elderly= 60-100/ minute). The report showed, the patient was found one half to one mile away from the facility. Review of the weather forecast for July 29, 2014 around 12 PM, showed the weather temperature for the location where the paramedics found Patient 1 was 95 degrees Fahrenheit (indicated the weather temperature was too hot for an elderly person). During a review of the hospital's ER records dated July 29, 2014; Patient 1 arrived at the ER at 1:50 PM, suffered with altered mental status and syncope. Patient 1 received 3 liters (3 large jugs of soda, 33.81 oz (ounces) per liter-more than 12 glasses of water) of IV (intra venous) fluids (indicating Patient 1 was dehydrated (lack of fluids). Patient 1 was discharged from the ER with diagnoses that included: altered mental status and syncope. During an interview with Patient 1 and his wife on July 31, 2014 at 12:00 noon, he stated he did remember the incident but could not remember the exact date when the incident occurred. Patient 1 stated he was wheeling his wheelchair on the street and not knowing where to go but he kept "going and going, I was tired and exhausted." Patient 1's wife stated she was called and informed that Patient 1 was in the emergency room (ER). She further stated Patient 1 received at least "2 bags of IV fluids." The facility failed to ensure adequate supervision was provided for Patient 1 by failing to develop a care plan to prevent repeat elopement for Patient 1 after he was found on July 27, 2014 in the facility back parking lot. On July 29, 2014, Patient 1 was found by the paramedics approximately a mile away from the facility. This failure resulted in Patient 1 experiencing a significant medical change of condition with an altered mental status (an abnormal change in responsiveness and awareness) and syncope (temporary loss of consciousness caused by a fall in blood pressure), and a transfer to the acute hospital for medical treatment which included IV (intravenous) fluids. 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. |
| 240000066 |
Hillcrest Nursing Home |
240013328 |
B |
13-Jul-17 |
7W2K11 |
7147 |
REGULATION VIOLATION:
72311 (a) (1) (B): Nursing Services General.
(a) Nursing services shall include, but not 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:
Ensure three of four patients (Patients B, C, and D) were free from abuse when Patient A's physical aggression was not managed by the facility as evidenced by:
1. Patient A's care plans were not updated to reflect each physical altercation,
2. Patient A's care plans were not updated to reflect adjustments to medications, and
3. The facility did not employ new interventions despite Patient A's repeated behavioral episodes.
These failures resulted in the physical abuse of Patients B, C, and D.
Findings:
During an interview with the Director of Nurses (DON) on June 6, 2017 at 1:16 PM, he stated Patient B was in an unprovoked physical altercation with Patient A on May 25, 2017. The DON stated Patient A approached Patient B; scratched Patient B's arm and hit Patient B in the mouth. The DON stated Patient B sustained abrasions to her left arm and a bloodied lip. The DON further stated Patient A had been in three previous altercations this year.
1. A review of Patient A's "Licensed Nurses Progress Notes" dated January 16, 2017 at 11:50 AM, reflected Patient A was involved in a physical altercation with Patient C. It was noted Patient A, "was observed striking out on another resident in the hand and chin."
A late entry dated January 19, 2017 at 2:00 PM, indicated Patient A was in a physical altercation with Patient D. It was noted Patient A, "wandered into the room of XXXXXXX and pulled her hair..."
Another progress note dated April 25, 2017 at 12:45 PM, indicated Patient A was involved in a physical altercation with Patient C. It was noted Patient A, "struck another resident [Patient C] in the face and right arm."
There was no documented evidence to show that Patient A's care plans had been updated to reflect the physical altercations occurring on January 19, 2017 or May 25, 2017.
During an interview with the DON on June 6, 2017 at 1:45 PM, he confirmed Patient A's care plans had not been updated to reflect the physical altercations occurring on January 19, 2017 or May 25, 2017.
During an interview with a Licensed Vocational Nurse (LVN 1) on June 14, 2017 at 9:08 AM, she stated LVNs are responsible for completing short term care plans and Registered Nurses (RNs) are responsible for completing long term care plans.
2. During a review of Patient A's "Licensed Nurses Progress Notes" dated January 19, 2017 at 2:00 PM, indicated Patient A's Ativan (a medication used to treat anxiety) was adjusted by the physician.
Another progress note dated May 30, 2017 at 10:00 AM, indicated Patient A's Risperdal (a medication used to treat psychosis) was adjusted by the physician.
There was no documented evidence Patient A's care plans had been updated to reflect the changes for Ativan or Risperdal.
During an interview with the DON on June 6, 2017 at 1:45 PM, he confirmed Patient A's care plans had not been updated to reflect the changes in medication for Ativan or Risperdal.
During an interview with the Minimum Data Set (MDS, a patient assessment tool) Nurse (MDS) on June 14, 2017 at 9:15 AM, he stated RNs and LVNs are responsible for updating and revising care plans. The MDS Nurse further stated that the medical records staff were responsible for ensuring care plans are in place and up-to-date. The MDS Nurse stated he, too, utilized assessment data from the MDS to complete and update care plans.
A review of the facility policy and procedure titled, "Resident Care Plans," undated, under section, "Revisions and Updating of the Resident Care Plans," indicated, "...The plans will be reviewed weekly when the nursing staff record their weekly summaries to determine if the problems are still exist and/or if all new problems have been recorded."
3. A review of Patient A's "Psychotropic (drugs affecting a person's mental state) Summary Sheet" recording the number of behavioral episodes of "striking out" each month, indicated the following:
For the month of December 2016, Patient A had a total of 52 episodes.
For the month of January 2017, Patient A had a total of 60 episodes.
For the month of February 2017, Patient A had a total of 14 episodes.
For the month of March 2017, Patient A had a total of 55 episodes.
For the month of April 2017, Patient A had no recorded episodes despite a documented physical altercation with Patient C.
For the month of May 2017, Patient A had a total of 2 episodes.
A review of the documented care plans for Patient A's physical aggression indicated she was to be "monitored for aggression with other residents". No further evidence of interventions protecting other patients from physical aggression could be found.
During an interview with the DON on June 8, 2017 at 2:20 PM, he confirmed Patient A's care plans had not been updated to reflect interventions to protect other patients from Patient A's physical aggression.
During an interview with LVN 1 on June 14, 2017 at 9:08 AM, she stated Patient A is monitored for aggression by all staff members. LVN 1 stated a "PRN" (as needed) medication is utilized when Patient A exhibits aggressive behavior. She further stated the "PRN" medication is usually administered after an altercation and, therefore, does not prevent the physical aggression.
LVN 1 further stated Patient A is monitored by a "safety float" staff member. LVN 1 stated this staff member monitors all patients for behaviors and intervenes when necessary. LVN 1 states the "safety float" staff member does not monitor patients on a one-to-one basis.
During an interview with the Social Services Designee (SSD) on June 14, 2017 at 9:28 AM, she stated Patient A exhibits territorial behavior. The SSD further stated Patient A is monitored for this territorial behavior and redirected by "safety float" personnel. The SSD confirmed "safety float" personnel monitor all patients at the same time and do not operate on a one-to-one basis.
A review of the facility policy and procedure titled, "Resident-to-Resident Altercations," revised December 2007, indicated, "...d. Review the events with the Nursing Supervisor and Director of Nursing including interventions to try to prevent additional incidents... f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness..."
Therefore, the facility failed to ensure patients (Patients B, C, and D) were free from abuse when Patient A's physical aggression was not managed by the facility.
These facility failures have a direct or immediate relationship to patient health, safety, or security. |
| 240000066 |
Hillcrest Nursing Home |
240013356 |
A |
24-Jul-17 |
DMFH11 |
5921 |
REGULATION VIOLATION:
72313 (a) (2): Nursing Services- Administration of Medications and Treatments
(a) Medications and treatments shall be administered as follows:
(2) Medications and treatments shall be administered as prescribed.
72313 (a) (7): Nursing Services- Administration of Medications and Treatments
(a) Medications and treatments shall be administered as follows:
(7) Patients shall be identified prior to administration of a drug or treatment.
The facility failed to administer medication as prescribed to two of four sampled patients (Patient 1 and Patient 2), when Patient 1 was given medications prescribed to Patient 2 and Patient 2 did not receive medications as prescribed by the physician.
This failure resulted in Patient 2 not receiving medications as prescribed and Patient 1 experienced slurred speech, blurred vision and a pulse of 42. Patient 1 was sent to the hospital for evaluation and treatment.
During a review of the clinical record for Patient 1, the Facesheet (admission record), dated February 14, 2017, indicated the resident had an allergy to Haldol (an antipsychotic medication) and had a diagnosis of heart failure.
During an interview with the Director of Nursing (DON) on May 12, 2017 at 3:00 PM, he stated that Patient 1 was given the wrong medications on May 11, 2017 at 9:00 AM. The medications included;
1. Buspar (an antidepressant).
2. Lasix (used to treat fluid retention in people with heart failure).
3. Lopressor (blood pressure medication).
4. Depakote (anti-seizure medication).
5. Haldol, (an antipsychotic medication).
6. Keppra (anti-seizure medication).
7. Klonopin (medication used to treat seizures and panic disorder).
8. Zyprexa (used to treat schizophrenia; a psychological disorder).
9. Dilantin (anti-seizure medication).
10. Nudexta (used to treat a neurological disorder with symptoms of uncontrollable laughing and crying, contraindicated for people with heart failure).
11. Dietary supplements; fish oil, Oscal D, and Senna.
In a review of the clinical record for Patient 1, the "Licensed Nursing Notes", dated May 11, 2017, indicated; "...BP [blood pressure] 124/85, p [heart rate]: 42 , R [respiration] 15..." Also noted was that the patient complained of "slurred speech", and "double vision." The physician was notified and orders were received to send the patient out to the acute care hospital.
Review of the facility's investigation letter, dated May 12, 2017, indicated that the Licensed Vocational Nurse (LVN 1) who gave the incorrect medications had asked a Certified Nursing Assistant (CNA) about the identity of Patient 2. The CNA pointed to Patient 1 and the LVN gave all the medications intended for Patient 2 to Patient 1. LVN 1 was terminated after the incident.
During an observation and a concurrent interview with Patient 1 on May 30, 2017 at 2:35 PM, she was in her room, sitting in her wheelchair. When asked how she was feeling, she stated, "Much better." When asked about the incident of her receiving the wrong medication, she stated that she did not like going to the hospital, and said she was grateful to be back at the facility.
Review of the clinical record for Patient 1, from the acute care hospital, titled "Consultation," dated May 11, 2017 at 4:51 PM, indicated the patient was, "extremely somnolent [drowsy]" and "...in ER, ekg [electrocardiogram; a test which shows heart rhythm] showed sinus bradycardia [slow heart rhythm]." Vital signs were noted as follows: ..."HR [heart rate] 38, RR [resting respiration]: 13, BP: 113/70."
Review of the clinical record for Patient 1, from the acute care hospital, titled, "History and Physical", dated May 11, 2017, at 4:56 PM, indicated, "...THE PATIENT IS ALLERGIC TO HALDOL AND APPARENTLY, SHE RECEIVED HALDOL." "...She became lethargic [drowsy] with slurred speech and upon arrival to the Emergency Department, her vital signs showed bradycardia." "...Assessment: 1. Polypharmacy [multiple medications] overdose. 2. Beta blocker [medication that reduces blood pressure] overdose. 3. Symptomatic bradycardia. Plan: At this time patient will be admitted to Intensive Care Unit. ...We might need to start Isuprel [medication to increase a slow heart rate] infusion to keep the heart rate more than 40."
Review of the clinical record for Patient 1, from the acute care hospital, titled, "Transfer of Care Summary," dated, May 13, 2017, at 2:56 PM indicated; "...Diagnosis: Adverse effect of beta-blocker,..."Ingestion, drug, inadvertent or accidental; ...Sinus bradycardia."
During an interview with the DON on May 31, 2017 at 9:55 AM, when asked what the facility's policy and procedure was on identifying residents when administering medications, he stated that they used photographs on the Medication Administration Record (MAR) and resident wristbands. The DON also stated that it is not the usual practice to ask another staff member to identify the residents when administering medications.
During an interview with the DON, on June 2, 2017 at 3:38 PM, he stated that Patient 2 was not given her usual morning medications as ordered because the window of time had expired when the medication error was discovered. The DON stated that Patient 2 has the same physician as Patient 1, and the physician was notified of the error in medication administration at the time it was discovered.
Record review of the facility policy and procedure, titled "Administering Medications," dated 2001, indicated; "...5. The individual administering medications must verify the identity before giving the resident his/her medications. This is done by photo in the MAR and wristband."
Therefore, the facility failed to ensure patients (Patients 1 and 2) were administered their prescribed medications as ordered.
These facility failures had a substantial probability of death or serious physical harm to patients. |
| 240000018 |
Healthcare Center of Bella Vista |
240013414 |
B |
11-Aug-17 |
JYRD11 |
6631 |
REGULATION VIOLATION
72313(a)(2) Nursing Service- Administration of Medications and Treatments
(a) Medications and treatments shall be administered as followed:
(2) Medications and treatments shall be administered as prescribed.
FINDINGS:
The facility failed to ensure three of three sampled patients (Patients 1, 2 and 3), were free from medication errors when a total of 19 doses of intravenous (given in a vein) antibiotics were not administered as ordered between June 24, 2017 through June 29, 2017, due to the lack of available registered nurses (RNs).
This failure resulted in antibiotic therapy not being administered as prescribed by the physician, which placed the patients at risk for their infectious process to progress which could lead to sepsis (bacterial infection in the blood) and possible death.
1. During a review of the clinical record for Patient 1, the face sheet (a record providing the demographic data of the patient), indicated that Patient 1 was admitted to the facility on XXXXXXX 2017, with diagnoses which included: chronic right lower extremity cellulitis (bacterial infection involving the inner layers of the skin) and osteomyelitis (inflammation in the bone caused by infection).
During a review of physician orders for Patient 1, dated June 22, 2017, the orders indicated that Patient 1 was to receive Vancomycin (medication to treat an infection) 1.5 gram (unit of measurement) intravenously every 12 hours beginning on June 22, 2017 through July 7, 2017.
During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Patient 1's Intravenous Therapy Medication Record (ITMR) for the month of June 2017, which indicated Patient 1 did not receive the Vancomycin 1.5 grams intravenously as ordered by physician on following dates:
June 24, 2017 at 8 PM,
June 25, 2017 at 8 PM,
June 27, 2017 at 8 AM,
June 28, 2017 at 8 AM,
June 28, 2017 at 8 PM and
June 29, 2017 at 8 AM.
Further review of Patient 1's physician's orders dated June 23, 2017, indicated Patient 1 was to receive IV Zosyn (a medicine to treat bacterial infection) 3.375 grams every 12 hours through June 28, 2017. An order dated June 29, 2017, indicated that this medication was to continue through July 1, 2017.
During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Patient 1's ITMR for the month of June 2017, which indicated Patient 1 did not receive IV Zosyn 3.375 grams as ordered by the physician for the following dates:
June 24, 2017 at 7 PM,
June 25, 2017 at 7 PM,
June 27, 2017 at 7 AM,
June 28, 2017 at 7 AM,
June 28, 2017 at 7 PM and
June 29, 2017 at 7 AM.
During an interview with the Administrator (ADM) on June 29, 2017 at 3:47 PM, she stated that she was not aware of the absence of RNs on the shifts in which the IV antibiotics were scheduled for Patient 1. The Administrator stated since there was no Director of Nurses (DON) employed at the facility at present that she was responsible for adequate staffing.
2. During a review of the clinical record for Patient 2, the face sheet indicated that Patient 2 was initially admitted to the facility on September 28, 2014, with a recent readmission from a General Acute Care Hospital (GACH) on June 27, 2017, after an acute hospitalization for pneumonia (infection of the lungs).
A review of Patient 2's physician orders dated June 27, 2017, indicated that Patient 2 was to receive Clindamycin (a medicine to treat infection) intravenously (IV, into the vein) 300 mg (milligrams- a unit of measure) every eight (8) hours for seven (7) days.
A review of Patient 2's ITMR dated June 29, 2017, indicated that Patient 2 received Clindamycin 300 mg IV on June 29, 2017 at 10:20 AM instead of 7:00 AM, as prescribed.
During a concurrent interview with RN 2 on June 29, 2017, at 9:58 AM, she stated she worked as a contract nurse and was called in to work at 9:00 AM on June 29, 2017.
3. During a review of the clinical record for Patient 3, the face sheet, indicated that Patient 3 was admitted to the facility initially on XXXXXXX 2017, and was readmitted on June 27, 2017, with diagnoses which included: anemia (lack of red blood cells in the blood), left below knee amputation (removal of natural leg) and pneumonia (infection of the lungs).
During a record review of Patient 3's physician admission orders dated June 27, 2017, indicated Patient 3 was to receive Cipro 200 mg intravenously every 12 hours for infection and Zosyn 2.25 gram intravenously every six (6) hours for pneumonia.
During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Patient 3's ITMR for the month of June 2017, which indicated Patient 3 did not receive the prescribed antibiotic as follows:
Intravenous Cipro on:
June 28, 2017 at 9 AM.
June 29, 2017 at 9 AM.
Intravenous Zosyn on:
June 28, 2017 at 6 AM.
June 28, 2017 at 12 Noon and
June 29, 2017 at 7 AM.
During an interview with RN 1, on June 29, 2017 at 4:03 PM, she stated that there was no RN scheduled for the times that the patients (Patients 1, 2 and 3) were prescribed to receive IV antibiotics.
A review of the facility file titled, "Nursing Staffing Assignment and Sign in Sheet", for the month of June 2017, was conducted. The staffing reflected the following date and shifts when there were no RNs scheduled to provide the prescribed IV antibiotics:
June 24, 2017, 3 PM to 11 PM shift and 11 PM to 7 AM shift.
June 25, 2017, 3 PM to 11 PM shift and 11 PM to 7 AM shift.
June 27, 2017, 7 AM to 3 PM shift.
June 28, 2017, 7 AM to 3 PM shift and 11 PM to 7 AM shift.
On June 29, 2017, Patient 3 received her scheduled 7 AM IV antibiotic at 10:20 AM.
During an interview with the Administrator on June 29, 2017 at 3:47 PM, she stated that omitted medication dosages were considered as medication errors and the nurses should have followed the medication error policy. She further stated neither the attending physician nor she was notified about the omitted doses by the staff.
During a review of the facility policy and procedure titled, "Medication Errors", revised on January 2012, indicated "...All errors related to the administration of medications or treatments will be reported to the Director of Nursing Services, the attending physician, and the Administrator immediately ..."
Based on the information obtained, the facility failed to administer medication as prescribed by the physician.
This facility failure has a direct or immediate relationship to patient health, safety, or security. |
| 250001525 |
HACIENDA HOUSE |
250010109 |
B |
09-Sep-13 |
JR6Q11 |
5354 |
The facility failed to ensure staff notified the California Department of Public Health (CDPH) of an incident of abuse for one client (Client 1), within five days. The facility notified CDPH 17 days after the incident occurred. This failure could affect the investigation and protection of facility clients, placing Client 1 at risk of fear, intimidation, further peer to client abuse, injury, infection, sepsis or death.On May 7, 2013, an unannounced visit was made to the facility, to investigate an incident of abuse to Client 1 at the day program/school. The review of the incident log indicated there was an incident on May 2, 2013, where Client 1 was bitten by another client at the day program/school. There was another incident on April 15, 2013, where Client 1 was bitten on the hand by a client, at the day program/school.On May 7, 2013, at 12:10 p.m., a visit was made to the day program/school. A concurrent interview with the Risk Manager and Program Director was conducted. They stated Client 1 was bouncing on the yoga ball, when a client passed by and grabbed Client 1's right hand. Client 1 was bitten on his little finger. The Risk Manager stated there were two incidents on April 15, 2013, one hour apart. The Manager stated there were two different students that bit Client 1. One client bit Client 1 on one hand, and the other client bit Client 1 on the other hand. The same client that bit Client 1 in May, also bit Client 1 on April 15, 2013.On May 7, 2013, the three incident reports were reviewed. The reports indicated the following: a. On April 15, 2013, the first incident occurred at 1:45 p.m. The document titled, "Narrative Description of Incident," was reviewed. The document indicated, "On Monday, April 15th at 1:30 pm, Student B was having exhibiting aggressive behavior and staff was attempting to exit him from the room. Client 1 was walking out of the bathroom when Student B walked over, grabbed his right hand and bit him...The skin was not broken so the hand was washed with soap and water..."; b. On April 15, 2013, the second incident occurred at 2:45 p.m. The document titled, "Narrative Description of Incident," was reviewed. The document indicated, "On Monday, April 15th at 2:45 pm I (Risk Manager) was standing at the classroom door talking with a staff member when I saw Student B rise from his seated position on the couch, walk over and bite Client 1 on the hand."; and, c. On May 2, 2013, the third incident occurred at 10:15 a.m. The document titled, "Narrative Description of Incident," was reviewed. The document indicated, "At approximately 10:15 am, Client 1 was bouncing on the yoga ball in the center of the classroom. Student A put his shoes in the closet and turned to walk across the room to his work area. Student A suddenly stopped while passing Client 1, grabbed his hand and bit Client 1 on the left pinky..."On May 10, 2013, at the home of Client 1, the record for Client 1 was reviewed. The Client was admitted to the facility April 28, 2011, with diagnoses that included ADHD (Attention deficit disorder with hyperactivity-difficulty concentrating).Review of the "QIDP (Qualified Intellectual Disabilities Professional) Notes", indicated the following: a. On May 2, 2013, at 9:30 pm, "At approximately 4 pm, on 5/2/13, I received a voicemail from day program/school Director, that Client 1 was bitten on the 4th (pinky) finger on left hand..."; b. On April 16, 2013, at 6:20 pm, "At approximately 4 pm on 4/15/13, QIDP was contacted by teacher,...., to report that Client 4 was bitten on both hands by 2 different students and that he was an innocent bystander..." Review of the "RN (Registered Nurse) Notes", indicated the following: a. On April 15, 2013, at 4:25 p.m., "Received a call from QIDP that day program reported that the resident had been bitten by 2 of his peers on both hands. Face to face assessment by the RN, there is bruise and redness about 3 cm (centimeters) long and 3-4 cm wide at the dorsal (back) part of the right hand. No swelling noticed. A skin tear about 0.5 cm long on the left middle finger (the palm/ventral side) not bleeding at this time. Another redness about 2 pennies on the left side (dorsal side) close to knuckles. No swelling noticed on the hands...MD (doctor) notified and MD ordered Augmentin..., clean the skin tear with Betadine solution, tetanus injection if the resident's previous shot is older than 10 years. However, the resident's last TDAP (tetanus, diptheria and pertussis-whooping cough) was on September, 2011..."On May 8, 2013, at 8:10 a.m., the QIDP was interviewed. The QIDP stated there was confusion regarding reporting the April 15, 2013 incidents. The report was faxed to CDPH on May 2, 2013.The facility policy and procedure titled, "Prevention of Abuse, Neglect, and Mistreatment," was reviewed. The policy indicated, "...The results of all investigations must be reported to the Administrator or designee representative or to other Officials in accordance with state law within 5 working days of the incident."The facility failed to report incidents of peer to client physical abuse to the Department within five working days. The facility did not report the incidents of peer to client physical abuse to the Department for 17 days. This failure had a direct relationship to the health, safety, or security of patients. |
| 250001525 |
HACIENDA HOUSE |
250010114 |
B |
09-Sep-13 |
JR6Q11 |
6994 |
Class B Citation-Abuse 483.420 (a) (5) w127 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The facility failed to ensure one client (Client 1), was protected from physical abuse in a day program. This placed the client at risk of fear, intimidation, further abuse, injury, infection, pain, sepsis (generalized infection), loss of function, or possible death. This failure could affect the protection of all facility clients.On May 7, 2013, an unannounced visit was made to the facility, to investigate an incident of abuse to Client 1at the day program/school by a peer. The review of the incident log indicated there was an incident on May 2, 2013, where Client 1 was bitten by another client at the day program/school. There were two other incidents on April 15, 2013, where Client 1 was bitten on the hand by peers, at the day program/school.On May 7, 2013, at 12:10 p.m., a visit was made to the day program/school. A concurrent interview with the Risk Manager and Program Director was conducted. They stated Client 1 was bouncing on the yoga ball, when a client passed by and grabbed Client 1's right hand. Client 1 was bitten on his little finger.On May 7, 2013, at 12:30 p.m., a visit was made to the cottage at the day program where Client 1 attended. Client 1 was observed sitting and bouncing on a yoga ball. Client 1 had a scabbed area on his left little finger. Three peers were observed in the room. Two peers were ambulating quickly in an erratic fashion. One peer was seated with a staff member and pushed the table that was in front of him.During a concurrent interview, The Risk Manager stated there were two other incidents on April 15, 2013, one hour apart. The Manager stated there were two different students that bit Client 1. One client bit Client 1 on one hand, and the other client bit Client 1 on the other hand. The same client that bit Client 1 in May, also bit Client 1 on April 15, 2013.On May 7, 2013, the three incident reports were reviewed. The reports indicated the following: a. On April 15, 2013, the first incident occurred at 1:45 p.m. The document titled, "Narrative Description of Incident," was reviewed. The document indicated, "On Monday, April 15th at 1:30 pm, Student B (possibly should be Student A) was having exhibiting aggressive behavior and staff was attempting to exit him from the room. Client 1 was walking out of the bathroom when Student B walked over, grabbed his right hand and bit him...The skin was not broken so the hand was washed with soap and water..."; b. On April 15, 2013, the second incident occurred at 2:45 p.m. The document titled, "Narrative Description of Incident," was reviewed. The document indicated, "On Monday, April 15th at 2:45 pm I (Risk Manager) was standing at the classroom door talking with a staff member when I saw Student B rise from his seated position on the couch, walk over and bite Client 1 on the hand."; and, c. On May 2, 2013, the third incident occurred at 10:15 a.m. The document titled, "Narrative Description of Incident," was reviewed. The document indicated, "At approximately 10:15 am, Client1 was bouncing on the yoga ball in the center of the classroom. Student A put his shoes in the closet and turned to walk across the room to his work area. Student A suddenly stopped while passing Client 1, grabbed his hand and bit Client 1 on the left pinky..." On May 10, 2013, the record for Client 1 was reviewed. The record indicated Client 1 was admitted to the facility April 28, 2011, with diagnoses that included ADHD (Attention deficit disorder with hyperactivity-difficulty concentrating).The "QIDP/QMRP (Qualified Intellectual Disabilities Professional/Qualified Mental Retardation Professional) Notes", indicated the following: a. On May 2, 2013, at 9:30 pm, "At approximately 4 pm, on 5/2/13, I received a voicemail from day program/school Director, that Client 1 was bitten on the 4th (pinky) finger on left hand..."; b. On April 16, 2013, at 6:20 pm, "At approximately 4 pm on 4/15/13, QIDP was contacted by teacher,...., to report that Client 1 was bitten on both hands by 2 different students and that he was an innocent bystander..." Review of the "RN (Registered Nurse) Notes", indicated the following: a. On April 15, 2013, at 4:25 p.m., "Received a call from QIDP that day program reported that the resident had been bitten by 2 of his peers on both hands. Face to face assessment by the RN, there is bruise and redness about 3 cm (centimeters) long and 3-4 cm wide at the dorsal (back) part of the right hand. No swelling noticed. A skin tear about 0.5 cm long on the left middle finger (the palm/ventral side) not bleeding at this time. Another redness about 2 previous side on the left hand (dorsal side) close to knuckles. No swelling noticed on the hands...MD (doctor) notified and MD ordered Augmentin..., clean the skin tear with Betadine solution, tetanus injection if the resident's previous shot is older than 10 years. However, the resident's last TDAP (tetanus, diptheria and pertussis-whooping cough) was on September, 2011..."On May 8, 2013, at 8:10 a.m., the QIDP was interviewed. The QIDP stated, Client 1 was held back from the day program after the third incident, until he then met with the day program staff.The facility policy and procedure titled, "Prevention of Abuse, Neglect, and Mistreatment," was reviewed. The policy indicated, "...The purpose of these procedures is to ensure prevention and prompt detection of abuse, neglect, or mistreatment; provide appropriate and thorough investigation; provide resolution for any occurrence of abuse, neglect, or mistreatment..."According to the emedicine health website: (http://www.emedicinehealth.com/human_bites), "...It is important to know which human bites need medical attention. Human bites consist of a range of injuries...but also any injury caused by coming in contact with the teeth...The two most important things to know about a bite are whether there is a skin break or signs of infection...A skin break increases the risk of infection, and it also makes it necessary to give a tetanus booster...Signs of infection are increasing pain and tenderness, increased or new redness; increased swelling, pus drainage (yellow colored and a late sign of infection), red streaks, or swollen glands..."The facility failed to protect Client 1 from physical abuse by a peer (Student B), after he was bitten on the hand by Students A and B, at the day program on April 15, 2013The facility failed to further protect Client 1 from physical abuse by a peer, when he was again bitten on the hand, at the day program on May 2, 2013, by Student B, causing a bruise, redness, and a skin tear to his left hand and fingersThis placed Client 1 at risk for fear, pain, infection, sepsis, loss of function, further abuse by Student B, or death.This failure "had a direct relationship to the health, safety, or security of patients." |
| 250000284 |
HIGHLAND SPRINGS CARE CENTER |
250010394 |
B |
24-Jan-14 |
90DJ11 |
9126 |
"B" Citation 72527 - Patient Rights (a) Patient have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right:(9) To be free from mental and physical abuse. 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to protect Patient 1 from injury. The facility failed to follow their written policy and procedure in preventing patient abuse that resulted in another patient (Patient 2) injuring Patient 1 wherein Patient 1 sustained a skull fracture. On May 20, 2011, CDPH conducted an unannounced visit of the facility to conduct an investigation of a complaint regarding an incident of alleged patient abuse. Based on record review, Patient 1 was an 86 year old female admitted to the facility on March 16, 2011, with diagnoses that included chronic obstructive pulmonary disease (progressive airflow obstruction,) subdural hematoma (localized collection of blood under the skull) without coma, senile dementia (memory and judgment problems,) and secondary Parkinson's disease (tremors and muscle rigidity.) On May 20, 2011, at 10:00 a.m., an interview was conducted with the Administrator. The Administrator stated that Patient 1 was hit by Patient 2 on the evening of May 15, 2011. He further stated that Patient 2 had approached the charge nurse after the incident and told her that Patient 1 was taking her (Patient 2's) belongings. The Administrator further stated that Patient 2 hit Patient 1 on the right side of her head above Patient 1's eyebrow. Review of Patient 1's MDS, (minimum data set, an assessment), dated March 28, 2011, indicated that Patient 1 had difficulty communicating some words or finishing thoughts but was able to do so if prompted or given time. It further indicated that Patient 1 missed some part/intent of messages but comprehended most conversations. Review of Patient 1's nurses notes dated May 16, 2011, indicated the following: "At 10:45 p.m. while doing rounds, RN was notified about fighting going on room with residents, CN (charge nurse) and 2 CNA (certified nurse assistant) went to room 39 to see what had happened. When CN enter room, she noticed that Resident (Patient 1) was just sitting in her bed very confused and upset. When asked what had happen she replied that the other resident (Patient 2) had hit her but she did not know why, she was just getting her stuff... CN noticed that Resident had a 6 cm (centimeter= 0.39 inches) x 3 cm bump (2 1/4 inches x 1 inch) elevated 0.5 cm on R side slightly above eyebrow..." Further review of Patient 1's record indicated that on May 18, 2011, two days after the incident, the patient had been transferred to a hospital to be evaluated for her vomiting and headache. On May 20, 2011, at 5:30 p.m., Patient 1 was observed in her room sitting on her bed. The patient's family was in the room visiting. Patient 1 had purplish-red bruising around both eyes extending to the top of her cheekbones. In addition, Patient 1 had light purplish to blue-green bruising above the bridge of her nose extending to the lower part of her forehead. The patient showed the surveyor a dark purple bruise on the left side of her abdomen. According to facility staff, Patient 2 was no longer in the facility. She had been transferred to another facility for further evaluation. The Activity Director was interviewed on May 20, 2011, at 5:40 p.m. The Activity Director stated, "She (Patient 2) is very territorial and goes into other patients' rooms and takes things such as a doll from another resident. Sometimes staff wants to look in her closet for other residents' missing things and Patient 2 tells them (staff) to stay out of her stuff. She is moody and confused." On May 25, 2011, review of Patient 1's emergency room record dated May 18, 2011, at 9:30 p.m., indicated that the patient had been assaulted three days ago by another patient. Further review of the emergency room assessment record indicated under the neurological system that Patient 1 had experienced headaches. The emergency room physician's wrote, "... + (positive) periorbital ecchymosis (bruising around the eyes,) B/L, (bilaterally) with ecchymosis (bruising) at nasal bridge," and "+ (positive) ecchymosis at Left Breast / Left Lower rib margin." A review of Patient's 1 CT (computerized tomography - "cat" scan) result of the head, completed on May 18, 2011, indicated that the patient had a right parietal (bone that forms the side and top of the skull) skull fracture. Review of the "LICENSED PERSONNEL WEEKLY PROGRESS NOTES" for Patient 1 indicated the following: "5/17/11, 2:30 p. ...Resident c/o (complaint of) headache 6/10 (pain scale, 10 being worse) at 1 p.m., (afternoon) and was given Tylenol 650 mg p.o. (by mouth) as ordered"... "5/17/11, 10:30 p.m., ...remain with bruise discoloration on or around eye areas, gave Tylenol #3 r/t (related to) c/o severe pain, HA" (Headache).... "5/18/11, 8:15 p.m., ...Pain 5/10 given Tylenol 650 mg. for moderate pain...In an interview with CNA 1 on May 25, 2011, at 12:40 p.m., she stated that when she returned to work on May 16, 2011 (Monday), she had observed bruising around Patient 1's eyes and had asked her what had happened. Patient 1 stated she told Patient 2 "Why do you have my robe?" and that's when Patient 2 started hitting her.In an interview with CNA 2 on May 25, 2011, at 1:18 p.m., she stated that she heard from other staff that Patient 1 was taking her stuff back from Patient 2's closet and Patient 2 had hit her with a basket or something. She further stated that she had never seen Patient 1 rummaging through other resident's stuff. On May 25, 2011, Patient 2's record was reviewed. The record indicated that Patient 2 was a 57 year old female who had been admitted to the facility on January 10, 2008, with diagnoses that included paranoid schizophrenia, (preoccupation with one or more delusion or with frequent auditory hallucinations related to a single theme), depression, psychosis, (gross impairment in reality,) and insomnia, (inability to sleep.) The patient's MDS, dated April 10, 2011, indicated that Patient 2's short and long term memory was intact. Review of the Social Service Notes for Patient 2 dated "1/12/09" indicated, "Resident (Patient 2) with episodes of rummaging with other persons belongings, hoarding stuffed toys and clothes..., Spoke with resident to refrain from taking others person's things, along with DSD, (Name omitted) and sister." (Name omitted)." Additional Social Service Notes dated "1/11/10" indicated, "Resident (Patient 2) continues with episodes of hoarding stuffs of other resident's personal belongings in her room." Review of the "LICENSED PERSONNEL WEEKLY PROGRESS NOTES" dated, "2/8/10 12 p.m.," indicated, "Has episodes of hoarding linens and taking other resident's clothes and putting it in her closet, not easily redirected." The nurse's weekly progress notes, dated May 2, 2011, was reviewed. It indicated, "Resident (Patient 2) is alert and responsive to both tactile and verbal stimuli with confusion noted. Usually able to make self-understood and usually understand others. Has clear and audible speech. No change in cognition and slightly impaired decision making skills."In an interview with CN 1 on June 9, 2011, at 4:48 p.m., she stated that when they (staff) entered into the room, Patient 1 was sitting on her bed. The CN said that she had noticed a slight raised area on her head. Patient 1 stated, "She (Patient 2) hit me, she hit me."In an interview with the Licensed Social Worker on August 28, 2013, at 9:30 a.m., she stated "She (Patient2) had a behavior of hoarding stuff. (She) takes other resident's belongings. I did try to retrieve stuff that she had taken from other residents and she got angry. She will scream or yell, Get out of my room, that's my stuff."Review of an undated policy titled "FACILITY POLICY REGARDING ABUSE" on June 8, 2011, indicated, "It is the policy of this facility to maintain an environment free of abuse and Neglect. The resident (patient) has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other Residents, consultants ..." Therefore, the facility failed to protect Patient 1 from Patient 2, and failed to follow their written patient care policy and procedure regarding patient abuse which resulted in Patient 1 sustaining a skull fracture and experiencing pain. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or emotional trauma to Patient 1 |
| 250000284 |
HIGHLAND SPRINGS CARE CENTER |
250010410 |
B |
30-Jan-14 |
90DJ11 |
3395 |
Health and Safety Code 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents.(a) A long - term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Based on interview and record review, the facility failed to notify the California Department of Public Health (CDPH) of an allegation of abuse within the 24 hours required that Patient 1 had been hit by Patient 2 with an unknown object causing Patient 1 to have a skull fracture.On May 20, 2011, at 9:55 a.m., an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged resident abuse that had occurred on May 15, 2011. A review of Patient 1's chart indicated that she is an 86 year old female that had been admitted to the facility on March 16, 2011, with diagnoses that included chronic obstructive pulmonary disease (progressive airflow obstruction), subdural hematoma without coma (localized collection of blood under the skull), senile dementia (impairment of memory and judgment), and secondary Parkinson?s disease (tremors and muscle rigidity). Review of the patient?s MDS (minimum data set- an assessment), dated March 28, 2011, indicated that Resident 1 had difficulty communicating some words or finishing thoughts but is able to do so, if prompted or given time. It further indicated that Patient 1 misses some part/intent of messages but comprehends most conversations.On May 20, 2011, at 10:00 a.m., an interview was conducted with the Administrator. The Administrator stated that Patient 1 was hit by Patient 2 on the evening of May 15, 2011. He further stated that Patient 2 approached the charge nurse after the incident and told her that Patient 1 was taking her belongings. Patient 2 hit Patient 1 on the right side of the head at the eyebrow. At 11:50 a.m., the Administrator stated that he had not reported the incident to CDPH, "Because of the type of patients that we have it's really hard to balance, especially resident altercations. We were going to report it (the abuse allegation), but it was already out in the open. The patient went to the acute (hospital), the police were notified, and the police came out on the 18th (May)." He further stated, "I should have reported within 24 hours because of the injury." In an interview with the DON (Director of Nurses) on May 20, 2011, at 12:10 p.m., he stated that the incident had not been reported to the CDPH, "Due to the complexity of the problem." When asked what he meant by "complexity" the DON stated, "We have to interview p.m. shift staff, LVN's (Licensed Vocational Nurses), and CNA's (Certified Nursing Assistants). He further stated that the facility's process was to interview staff and talk to patients.He further stated, ?The facility had to arrange a transfer for Patient 2. A part time nurse (LVN) sometimes she answers her page and sometimes she doesn't. We did not finish our investigation fast enough to report." Therefore, the facility failed to notify the California Department of Public Health (CDPH) of an allegation of abuse within the 24 hours required that Patient 1 had been hit by Patient 2 with an unknown object causing Patient 1 to have a skull fracture. The above violation had direct or immediate relationship to the health, safety, or security of patients. |
| 250001502 |
HEMET VALLEY HEALTHCARE CENTER D/P SNF |
250010457 |
B |
12-Feb-14 |
H79L11 |
9369 |
Title 22, ?72315 (b) - Each patient shall be treated as an individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Welfare and Institutions Code 15610.07 (a), abuse of an elder or a dependent adult includes physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering.Welfare and Institutions Code 15610.57 (b) (3), neglect includes, but is not limited to, failure to protect from health and safety hazards. On January 6, 2011, an unannounced visit was made to the facility for the purpose of investigating an incident of facility staff warming a blanket in a microwave oven before placing it on a resident, resulting in a burn. Subsequent visits were made on March 22, 23, 24, and 29, 2011.On March 29, 2011, after completing the investigation, it was determined the facility failed to ensure one resident (Resident 2) was protected from neglect (a form of abuse), when nursing staff warmed a blanket in a microwave oven, placed it on the resident, and left the room. This failed practice resulted in second degree burns to the resident. During an interview with the Chief Nursing Officer (CNO) on January 6, 2011, at 11:30 a.m., the CNO stated on November 11, 2010, the Registered Nurse (RN) Charge Nurse (CN) told the Licensed Vocational Nurse (LVN) to warm a blanket in the microwave and put it on Resident 2 to warm her. She stated the LVN did as she was told, and the blanket smoldered through and burned the resident on her right chest area. At 11:40 a.m., the blanket was observed to be a hospital bath blanket, white in color. The blanket had 16 holes, each measuring six inches wide by 11 inches long, with dark brown frayed edges around each hole. The record for Resident 2 was reviewed on March 22, 2011. Resident 2, a 32 year old female, was admitted to the facility on August 11, 2009, with diagnoses that included quadriplegia and respiratory failure. The Physician Progress Notes dated November 11, 2010, indicated the previous night the resident was very cold, so the staff placed a blanket in the microwave and gave it to her. Following this, smoke was noted, and the blanket was immediately removed. The resident sustained a burn to her right chest area.A Dermatology consult dated November 11, 2010, indicated the resident sustained a second degree burn on her right breast due to a heated blanket. The physician noted an erythematous, non-blanchable patch on the right breast (red area that does not fade when pressure is applied), with a single bullae (blister) in the middle. According to the notes, the patch covered, "roughly 50% of the R (right) breast, not involving the nipple". A Dermatology consult dated November 15, 2010, indicated the wound may take several weeks to heal. A review of the Licensed Nurses Notes, dated November 11, 2010, indicated the following:-At 6 a.m., the resident was assessed following an, "incident." The nurse noted skin discoloration, "pinkish in appearance," on the right breast;-At 7:10 a.m., the nurse received an order to apply silvadene cream (an antibiotic cream used to prevent and/or treat infection) to the right breast every shift;-At 7:20 a.m., the redness on the right breast measured 11.0 Centimeters (cm) long, and 11.5 cm wide (approximately four inches by four and one half inches) with a small blister;-At 8 a.m., the nurse received an order to monitor the right breast for infection;-At 9:15 a.m., the nurse received an order to obtain a dermatology consult for the right breast burn area; and,-At 1 p.m., the dermatologist arrived for a consult. The nurse received an order to change the treatment to apply silvadene cream to the right breast burn area and cover it with vaseline (soaked) guaze every shift. The staff requested, and the resident agreed to change rooms due to, "some smell," and to have the room cleaned. On November 14, 2010, at 12:30 p.m. (3 days later), Resident 2 was moved back into her room. A review of the Wound Progress Notes indicated the following:-On November 11, 2010, the wound measured 11.0 cm long and 11.5 cm wide;-On November 16, 2010, there was no change in size, and there was blistering over the entire wound with a moderate amount of drainage; and,-On November 18, 2010,there was no change in size, and necrotic (dead) tissue was present. A review of The Resident Care Plan indicated problem #3 (Skin Integrity) included the following:-On November 11, 2010, the problem of right breast redness was added, with a goal to be clear in 14 days, and a future review date of November 25, 2010;-On November 15, 2010, the problem was changed to right breast redness with an intact blister related to a second degree burn, with a goal to be clear in 14 days, and a future review date of November 29, 2010;-On November 29, 2010, the problem was changed to right breast open areas, with a goal to be healed in 14 days, and a future review date of December 13, 2010;-On December 13, 2010, there was no change in the problem, the goal remained to heal in 14 days, with a future review date of December 31, 2010;-On January 1, 2011, the problem was changed to right breast open areas - non pressure, with a new goal to heal in 30 days, and a future review date of February 1, 2011;-On February 1, 2011, there was no change in the problem, the goal remained to heal in 30 days, with a future review date of March 1, 2011; and,-On March 1, 2011, there was no change in the problem, the goal remained to heal in 30 days, with a future review date of March 27, 2011. The wound was still present at the time of the investigation. During an interview with the DON and RN 1 on March 24, 2011, at 10:45 a.m., they stated on November 11, 2010, at approximately 4 a.m., Resident 2 was complaining she was cold. They stated the RN CN instructed the LVN caring for Resident 2 to warm a blanket in the microwave and put it on the resident. They stated the LVN warmed the blanket in the microwave, then folded it over many times, and wrapped it around Resident 2's head with the ends draped over her shoulders and chest area. They stated the staff later smelled burning, went to check on Resident 2, and the blanket was smoldering. They stated the blanket was removed and the resident was assessed, and she had a burn to the right breast area. During an interview with Resident 2 on March 24, 2011, at 3:40 p.m., the resident stated on the night of November 11, 2010, she was very cold and could not sleep, so the staff put a blanket in the microwave to warm it, then put it on her. She stated she fell asleep, and woke to the staff shaking her and asking if she was OK. She stated the staff pulled her blankets off, and the room filled with smoke. She stated the staff told her she was burned, but she had no feeling below her neck, so she did not know what was happening. She stated the staff had to move her and her roommate out of their room and get rid of the smoke smell. She stated, it was, "scary." The RN CN was no longer employed at the facility, so she was not available for interview. During an interview with Certified Nursing Assistant (CNA) 1 on March 29, 2011, at 6:30 a.m., the CNA stated on November 11, 2010, at approximately 4 a.m., the RN CN asked her to check on Resident 2 because she smelled a burning smell and knew a microwaved blanket had just been given to the resident. She stated she went to the room and saw a blanket wrapped around Resident 2's head and draped over her shoulders and chest, and the blanket had a burnt hole with black edges on the right side. The CNA stated she pulled the blanket off and smoke started coming out of it, so she doused it with water. She stated the room filled with smoke, and she opened the window to get the smoke out of the room. The job description for the RN CN was reviewed on March 29, 2011. The job description indicated the RN CN was responsible for maintaining a safe, comfortable, and therapeutic environment for the residents. The job description for the LVN was reviewed on March 29, 2011. The job description indicated the LVN must demonstrate the knowledge and skill necessary to provide safe care.According to the Emergency Care Research Institute, Hazardous Health Devices, June 1989, using a microwave oven to warm a blanket, ?may result in severe hot spots in the blanket and ignition due, in part, to uneven heating patterns within the oven. Unlike items heated within a conventional oven or warming cabinet, items heated in microwave ovens do not equilibrate to a set chamber temperature. Rather, they continue to heat as long as they are exposed to the microwave energy. Hot spots from microwave heating can cause smoldering and burning of the blanket while it is in the oven. Once removed from the oven, a blanket that is smoldering within its folds may burst into flames if exposed to oxygen or if permitted to smolder long enough?. The organization recommends the following: 1. ?Do not use microwave ovens for warming any blankets. Such use can result in fire, which could cause injury or death?; and,2. ?Use commercially available hospital blanket warming cabinets. Such cabinets are warmed by either electric heaters or steam and do not present a blanket ignition hazard, even if the warmed blanket is subsequently exposed to an open oxygen source?. |
| 910000046 |
HARBOR POST ACUTE CARE CENTER |
910010582 |
B |
04-Apr-14 |
5Q0F11 |
8194 |
Title 22 Section 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On September 7, 2011, the Department of Public Health received a complaint reporting that a patient was brought to the dialysis center with a gauze pressure dressing over the dialysis access site which had not been changed in three days and the pressure dressing caused the patient?s dialysis access to clot.Based on observation, interview and record review, the facility failed to ensure a gauze pressure dressing was removed from Patient 3?s hemodialysis (the removal of blood and waste products and free water from the kidneys) access site six to eight hours after the dialysis was performed resulting in the clotting of Patient 3?s arteriovascular graft (AV graft [vascular access for hemodialysis]). Failure to remove the dressing from the AV graft site timely had a direct impact on the clotting of Patient 3?s AV graft and required the patient to undergo a thrombectomy (a surgical procedure to remove a clot from a blood vessel). The thrombectomy was necessary for Patient 3 to further receive dialysis through the A V graft.On September 21, 2011, at 1:30 pm, an unannounced complaint investigation was conducted. On September 21, 2011, at 2:30 pm, Patient 3 was observed with a gauze pressure dressing covering on his right upper extremity AV graft. The gauze was taped at both ends and placed securely over the dialysis access site.A review of the medical record indicated Patient 3 was admitted to the facility on October 9, 2010, with diagnoses including end stage renal disease (a progressive loss of kidney function). The Minimum Data Set (MDS) assessment and care screening tool, dated February 17, 2011, indicated Patient 3 had independent cognitive skills for daily decision making, had clear speech, was able to make himself understood and understood others.A physician?s order dated October 3, 2010, indicated Patient 3's AV graft gauze dressing was to be removed after dialysis at 5 pm.According to the interview with the licensed vocational nurse (LVN 8) on September 21, 2011, at 3:45 p.m., Patient 3 attended dialysis in the mornings and was back in the facility during the early evenings around 5 pm. A review of a care plan dated June 16, 2011, addressed Patient 3's need for hemodialysis related to end stage renal disease. The nursing interventions included monitoring Patient 3's AV graft for redness, pain, signs and symptoms of infection and the presence or absence of a bruit (the rushing sound of blood) and thrill (vibration of the blood flow) to ensure the graft was patent.A review of the treatment records for August and September 2011, indicated the licensed staff were checking Patient 3's bruit and thrill and monitoring the site for signs and symptoms of infection, bleeding, swelling and discharge on each shift. However, during an interview on September 21, 2011, at 2:30 p.m., Patient 3 indicated the staff did not check his AV graft site when he returns back from the dialysis center. In addition, the observation made on September 21, 2011, at 2:30 p.m., indicated the patient still had the gauze pressure dressing over the AV graft site, nearly 24 hours after the patient received dialysis on September 20, 2011. A review of a care plan dated August 10, 2011, addressed Patient 3 as being prone to occlusion (blockage/clotting) of his hemodialysis AV graft. The care plan outcome included Patient 3 not having occlusion at the graft site. However, the nursing interventions did not include the removal of the pressure dressing as part of the plan of care. A review of the Nursing Evaluation and Progress Notes, dated September 6, 2011, indicated a call was received from the dialysis center regarding Patient 3's AV graft site. The note indicated the patient's graft site was clotted and the patient had to be sent from dialysis center to the vascular center to have the graft declotted (thrombectomy; a surgical procedure to remove a clot from a blood vessel). Potential complications of thrombectomy include artery puncture or tearing, heart attack (from dislodged fragments that travel to the heart or lungs), occlusion of more distal (away from the point of origin) arteries in the affected extremity, bleeding, infection and swelling of an extremity after the blood flow is restored (Journal of Vascular Surgery January 27, 2014). A review of the documentation from the Los Angeles Vascular Center dated September 6, 2011, indicated the thrombectomy of Patient 3's A V graft was an urgent matter in order to provide dialysis and sustain the patient's life.A review of the Dialysis Communication Record, dated September 8, and again on September 20, 2011, indicated the facility's nursing staff had been instructed to remove the pressure gauze dressing six to eight hours after dialysis if Patient 3's AV graft site was not bleeding. However, despite the instructions a pressure dressing was observed on Patient 3's AV site the day after dialysis on September 21, 2011, during the complaint investigation. The pressure dressing remained in place beyond the six to eight hours recommended by the dialysis center. On September 21, 2011, at 2:30 pm, the patient was interviewed and asked if the nurses look and listen (check bruit and thrill) to his AV graft site after the dialysis. Patient 3 shook his head from side to side indicating "no". When asked if the staff usually remove the tape and the gauze from the graft site the patient again shook his head indicating "no". On September 21, 2011, at 2:50 pm, LVN 8 stated, the gauze and tape on the graft sites are for a pressure, to prevent the site from bleeding. LVN 8 stated the pressure bandages are put on at the dialysis center and remain on the patient until they go back to dialysis. LVN 8 also stated the dressings stay in place to prevent infection at the site.On September 21, 2011, at 3 pm, LVN 6 stated the pressure dressings were to be checked and changed to make sure there was no bleeding, swelling or signs and symptoms of infection at the AV graft site. LVN 6 was not sure why the dressings were left in place on Patient 3 when he had been back from the dialysis for more than 24 hours. LVN 6 stated she had seen the notes from the dialysis center to remove the pressure gauze from the graft site after six to eight hours, however, she could not explain why it was not done. Both LVN 6 and LVN 8 stated they were aware if a patient's AV graft were to clot the patient would not be able to have dialysis. During an interview on August 16, 2013, at 10:20 am, the registered nurse from the vascular lab stated a graft access would clot because the pressure from the gauze pressure dressing doesn't allow the blood to flow freely. She stated a thrombectomy is a procedure where the physician gains access to the graft to remove the clot. She stated the physician uses a needle, different instruments and blood thinning medication to break up the clot. Upon completion of the procedure, which last approximately 45 minutes to one hour, the patient requires stitches. A facility policy and procedure on Vascular Access Care (not dated) indicated the resident should not wear anything tight on the arm or leg with the AV graft. It was indicated to avoid tight dressings or long pieces of tape on the needle site after dialysis treatment. A single piece of gauze and a stretch band aid provide adequate pressure. Keep the band aid on the needle site for 6 - 12 hours after the treatment and then remove. The facility failed to ensure a gauze pressure dressing was removed from the hemodialysis access site six to eight hours after dialysis was performed resulting in the clotting of Patient 3?s AV graft. Failure to remove the dressing from the AV graft site timely had a direct impact on the clotting of Patient 3?s AV graft and required the patient to undergo a thrombectomy. The thrombectomy was necessary for Patient 3 to further receive dialysis through the AV graft.The above violation had a direct relationship to the health, safety or security of patients. |
| 910000047 |
HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP |
910012297 |
A |
10-Jun-16 |
6D7M11 |
15654 |
483.25 Quality of Care F 309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care Based on interview and record review, the facility failed to provide the necessary care and services to prevent harm to Resident 1 by failing to: 1) Follow the physician?s order to obtain a psychiatric evaluation for Resident 2, who was admitted to the facility with known combative and disruptive behavior, which resulted in the facility?s not identifying the resident was Bipolar and had problems with anger, agitation and a desire to hit and strike people randomly. 2) Monitor Resident 2, who was prescribed Haldol (an antipsychotic medication that treats mental and mood disorders) for agitation as indicated in the plan of care 3) Develop a plan of care to address Resident 2?s dissatisfaction when she voiced she was upset with having a new roommate (Resident 1). These failures resulted in Resident 2 becoming agitated and pulling Resident 1?s leg which had been recently operated on, causing a dislocation of Resident 1?s repaired left hip prosthesis requiring a repeated hip surgery and the risk of possible harm from repeated surgery. On November 16, 2011, the Department received a complaint indicating on August 18, 2011, Resident 1 was assaulted by her roommate, Resident 2, and an x-ray of the left hip was taken and indicated Resident 1 sustained a hip dislocation. On December 12, 2011, at 3 p.m., an unannounced visit was made to the facility to conduct a complaint investigation. Resident 1 was admitted to the facility on XXXXXXX with diagnoses that included chronic left femoral fracture, status post left hip replacement, chronic pain, special posterior hip precautions, weight bearing as tolerated and an abduction pillow (a medical recovery device used to keep the legs stable after hip replacement surgery), and a history of falls. A review of the Psychosocial Assessment, dated August 17, 2011, indicated the resident?s cognitive skills for daily decision making and her short and long term memory were intact. And a review of the initial history and physical dated August 19, 2011, indicated Resident 1 had the capacity to understand and make decisions. According to the Orthopedic Surgery Transfer Summary form dated August 22, 2011, Resident 1 presented to the acute hospital emergency room on August 6, 2011, and a left hip x-ray was taken. The x-ray report indicated Resident 1 had a chronic left femoral neck fracture and a shortened femur length of nearly 4 centimeter (cm). The report further indicated given the severity of Resident1?s injury operative fixation was offered. On August 10, 2011, Resident 1 underwent a left total hip arthroplasty (replacement). On XXXXXXX, Resident 1 was discharged to the facility in stable and fair condition. The resident was to continue to receive care and bathing, washing and toileting while recovering from her surgery. The transfer instructions included weight bearing as tolerated, left lower extremity, with posterior hip precautions and an abduction pillow while in bed. During an interview on February 10, 2011, at 11 a.m., with Resident 1, she stated around 2 a.m., on August 18, 2011, she was lying in the middle bed B, asleep and opened her eyes and felt someone looking at her. The lady next to her in Bed C, Resident 2, was at the end of her bed and placed her two hands on her left leg, with one hand on her knee and the other hand on her ankle and pulled her left leg outward. Resident 1 stated she screamed because it was painful. Resident 1 stated she had just had a left hip replacement. Resident 1 stated when she screamed the nurses came into her room and removed the lady (Resident 2) from the room. Resident 1 stated the facility called a family member and the family member arrived at the facility and requested an x-ray of her left hip. Resident 1 further stated when she transferred to acute hospital 2, she was told her left hip ball was dislocated and had to be manipulated. The acute hospital physician (Physician 2) explained to her they were going to manipulate her left hip into place, by manually pushing her hip into place. Resident 1 stated the physician told her if the manual manipulation did not work she would have to go back to surgery to replace her left hip. During an interview on February 15, 2011, at 6 a.m., with LVN 1, who worked the 11 p.m., to 7 a.m., shift, she stated at 12 a.m., while making rounds on August 18, 2011, he observed Resident 1, a new admission to the room, asleep lying in the middle Bed. Resident 2, who had been admitted one week prior was in the same room, lying in the bed next to the window and was fussing about the new resident next to her bed, Resident 1. LVN 1 stated he informed Resident 2 the room is a room for three beds and the room has to be shared with other residents and now there is a resident in the middle bed. LVN 1 stated Resident 2 calmed down and stated okay. LVN 1 stated he continued making his rounds and around 2 a.m., (2 hours later) he heard screaming coming from Resident 1?s room and went to the room and observed Resident 1 lying in bed and Resident 2 standing at the foot of Resident 1?s bed, leaning over Resident 1 with her hand over Resident 1?s left leg. LVN 1 stated he removed Resident 2 from the room and returned to the room to assess Resident 1. Resident 1?s abduction pillow was in place and there were no injuries. Resident 1 complained of no pain at that time. The physician and the family were notified with no new orders. During an interview on February 15, 2011, at 6: 30 a.m., with certified nursing attendant (CNA 2), she stated she was sitting outside the residents? room in the corridor and heard Resident 1 screaming, ?Get off of me.? CNA 2 stated she went into the room and saw Resident 2 sitting in her wheelchair next to Resident 1?s bed. Resident 2 had her hand over Resident 1?s feet and the abduction pillow was in place. CNA 2 stated she heard Resident 2 telling Resident 1 to get out of her room. CNA 1 stated she told LVN 1 that Resident 2 told Resident 1 to get out of her room. CNA 2 stated LVN 1 removed Resident 2 from the room and took Resident 2 to the nursing station. A review of the licensed personnel progress notes dated August 18, 2011, indicated screaming was heard coming from Resident 1?s room and upon entering Resident 2 was observed sitting in her wheelchair at the foot of Resident 1?s bed pulling and tugging Resident 1?s left leg. The residents were immediately separated, and Resident 2 was taken out of the room. LVN 1 stated he asked Resident 1 what happened and Resident 1 said she was sleeping and when she opened her eyes she saw Resident 2 at the foot of her bed staring at her. She ignored Resident 2 and closed her eyes. She then felt Resident 2 grab her legs and started tugging at her, which was painful. When asked if she was still in pain, Resident 1 reported she had no pain or distress. The licensed nurse documentation further indicated there were no injuries noted during the examination. The physician was notified of the incident and no orders given. A review of a physician order dated August 19, 2011, indicated to take an x-ray of the left hip STAT (immediately) per the family?s request. The results indicated a status post left total hip replacement with disruption of the hip prosthesis and a superior lateral displacement of the left femur. A review of the licensed personnel progress notes dated August 19, 2011, at 10 p.m., indicated the physician was made aware of the Stat x-ray result and ordered Resident 1 to be transferred to the acute hospital. According to the acute hospital 2 discharge summary dated August 22, 2011, Resident 1 was discharged to the skilled nursing facility (SNF) on August 17, 2011. Over the night of August 18, 2011, the resident was attacked by her roommate at the SNF and the roommate who reportedly pulled on the resident?s leg caused an increase in pain. A workup was done by the physician at the SNF and apparently revealed a dislocation of the left hip prosthesis. The resident was brought into the GACH?s emergency room on August 20, 2011, with diagnosis of a left posterior hip dislocation where a closed reduction (a procedure to set (reduce) a broken bone without surgery) was attempted without conscious sedation (without anesthesia [artificially induced loss of ability to feel pain]). The closed reduction was unsuccessful and the resident was taken back to the operating room again and attempted a closed reduction of the left hip posterior dislocation under anesthesia. The second attempt was unsuccessful. The resident was taken to the operating room (OR) for a final attempt at closed reduction of the joint dislocation which was unsuccessful and required an open-reduction and internal fixation (surgically repairing a broken bone) of the left hip posterior dislocation. According to the admission record, Resident 2 was admitted to the facility on XXXXXXX, with diagnoses that included congestive heart failure (heart unable to pump sufficiently to maintain blood flow to meet the body needs) and hypertension. The Minimum Data Set (MDS) an assessment and screening tool dated August 12, 2011, indicated Resident 2?s speech was clear and she had the ability to make herself understood and to understand others, had intact cognitive skills for daily decision making and used a wheelchair or the walker. The assessment further indicated Resident 2 had no hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). The assessment also indicated the resident had behavioral symptoms and her overall presence of behavioral symptoms put others at risk for significant risk for physical injury and had no psychiatric mood disorder. The initial history and physical dated 7/31/11, indicated Resident 2 was confused and had fluctuating capacity to understand and make decisions. A review of the physician?s order dated July 21, 2011, indicated to administer Haldol 2 milligrams (mg)/0.4 milliliter (ml) intramuscular (IM [medication given by needle into the muscle]) every six hours as necessary for agitation. On July 30, 2011, the physician order indicated to decrease the Haldol and administer Haldol l mg/0.2 mg IM every six hours as necessary for agitation. On July 31, 2011, at 2 p.m. the physician order indicated to obtain a psychiatric evaluation. A review of the Medication Record (MAR) dated July 2011 indicated to there was no Haldol administered for the month of August 2011 for agitation. A review of the licensed personnel progress notes dated August 18, 2011, at 2 a.m., indicated LVN 1 heard screaming from Resident 1?s room and upon entering observed Resident 2 in wheel chair at the foot of Resident 1?s bed. While transferring Resident 2 she was yelling, ?All of you get out of my house?. A review of Resident 2?s clinical record indicated there was no documented evidence Resident 1 was monitored for agitation and there were no tally marks documented on the 7 a.m., to 3 p.m., shift, the 3 p.m., to 11 p.m., shift and the 11 p.m., to 7 a.m., shift noting the resident was monitored for agitation or no agitation. A further review indicated there was no psychiatric consultation or evaluation conducted as ordered by the physician or presented to the surveyor during the investigation. During an interview on February 15, 2011, at 9:35 a.m., with the Acting Director of Nursing (ADON), she stated Resident 2 was monitored for behavior due to the physician?s order for Haldol as necessary. The ADON reviewed Resident 2?s MARs for July 2011 and August 2011 and stated Resident 2 was not monitored for agitation as indicated by the lack of hash marks and there was no indication Haldol was administered to Resident 2. The ADON stated a physician order was written on July 31, 2011, for a psychiatric consultation and evaluation, however, during a review of the clinical record there was no documented evidence of a psychiatric consultation or a psychiatric evaluation in Resident 2?s clinical record. A Plan of Care dated July 21, 2011, indicated Resident 2 had an alteration in behavior manifested by severe agitation evidenced by climbing out of bed unassisted related to psych. The nursing interventions included to monitor the resident?s behavior, tally every shift and medication as ordered. On XXXXXXX, Resident 2 was transferred to acute hospital 2 for a psych evaluation. According to the Neurology Consultation Note, dated August 21, 2011, Resident 2 was transferred from a skilled nursing facility for bad behavior. The resident had been irate, erratic and aggressive. Resident 2 pulled and grabbed her roommate?s leg and said she was here because she was arguing with people and people felt she was crazy. The resident claimed she strikes out at people, but does not actually hit them. And she was mad because there was a new person in the room and because the staff told the resident a new person had moved in. The resident was upset because the facility moved another resident into her room and into a bed. On XXXXXXX, Resident 2 transferred to acute hospital 3. According to the acute hospital 3?s Psychiatric History and Mental Status Examination dated August 22, 2011, the resident was fighting and threatening others at her facility, and continued to state she had problems with anger, agitation and wanted to hit and strike people randomly. The examination further noted Resident 2 was very confused and had disorganized thought process, racing thoughts, and pressured speech and required psychiatric medications for stabilization. The Resident was depressed, agitated and diagnosed as Bipolar II (also known as manic depressive illness a serious medical illness that causes shifts in mood, energy, and ability to function). The resident was ordered Risperdal 0.5 mg (anti psychotropic medication) twice a day orally to reduce her level of agitation and to provide some mood stabilization along with an order for Haldol 1 mg IM every six hours as necessary for agitation. From XXXXXXX, when Resident 2 was admitted to the facility through XXXXXXX Resident 2 had no psych evaluation or psych medications to stabilize her moods. The facility failed to ensure a psychiatric evaluation and consultation was conducted in accordance to the physician?s order, to provide the resident the required psychiatric medications for stabilization. These failures included but are not limited to failure to: 1) Follow the physician?s order to obtain a psychiatric evaluation for Resident 2, who was admitted to the facility with known combative and disruptive behavior, which resulted in the facility?s not identifying the resident was Bipolar and problems with anger, agitation and desires to hit and strike people randomly. 2) Monitor Resident 2, who was prescribed Haldol (an antipsychotic medication that treats mental and mood disorders) for agitation as indicated in the plan of care 3) Develop a plan of care to address Resident 2?s dissatisfaction when she voiced she was upset with having a new roommate (Resident 1). The above violations had a direct or immediate relationship to the health, safety and security of Resident 1 and all residents. |
| 910000047 |
HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP |
910012317 |
A |
21-Jun-16 |
F83R11 |
13201 |
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 January 13, 2011, at 11 a.m., an unannounced visit was made to the facility to conduct a complaint investigation regarding Resident 1 who was transferred to the acute hospital due to a critical blood sugar level of 1198 mg/dl. Based on interview and record review the facility failed to ensure Resident 1, who was diagnosed with diabetes and was severely impaired cognitively, requiring extensive assistance from staff, and totally dependent in activities of daily living and received daily enteral feedings, was provided the care and services to maintain her physical well-being in accordance to a comprehensive care plan by failing to: 1. Implement its policy and procedure to obtain quarterly blood glucose checks for Resident 1. 2. Develop a comprehensive plan of care to manage Resident 1?s diabetes that included the methods to be used to monitor and determine abnormal blood glucose levels and the frequency with which these methods would be carried out to prevent hyperglycemia and hypoglycemia. 3. Conduct routine insulin sliding scales, glucose serum labs and blood sugar readings to monitor Resident 1?s glucose levels to afford effective glucose control. Consequently, Resident 1 became sluggish and had a critically elevated blood sugar of 600 mg/dl (normal reference range for a diabetic is 70 mg/dl to 130 mg/dl). This resulted in Resident 1 being transferred to the acute hospital with an altered level of consciousness and a critically high blood sugar which measured 1198 mg/dl. Resident 1 was subsequently diagnosed with acute renal failure secondary to hyperglycemia, was dehydrated and remained in the hospital for three days and was ultimately diagnosed with uncontrolled diabetes requiring insulin therapy. On 6/10/11, the Department received a report from the acute hospital which noted Resident 1 was admitted to the acute hospital emergency room with an elevated blood sugar of 1198 mg/dl. LVN 1 told the hospital staff the resident was not on diabetic medication and according to the documentation in the medical record dated 3/30/11, the resident?s diabetes was controlled and managed without agents. The report further indicated LVN 1 stated the doctor did not order a routine blood stick and it?s not up to her to write the order or second guess the doctor. According to the admission record, Resident 1 was admitted to the facility on XXXXXXX, with diagnoses that included status post gastrostomy tube (GT- surgical opening into the stomach to administer medication and nutrients), dysphagia (difficulty swallowing), diabetes mellitus type II, and hypertension (high blood pressure). A review of the plan of care dated February 18, 2008, and updated through May 2011, identified the resident had a potential for blood sugar fluctuation related to her diagnoses of diabetes mellitus, which was controlled by diet. The listed approaches indicated to be alert for signs and symptoms of hypoglycemia and changes in blood sugar less than 50 mg/dl and to be alert for signs and symptoms of hyperglycemia and changes in blood sugar greater than 200 mg/dl, administer insulin as ordered and call the physician for abnormalities. However, there was no indication as to what method (glucometer, routine labs) and how often (frequency) to check for blood sugars. Additionally, there was no insulin order as indicated in the plan of care. There was no documented evidence the IDT discussed the plan of care to ensure these methods were addressed in Resident 1?s plan of care. A review of Resident 1 ?s lab results indicated the most recent blood serum glucose level and AIC results for Resident 1 was drawn on February 11, 2010, and on November 4, 2010. On February 11, 2010, Resident 1?s serum glucose level was 160 mg/dl (normal reference range for a diabetic is 70 mg/dl to 130 mg/dl). The glycohemoglobin (A1c) -[An A1c test does not directly measure the level of blood glucose, however, the result of the test is influenced by how high or low your blood glucose levels have tended to be over a period of 2 to 3 months.]) was 9.2 (normal reference range for a diabetic should be less than or around 7.0). Ten months later on November 4, 2010, Resident 1?s serum glucose level was 120 mg/dl, and the (A1C) was 6.7. There were no further labs drawn or ordered by the physician or the physician?s assistant from November 10, 2010, to May 25, 2011, to determine Resident 1?s blood sugar level, in accordance with the facility?s policy, to draw blood glucose levels every three months, and the plan of care which notes to monitor for changes in blood sugars. Resident 1 should have had blood glucose levels drawn at or around February 10, 2011, and May 10, 2011. There is no documented evidence this was done. A review of the minimum data set (MDS) an assessment and care screening tool, dated February 17, 2011, indicated Resident 1 was severely impaired in her cognitive skills for daily decision making, had unclear speech and was able to usually understand others and was usually able to make herself-understood, required extensive assistance from the nursing staff in the areas of bed mobility, and transferring, and was totally dependent upon the nursing staff for personal hygiene. A review of the patient care conference notes dated February 15, 2011, and May 19, 2011, did not contain documented evidence the Interdisciplinary Team discussed obtaining orders from the physician to perform routine blood glucose serum levels and blood finger sticks to check and monitor the residents blood glucose levels and antidiabetic medications. The physician assistant (PA) notes, dated April 27, 2011, indicated Resident 1 was a long-term care patient with a gastrostomy feeding which infused at 55 ml per hour for twenty hours and had chronic diabetes mellitus which was controlled. A review of the physician?s order dated May 1, 2011, to June 15, 2011, indicated to administer diabetic Source-AC at 55millitier/hour (ml/hr for 20 hours to provide 1100 ml and 1320 calories per day via the enteral pump. A review of the physician orders from May 1, 2010, to May 25, 2011, did not contain physician orders regarding management of Resident 1?s chronic diabetes such as quarterly blood sugar levels, antidiabetic medications or common blood work for diabetics. Review of the licensed personnel progress notes dated May 25, 2011, at 4 a.m., indicated Resident 1was in bed sleeping and had no change in condition or signs and symptoms of distress. Two hours later, at 6:05 a.m., during the final nursing round, Resident 1 was found in bed, awake and had a sluggish response to verbal communication. A blood sugar check was done via a glucometer (a hand-held machine which allows diabetics to monitor the amount of glucose in their blood) twice, (although there was no physician order to do so) and the resident?s blood sugar level measured 600 mg/dl. Therefore 911 was called and the resident was transferred to the acute hospital for evaluation. The acute care hospital record dated May 25, 2011, indicated the patient?s chief complaint was an altered level of consciousness secondary to hyperglycemia. The laboratory data indicated the resident?s glucose level was 1198 mg/dl. The acute hospital discharge summary dated XXXXXXX, indicated the resident was admitted with hyperglycemia as well as dehydration for her uncontrolled diabetes. She remained in the acute hospital for three days and was started on insulin. Her insulin was increased and she was continued on tube feeds. Her sugars had been in the 200 to 300 mg/dl range. She was also diagnosed with acute renal failure which resolved with IV fluids. The resident was discharged back to the facility on Levemir (along acting insulin used to control diabetes) 25 units every 12 hours as well as an Insulin sliding scale regimen to be checked every six hours, During an interview on June 13, 2011, at 12:30 p.m., PA 1 stated Resident 1?s February 11, 2011, glucose level was 160 mg/dl and the level was acceptable for her age and population. PA 1 further stated the patient had no medication ordered for diabetes mellitus, and was only on a diabetic controlled diet with oral gratification at lunchtime with no concentrated sugar (NCS). . During an interview, on June 13, 201l, at 1 p.m., licensed vocational nurse (LVN 5) stated Resident 1 had no diabetic medication ordered for diabetes mellitus. LVN 5 stated PA 1 visited the resident monthly and the resident had an order for GT feedings and oral gratification for lunch and the resident?s diabetes was diet controlled. LVN 5 stated the physician or the PA wrote orders for the resident. LVN 5 stated she worked the 7 a.m., to 3 p.m., shift on May 24, 2011, and assessed the resident and the resident did not have early signs and symptoms for hyperglycemia. On XXXXXXX on the 11 p.m., to 7 a.m., shift, the resident was sluggish and had an accucheck check reading of 600 mg/dl and was transferred to the acute care hospital. During a review of the licensed personnel progress notes in the presence of LVN 5, on June 13, 2011, at l: 30 p.m., there was no documentation that LVN 5 had assessed Resident 1 on May 24, 2011 on the 7:00-3p.m shift. When asked why there was no documentation of her assessment of Resident 1, on May 24, 2011, LVN 5 did not respond. According to the facility?s policy titled ?Enteral Nutrition Program? dated December 1, 2003, enteral nutrition is provided for those patients who cannot or will not take necessary nutrients by mouth, due to disease or physical disorders, and who have a functioning gastro-intestinal tract and recommended the glucose blood sugar lab test be done quarterly. There was no documented evidence the facility implemented this policy or documented justification as to why quarterly blood glucose checks should not be drawn for Resident 1. On June 14, 2011 at 9:30 a.m., during a telephone interview, the medical director, stated the resident was admitted to the facility in 2008 and was not on diabetic medication for diabetes mellitus. However, initially the patient?s blood sugar was being monitored. PA 1 had ordered the patient?s blood sugar to be monitored when the resident was first admitted into the facility in 2008. The medical director also stated the PA visited the patient monthly and the resident presently was not administered diabetic medication. The medical director further stated PA 1 would have ordered accucheck(s) to monitor the patient blood sugar level, but at this time, the resident is not on diabetic medication but is diet controlled. A review of the clinical record on June 15, 2011, at 2 p.m., with the assistant nursing director (ADON), when asked were there any physician orders written for lab work for glucose levels after November 11, 2010 and/ or an order for accu checks to monitor the resident?s blood sugar level. The ADON stated, ?No.? The ADON further stated the residents? diabetes was diet controlled. During an interview, on June 15, 2011, at 3 p.m., the ADON stated the plan of care for the resident?s problem/concern diabetes mellitus and the nursing written approach/intervention was incomplete. Also, the nursing approach and interventions should have been completely documented to indicate abnormal labs. People with type 2 diabetes should take a blood sugar reading at least once a day. Kathy Honick, RN, CDE, a diabetes educator at Barnes Jewish Hospital in St. Louis, explains that not only does regular blood sugar testing tell you if you?re doing well, it can "identify a pattern of highs and lows, which may be out of range," if your levels are not well-controlled. Blood glucose monitoring is a cornerstone of diabetic management. The monitoring method must match the patient?s skill level. Patients not receiving insulin should have their blood glucose levels at least two to three times per week. For all patients, testing is recommended whenever hypoglycemia or hyperglycemia is suspected. (Brunner & Suddarth? Textbook of Medical Surgical nursing 10th Edition p.1162). The facility failed to provide the necessary care and services by failing to: 1. Implement its policy and procedure to obtain quarterly blood glucose checks for Resident 1. 2. Develop a comprehensive plan of care to manage Resident 1?s diabetes that included the methods to be used to monitor and determine abnormal blood glucose levels and the frequency with which these methods would be carried out to prevent hypoglycemia and hyperglycemia. 3. Conduct routine insulin sliding scales, glucose serum labs and blood sugar readings to monitor Resident 1?s glucose levels to afford effective glucose control. 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. 1 |
| 910000049 |
Hyde Park Convalescent Hospital |
910012351 |
A |
28-Jun-16 |
K3UV11 |
9580 |
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: 1. Ensure the direct care staff transferred Resident 1 in a safe manner to prevent his arm from getting stuck in the wheelchair resulting in a fractured humeral shaft (right lower arm). 2. Implement its policy and procedure to place both of Resident 1?s hands on the arms of the chair during a transfer 3. Ensure the direct care staff followed the facility?s policy and procedure for abuse reporting of accidents and incidents. Resident 1 sustained a fractured right arm when he was transferred from the wheel chair to the bed without use of proper transfer techniques. Resident 1's right arm was caught under the armrest of the wheelchair while being transferred by a certified nursing assistant (CNA 11). On April 20, 2012, at 12:30 pm, an unannounced visit was made to the facility to investigate an entity reported incident to the Department of Public Health on March 30, 2012, regarding a resident?s arm being caught between the armrest and the wheelchair while being transferred to the bed, with complaints of pain and a diagnosis of a fractured right upper extremity. A review of the medical record indicated Resident 1 was admitted to the facility on XXXXXXX, with diagnosis of hypocalcemia (low calcium levels in the blood). A review of a Nurse's Aide Orientation Checklist, dated August 10, 2011, indicated CNA 11 had been provided orientation for body mechanics, which included lifting and/or transferring a resident. CNA 11 provided care for Resident 1, which included lifts and transfers, on more than one occasion and during the time of the incident in March of 2012. A review of the Minimum Data Set (MDS) Assessment, dated March 14, 2012, indicated Resident 1 was independent in his cognitive skills for daily decision making, was able to make himself understood and was able to understand others. The MDS further indicated Resident 1 required one person physical assistance with transfers which included moving from the wheelchair to the bed. . A review of the Medication Administration Record (MAR) for March 2012, indicated Resident 1 was administered Tylenol 500 milligrams two tablets on 3/25/12, which had been ordered on 3/25/12, for severe pain to the right arm and the Tylenol was effective in relieving the pain. A review of the nurse?s notes dated March 25, 2012, at 8 a.m. (which was noted as a late entry dated 3/26/12) indicated the charge nurse was notified that Resident 1 complained of pain to the right arm and was assessed to have no bruises or discolorations. The nurse?s note further noted the resident had complained of a pain level of four, on a scale of one to ten, to the right arm and denied any knowledge about the cause of his pain and was administered Tylenol 500 milligrams two tablets as ordered by the physician. A further review of the (late entry) Nurses Notes dated March 25, 2012, at 9 am, 11 am, 12 pm, 2 pm and 3 pm, indicated Resident 1 denied having any pain. The nurse's notes indicated the findings regarding Resident 1 had been endorsed from the day shift charge nurse to the oncoming charge nurse. The Nurses Notes dated March 25, 2012, at 4 pm, in contrast to the 3 pm notes, indicated the resident reported severe right arm pain to the charge nurse. The notes indicated Resident 1 requested Tylenol # 3 (a narcotic pain reliever) for his pain. On April 20, 2012, at 1:30 pm, LVN 20 stated CNA 11 informed her that the resident?s right arm hurt and therefore, she administered Tylenol 500 mg. LVN 20 stated Resident 1 was guarding his arm, had facial grimacing and was very sensitive in regard to his arm. LVN 20 further stated that she did not ask Resident 1 how he hurt his arm, and did not report it to the DON. On April 20, 2012, at 2 pm, during an interview, Resident 1 stated initially his pain was an eight on a scale of one to ten. The resident stated the licensed vocational nurse (LVN 20) did not look at his arm or ask any questions about the rate or type of pain he had. Resident 1 stated LVN 20 gave him regular Tylenol for the pain which was not effective and LVN 20 really did not check on him after the incident. On April 20, 2012, at 2:05 pm, during an interview, the resident stated later that day (3/25/12) and the next day his pain remained at least an eight on a scale of one to ten. The resident stated the medication (Tylenol #3) was effective for a short time, however, the licensed staff still did not ask how he hurt his arm. On April 20, 2012, at 2:10 pm, CNA 11 stated the day of the incident Resident 1 had put on the call light so he could go back to bed from the wheel chair. CNA 11 stated during the transfer he put his hands on both sides of Resident 1?s waist and picked him up. CNA 11 stated he then swiveled and placed the resident in his bed. During an interview on April 20, 2012, at 2:10 pm, the DON and the administrator stated CNA 11 told them he did not know where the resident's arms were during the transfer. However, CNA 11 had training on the proper transfer techniques on 8/10/11. The DON and administrator stated CNA 11 was definitely aware that any accident/incident with a resident should be reported right away. During an interview on April 20, 2012, at 2:10 pm, CNA 11 initially stated he did not hear a ?pop? but then stated he thought he heard a ?pop? sound while transferring Resident 1. CNA 11 stated he reported the incident to the director of staff development on the next day but did not mention what happened (that day) because he was afraid. He further stated that he was aware he should have reported the incident to the charge nurse. He admitted that he should have checked where Resident 1's arms were before pulling him up out of the wheelchair. On April 20, 2012, at 2:45 pm, Resident 1 stated his arm was down between his body and the arm of the wheelchair during the transfer. He stated CNA 11 pulled him up from the w/c, his arm was stuck for a moment, popped out and hit the arm rest. Resident 1 stated CNA 11 did not give him any instruction on what to do with his arms during the transfer. The resident stated CNA 11 did not place his arms around his neck during the transfer. Resident 1 stated other CNA's would give him instructions on where to place his arms or put his arms around their neck before transferring him. On April 20, 2012, at 3:30 pm, the director of staff development (DSD) stated she personally worked with CNA 11 upon orientation to demonstrate the proper technique for transferring residents. The DSD further stated CNA 11 seemed to understand the instructions and was able repeat them to her. The Nurses Notes dated March 26, 2012, at 5:50 am, indicated Resident 1 complained of pain to the right side of his body and rated his pain at a ten. Resident 1 was transferred to the general acute care hospital (GACH) for an evaluation, and returned to the facility at 2pm on the same day with a diagnosis of a fracture to his right upper extremity. A review of the x-ray results dated March 26, 2012, indicated Resident 1 had a fracture through the mid-right humeral shaft (upper arm bone). A physician?s order dated March 26, 2012, indicated Resident 1was to have a fiberglass splint immobilizer for his right upper extremity and was to keep the splint in a sling while sitting up in his wheelchair. A review of a Resident Assessment Protocol (RAP) Summary dated March 26, 2012, which did not include a time, indicated Resident 1, and was interviewed regarding how the fracture occurred. Resident 1 informed the director of nursing (DON) the injury occurred when he was transferred from the wheel chair to the bed. He stated his arm was caught under the arm of the wheel chair during the transfer. The RAP Summary Note dated March 26, 2012, indicated during an interview CNA 11 verified the incident with Resident 1. However, CNA 11 did not provide an explanation as to what happened to Resident 1's arm. The note indicated CNA 11 reported to the charge nurse Resident 1 said his arm hurt. A review of a facility's undated policy and procedure on,? Moving a Resident, Bed to Chair/Chair to Bed? indicated to instruct the resident to place both hands on the arms of the chair. A review of the facility?s undated policy and procedure titled ?Abuse: Reporting/Investigating Resident Accidents/Incidents,? indicated all accidents/incidents involving Resident s/residents must be reported to the director of nursing services and to the administrator. The facility failed to: 1. Ensure the direct care staff transferred Resident 1 in a safe manner to prevent his arm from getting stuck in the wheelchair resulting in a fractured humeral shaft (right lower arm). 2. Implement its policy and procedure to place both of Resident 1?s hands on the arms of the chair during a transfer 3. Ensure the direct care staff followed the facility?s policy and procedure for abuse reporting of accidents and incidents. As a result, Resident 1 sustained a fractured right arm when he was transferred from the wheel chair to the bed without use of proper transfer techniques. The above violations presented either imminent danger that serious harm would result, or a substantial probability that serious physical harm would result to Resident 1. |
| 910000049 |
Hyde Park Convalescent Hospital |
910013153 |
A |
3-May-17 |
UZ4U11 |
11704 |
F323
(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.
(2)
On 3/9/17, an unannounced visit was made to the facility to investigate an entity reported incident which indicated on 3/7/17, at 10:30 a.m., Resident 1 was missing from the facility and his whereabouts were unknown. The facility was not aware the resident had eloped and had not recognized the elopement for over an hour.
Based on observation, interview and record review the facility failed to ensure Resident 1 who was assessed as having a high risk of elopement, was provided continuous, adequate supervision and monitoring by failing to:
1. Ensure the licensed nurse and CNAs were aware of Resident 1's high risk and history of elopement to ensure they provided monitoring to ensure Resident 1's safety.
2. Monitor and supervise Resident 1 every two hours as indicated in the Interdisciplinary Team (IDT) notes.
3. Implement the facility's Elopement Risk Prevention Program policy and procedure to provide a wander guard (a device that alarms when residents attempt to elope or wander from a safe environment), 1:1 Supervision, and alternative placement when Resident 1 exhibited elopement behaviors.
These deficient practices resulted in Resident 1, who was diagnosed with a history of traumatic brain injury (injury of the brain that results in temporary or permanent symptoms), schizophrenia (a mental disorder characterized by failing to understand what is real), and assessed as having poor decision-making skills, and refusal to wear a wander guard to elope from the facility undetected and missing for 23 consecutive days. The facility staff could not locate the resident. Unbeknownst to the facility, the following day Resident 1 was located 18 miles away from the facility and was unresponsive. Consequently, this resulted in harm to Resident 1. Resident 1 was admitted to the acute hospital, where he was diagnosed as having blunt head trauma and an intracranial bleed (bleeding around or within the brain). Resident 1 remains in the acute hospital in a persistent vegetative (severe brain damage) state and had underwent two brain surgeries.
A review of the physician's history and physical (H & P) from the GACH dated 12/21/16, indicated Resident 1 had eloped from the GACH's medical floor, and was found in a coffee shop mumbling to himself. The H & P further noted the resident had difficulty following re-directions, was confused, disoriented and disorganized, had slurred speech, was not quite coherent, and wanders into the streets placing his life at risk.
A review of the admission record indicated Resident 1 was admitted to the facility on XXXXXXX17, from the general acute care hospital (GACH) with diagnoses that included traumatic brain injury, schizophrenia convulsions (uncontrolled body shaking).
A review of the admission assessment dated 3/2/17, indicated Resident 1 was alert, oriented, aggressive and denied sensory problems.
A review of the elopement risk assessment dated 3/2/17, indicated Resident 1 was assessed a score of 13. A total score of 10 or above represents high risk. The assessment also indicated the resident was cognitively impaired with poor decision-making skills, had a history of leaving the facility without supervision and without informing the staff and had a history of eloping while he was at home.
A review of Resident 1's plan of care titled "Wanderer/Elopement Risk" dated 3/2/17 indicated Resident 1 had a potential for injury related to wandering, attempts to leave the facility grounds, which posed a danger to himself and others, a history of elopement prior to admission and refusing to wear a wander guard. The listed approaches included to monitor the resident's whereabouts, and to identify and minimize situations that lead to wandering behavior.
A review of the facility's IDT conference record dated 3/3/17 indicated Resident 1 had a history of elopement during his previous placement, and refused to wear a wander guard. The IDT notes also noted Resident 1 was being monitored every two hours for his whereabouts and was placed in a room by the nurses' station for close watch. However, upon further review there was no documented evidence in Resident 1's clinical record to confirm he was monitored every two hours.
During an interview on 3/9/17 at 9:15 a.m., the Director of Nursing (DON) stated when Resident 1 refused to wear a Wander Guard the facility's measures were to place the resident near the nurses' station, bi-hourly (every 30 minutes) rounds and have the receptionist on guard.
A review of the facility's internal investigative report indicated on 3/7/17, at 10:30 a.m., indicated Resident 1 was observed standing in the doorway threshold of his room. On 3/7/17 at 11:30 a.m., one hour later, the resident was not observed to be in the facility. An internal and external search was conducted but, facility staffs were not able to locate the resident. The facility notified the local authorities and a missing person's report was generated.
During an interview on 3/9/17 at 9:45 a.m., with Employee X, she stated, on the 3/7/17, she did not observe Resident 1 leaving the facility due to multi-tasking. She further stated on 3/6/17, the day before Resident 1 eloped, Resident 1 walked towards the receptionist desk and pointed at the main door of the facility. Employee X re-directed the resident back to his room and told the staff sitting at nurses station one that the resident was near the entrance of the facility. Employee X stated she was informed by the DON on 3/9/17, after the resident eloped, that he was a high risk for elopement.
During an interview on 3/9/17 at 11:00 a.m. the Director of Staff Development (DSD) stated she administered the routine morning medications to Resident 1 on 3/7/17 at 8:10 a.m. The DSD further stated that she was not aware and had not been informed prior to Resident 1's elopement that he was a high risk of elopement and had eloped from previous health facilities.
During an interview on 3/9/17 at 11:35 a.m., certified nurses' assistant (CNA 1) stated she provided care for Resident 1 on 3/5/17 and 3/6/17 from 7 am to 3 pm and was not informed the resident was a high risk for elopement and had eloped from previous health facilities.
During an interview on 3/9/17 at 2:35 p.m., with Family member (FM 1), she stated Resident 1 had a history of eloping from several health facilities. A year ago the resident eloped from a facility and was found in San Diego California. He had been brutally assaulted, half of his brain was missing and he was not able to talk. FM 1 further stated Resident 1 becomes bored easily.
A review of the Social Services assessment dated 3/6/17 indicated FM 1 was involved in Resident 1's care. FM 1 also indicated that upon discharge Resident 1 should be in a locked facility.
During an interviews 3/9/17 at 3:48 p.m., 4:05 p.m., and 4:20 p.m., the registered nurse supervisor (RNS) stated that he performed the initial elopement risk assessment on Resident 1 on 3/2/17. The RNS further stated that he was not aware that the resident has a history of elopement. However, the elopement risk assessment indicated that Resident 1 had a history of leaving the facility without supervision and without informing the staff. The RNS stated that he could not recall notating the elopement risk assessment and believed that he read somewhere in the resident's chart that the potential existed. The RNS stated after a high risk of elopement was determined the physician would be notified, but could not recall if the physician was notified.
During an interview on 3/9/17 at 4:25 p.m., with the Administrator, she was asked if there were any residents who had eloped from the facility prior to 3/7/17, and he stated back in January 2017 Resident 3 eloped from the facility. Resident 3 walked out the front door and was found one week later downtown Los Angeles at the Mission (a homeless shelter). The Administrator also stated Resident 2 made an attempt to go across the street to the liquor store and was found outside of the facility without supervision.
During an interview on 3/9/17 at 4:32 p.m., the Administrator and the DON were asked how information is communicated to the staff after an IDT meeting. The DON stated the charge nurses are present during the IDT meeting and are responsible for informing the licensed nurses and CNA's of the resident's ongoing conditions and/or changes. The DON stated the staffs were only in-serviced for "High Risk Elopement" after Resident 1 had eloped from the facility.
During a telephone interview on 3/13/17 at 8:38 a.m., FM 1 stated that she was concerned and afraid that Resident 1 maybe deceased.
During a telephone interview on 3/14/17 at 1:00 p.m., the Administrator stated that Resident 1 has not been located at this time and several attempts were made to locate the resident.
During a telephone interview on 3/20/17 at 4:20 p.m., the DON stated that Resident 1 has not been located and the facility has made daily attempts in locating the resident.
During a telephone interview on 4/5/17, with the DON, she stated Resident 1 had been located and is in the general acute care hospital.
A review of the acute hospital record indicated Resident 1 was found down at the train station on 3/8/17, and was admitted with a large epidural hematoma. He underwent surgery for evacuation of the hematoma and remains in a persistent vegetative state.
A review of the facility's revised policy dated 2016 and titled "Elopement Prevention Program" indicated all residents will be assessed of elopement risk upon admission and as needed. The resident who is identified at risks for elopement the implementation will be but not limited to: wander guard bracelet if applicable to the facility setting; 1:1 supervision; secured unit placement; activity re-assessment; family intervention; environmental assessment; medication review; physical re-assessment; psychosocial assessment and evaluation of alternate placement.
A review of the facility's undated protocol titled "Elopement Prevention Protocol" indicated appropriate staff will monitor resident whereabouts including the monitoring of responses/reactions to events/activity in surroundings at the time of wandering and report unusual behaviors to supervisor immediately. Communication such as but not limited to: written notification to appropriate departments regarding resident at risk.
The facility failed to ensure Resident 1 who was assessed as having a high risk of elopement, was provided continuous, adequate supervision and monitoring by failing to:
1. Ensure the licensed nurse and Certified Nurse Assistants (CNAs) were aware of Resident 1's high risk and history of elopement to ensure they provided monitoring to ensure Resident 1's safety.
2. Monitor and supervise Resident 1 every two hours as indicated in the interdisciplinary Team (IDT) notes.
3. Implement the facility's Elopement Risk Prevention Program policy and procedure to provide a Wander Guard, 1:1 Supervision (1:1 staff must remain with the patient at all times, including use of the bathroom and during visiting hour), and alternative placement, when Resident 1 exhibited elopement behaviors.
The above violation presented either imminent danger that serious harm would result, or a substantial probability that serious physical harm would result to Resident 1. |
| 920000068 |
HOLIDAY MANOR CARE CENTER |
920011508 |
A |
25-Aug-15 |
I2I911 |
27152 |
F323 CFR 42 483.25(h) ACCIDENTSThe facility must ensure that -- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. F309 CFR 42 483.25 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 August 14, 2012, the Department received a complaint (CA00321696) alleging that Resident 1 had several falls at the skilled nursing facility (SNF), and the last fall on May 23, 2012, contributed to her death. On May 23, 2012 at 1:50 p.m., the resident was found on the floor at the foot of her bed in the sitting position, was sent to the general acute care hospital (GACH), where she was diagnosed with a broken hip. On May 24, 2012, the resident had surgery to repair the fractured hip. On June 1, 2012, after returning to the SNF, the resident was taken to the shower, had complications and died. It was alleged that the resident?s death was due to the fall and the fracture. On August 20, 2012, at 9:40 a.m., a complaint investigation was initiated.The facility failed to ensure Resident 1, who was assessed as being a high risk for falls, was provided one-to-one supervision and assistive devices to prevent avoidable accidents, based on the facility?s assessment and care planning to prevent falls and injuries, including but not limited to, failure to:1. Implement the care plans that were developed upon admission to reduce Resident 1?s fall risks and injuries; and 2. Monitor the effectiveness of the care plan interventions and modify them as necessary after each fall incident in accordance with the facility?s policies and procedures. The facility also failed to provide pain management after Resident 1?s fourth fall incident that resulted in a broken hip. Resident 1 subsequently died at the facility on June 1, 2012, after returning from a seven-day hospitalization stay after surgery to repair her broken hip. A review of the skilled nursing facility (SNF) admission record indicated an 89 year-old Resident 1 was originally admitted to the facility on February 13, 2012, with diagnoses that included dementia (deterioration of brain function that interferes with normal functioning and relationships) with psychosis (a form of mental illness that includes loss with reality), gait instability (unstable walking), high blood pressure, osteoporosis (brittle bones) and anemia (decrease in the amount of red blood cells). The History and Physical Examination dated February 14, 2012, indicated Resident 1 did not have the capacity to understand and make decisions. The Minimum Data Set (MDS), an assessment and care screening tool,dated February 25, 2012, indicated Resident 1 had short and long term memory problems, had moderately impaired cognitive skills for daily decision making (decisions were poor, cues/supervision required), and was occasionally incontinent of bladder. The resident required one-person physical assist for transfers and toileting, supervision for walking in the room/corridor, and moving in her room and on the same floor, and she required the use of a front-wheel walker (FWW) when walking. In the area of mobility devices, the MDS indicated the resident required a walker, and that her balance during transition (sitting to standing) and walking is unsteady, but can stabilize without human assist.The Care Area Assessment (CAA) dated February 26, 2012, indicated falls were a problem area that should be addressed on the care plan (plan of care) due to wandering, impaired balance during transitions and walking such as moving from seated to standing or surface to surface transfers. The CAA for behavior symptoms was indicated because of wandering, and to focus on the resident?s safety, and to ensure she is not a danger to herself and others. A review of the Fall Risk Assessment document for the dates of February 14, 2012, April 17, 2012, and May 9, 2012, indicated Resident 1 was considered to be a high risk for falls, and a prevention protocol should be initiated immediately and documented on the care plan. This document indicated the areas that contributed to the assessment were that Resident 1 had intermittent confusion, decreased muscular coordination, and used a walker. Also considered were that the resident was taking medications and had diseases which contributed to the assessment decisions. Resident 1 had physician's orders dated February 13, 2012, for one side rail up to enable bed mobility, and an order dated April 18, 2012, for Ativan 1 milligram (mg) IM [(intramuscular)in the muscle] prn (as needed) for agitation manifested by refusing necessary care. A care plan had been developed for Resident 1 on February 13, 2012, for problem behavior related to paranoid delusions and visual and auditory hallucinations. The approaches included one-to-one (1:1) staff supervision (a direct staff person with the resident) if needed, notify the physician if behavior interferes with functioning, keep environment safe and hazard free at all times, and implement visual monitoring. The care plan was not specific as to when 1:1 supervision was to be implemented, by whom and for how long, or how often the visual monitoring was to occur or by whom.There was another care plan developed February 13, 2012, for Resident 1?s being at risk for falls due to unstable gait (walk), cognition, unsafe behavior, wandering, and antipsychotic drug use. The goal was for the resident to be free from serious injuries due to falls, to be reevaluated in three months. The interventions included to monitor for signs and symptoms of gait disturbance, notify the physician, and to apply one side rail up.A review of the Nurses Notes and corresponding investigations regarding four fall incidents that Resident 1 had indicated the following: The Nurses Notes indicated on April 12, 2012, at 5:30 a.m., Resident 1 was awake and ambulating with a slow, steady gait, with no episodes of agitation during the shift.On April 17, 2012, at 2:30 p.m., the Nurses Notes indicated the activities staff found the resident sitting on the floor, confused, and said she had pain, but couldn?t explain.A review of the facility?s Accident/Incident Investigation for this incident indicated the resident ambulates ad lib (freely), wanders in and out of hallway and other rooms, and is confused and disoriented. She was in an activity in the activities room, missed the chair, and slid down to the floor. There were no injuries. Interventions that were to be implemented included monitoring the resident?s whereabouts.During an interview on August 20, 2012, at 3 p.m., regarding Resident 1?s April 17, 2012, incident, the Activity Assistant (AA), who witnessed the incident, said that Resident 1 was sitting in a chair in activities. When the resident got up to leave, the AA told Resident 1 to sit down, and when she sat down she missed the chair.There was a plan of care developed on April 17, 2012, for status post fall and Resident 1 was referred to physical therapy (PT) three times a week for two weeks. There was no documented evidence that an Interdisciplinary (IDT) meeting was held to review and evaluate the effectiveness of the resident?s plan of care in accordance with the facility?s policies on fall prevention. The Nurses Notes dated April 22, 2012, at 1 p.m., indicated Resident 1 was found on the floor (no indication as to where) in a sitting-down position. She was helped ?back to her room? and fell to sleep. There was no investigation regarding this fall incident, and there was no update to the care plan to address this fall. There was no documented evidence that an Interdisciplinary (IDT) meeting was held to review and evaluate the effectiveness of the resident?s plan of care in accordance with the facility?s policies on fall prevention. On May 7, 2012, the February 2012 care plan for falls was updated to include the resident always forgets her FWW to use during ambulation. The interventions included to remind her to use her FWW.According to the Nurses Notes, on May 9, 2012, at 9 a.m., Resident 1 was ?roaming? around the facility. She had hallucinations and was agitated. Staff redirected her; she attempted to strike out at staff. She was redirected, but was still agitated; she was assisted back to her room. There was no documentation that 1:1 supervision was implemented as needed when the resident was agitated and at risk for falls and/or injuries or that the physician was contacted when interventions for her behavior were not effective, in accordance with her care plan. At 10 a.m., according to the Nurses Notes, Resident 1 had calmed down, and was in the hallway, "but still" trying to push a Merry Walker (assistive device for walking) of another resident; Resident 1 was also trying to get the locked door open. "Continue redirecting the resident." There was no indication or documentation that 1:1 supervision was implemented when the resident continued to be agitated and at risk for falls and/or injuries or that the physician was contacted, in accordance with the care plan. At 2:40 p.m., the Nurses Notes indicated Resident 1 was noted with increased agitation, banging on the locked doors, striking out at staff, verbally abusive saying, ?I hate you. Leave me alone.? Resident 1 was physically aggressive, holding staff tight. Ativan IM was given at 2:45 p.m. and assisted to her room. The resident pulled the side rail pad and hit staff with it. Resident 1 was assisted out from the room to redirect; started walking around banging on doors. At 3:40 p.m. the resident was taken back to her room. ?Two? staff stayed with the resident until she calmed down. At 4:40 p.m. the resident was calmed down and resting in her room with no agitation. There was no documentation to indicate whether the physician was contacted regarding the resident?s behavior, why there were two staff (2:1) assigned to the resident or when it was discontinued, or that 1:1 supervision was implemented in accordance with the care plan, as needed for the resident?s safety. At 5:30 p.m. (50 minutes later), Resident 1 was found on the floor in the hallway, in a sitting position. No physical injury was noted. She was assisted to sit on a chair; noted to be sleepy and assisted back to bed, and she went ?back? to sleep.An hour later, at 6:30 p.m., the Nurses Notes indicated Resident 1 was up again, standing next to her bed. She was assisted back to bed, and she went back to sleep. There was no documentation to indicate why staff continued to put Resident 1 back to bed or that she was assessed as to why she was agitated and continued to get up out of bed. At 7:15 p.m., a CNA (certified nursing assistant) reported that Resident 1 was up again, and when she started to walk with her walker, she had a limp. (The nurse) assessed and noted that Resident 1 was limping on the left leg and complained of pain to the left hip. There was no documented evidence that 1:1 supervision was implemented after the two staff left the resident, even though she still had intermittent agitation and continued to get up out of bed, which ultimately resulted in her third fall and injury. The physician was called and gave an order to transfer Resident 1 to the GACH emergency room (ER) for evaluation. She was picked up by non-emergency transport at 8:45 p.m. A review of the Accident/Incident Investigation dated May 10, 2012, indicated that behavior that contributed to the fall was that Resident 1 was agitated, but nursing interventions were ineffective and she ?refused? to be redirected. It was noted, ?Staff left her for a while, but constant supervision.? It was noted that Resident 1 is always wandering, is confused and disoriented, always trying to help other residents by pushing wheelchairs or a Merry Walker. A review of the GACH-ER Report dated May 9, 2012, indicated Resident 1 had a scan of the pelvis that showed no acute fracture or dislocation, but showed a left hip strain. The Nurses Notes indicated on May 10, 2012, at midnight Resident 1 returned from the ER, alert and able to move all extremities except slight difficulty with her left leg. Resident 1 had no swelling or discoloration, and ice pack was applied. Upon Resident 1?s re-admission there was a physician?s order dated May 10, 2012, for one side rail up when in bed, apply a tab alarm (alarm sounds to alert staff when the resident attempts to get out of bed without assistance), and landing pads on both sides of the bed for safety. There was an update to the care plan on May 10, 2012, for the fall incident, and interventions added were to apply a tab alarm when in bed to alarm staff when the resident attempted to stand unassisted, and to place landing pads on both sides of the bed. On May 11, 2012, at 6 a.m., the Nurses Notes indicated Resident 1 was in bed, awake, alert, but confused with no pain and no agitation. At 7 p.m. the resident was sleeping in bed. Resident 1 had a contusion (bruise) on the left hip, and said she had pain; she was given prn (as needed) medication. The Nurses Notes indicated that on May 12, 2012, at 7 p.m., Resident 1 was sleeping with episodes of agitation. "Nursing interventions" given, and the resident was put ?back? to bed. It was noted that the resident was at risk for falls, and was ?constantly trying to climb out of bed.? Ativan (for agitation) IM (intramuscular) prn (as needed) was given at 10 p.m. There was no documentation to indicate that 1:1 supervision was implemented in accordance with the care plan, or that the physician was contacted regarding the resident?s behavior of constantly trying to climb out of bed for possible further instructions of care for the resident?s safety. There was also no documentation to indicate that an IDT meeting had been conducted to review and evaluate the effectiveness of the care plan interventions per the facility policies.A review of the Medication Record (MAR) revealed Ativan IM 1 mg was administered April 18, 2012, May 9, 12, and 15, 2012. The Nurses Medication Notes document indicated on May 9, 2012 at 2:45 p.m. Resident 1 had increased agitation, refusing care, banging doors, striking out. Nursing interventions implemented, but not working. Physician agreed. At 3:45 p.m., resident had decreased agitation. On May 12, 2012, at 9 a.m. Resident 1 was very agitated, refusing nursing interventions, constantly standing; Resident at risk for falls. Ativan IM was given. At 12 p.m. Resident 1 was sleeping. A review of the Nurses Notes dated May 23, 2012, at 1:20 p.m., indicated the resident was assisted to bed to take a nap and there was one side rail up. It was indicated at 1:50 p.m., the tab alarm went on and the resident was found on the floor in a sitting position on the left foot edge of the bed. The resident was noticed limping on the left leg and complained of minimal pain on the left hip. The physician was notified and gave an order to transfer the resident to the GACH for further evaluation.A review of the first responder?s documentation dated May 23, 2012, indicated that [the registered nurse (RN 5)] was ?passing by? Resident 1?s room at around 1:50 p.m. and heard a tab alarm on. She went in to the room and found the resident sitting on the floor at the left foot edge of the bed with her FWW at the bedside. Two staff were called and they helped pick the resident up. Resident 1 attempted to take a few steps, but was limping. Staff put her into bed and she was assessed with facial grimacing and pointing to her left hip saying that it hurt.There was no documented evidence in the Nurses Notes, the investigation record, or the notes written by the first responder for the May 23, 2012 fall incident, that landing pads were in place to both sides of the bed as indicated in the care plan. The investigation report indicated that the resident was found on the ?floor?. A review of the facility?s Resident Assessment and Care Planning policy indicated the licensed nurse will update the resident care plan as needed and complete a weekly summary documenting the resident?s response to goals. During interviews with the director of nursing (DON) on August 20, 2012, from 2 p.m. to 3:30 p.m., and from a telephone interview October 11, 2012, at 3:40 p.m., she stated that Resident 1 had only three falls at the facility. The falls discussed were April 17, 2012, May 9, 2012, and May 23, 2012. She did not address the April 22, 2012, fall incident. She said Resident 1 was active, and from the beginning she had one side rail up. She was able to get in and out of her bed freely and use her FWW. Resident 1 had a chair that was put in front of her room that she used to sit on.The DON stated Resident 1?s bed was at regular height. She could not provide documentation that the bed could be put in a low position to prevent less injury if a fall from bed occurred. She stated that this was not discussed with the responsible party (RP) during any care plan meeting. The DON could not provide documentation that the care plan interventions were implemented, including the frequency of visual monitoring and by whom; that landing pads were consistently applied to both sides of the bed; or of 1:1 supervision when other nursing interventions were not successful, and when Resident 1 was agitated and/or refusing care.The DON stated Resident 1 was found on the floor, not on a landing pad, on May 23, 2012. She said that the purpose of applying a tab alarm was to alert staff when the resident attempted to stand without assistance. She was unable to explain why staff members did not respond to the tab alarm timely when it first sounded on May 23, 2012, in an attempt to prevent the fall that resulted in the hip fracture. She could not provide documented evidence that staff were monitoring the placement of the landing pads. The DON was not able to find any documented evidence that an IDT meeting and/or a staff stand-up meeting was held for Resident 1?s actual falls on April 17, 2012, April 22, 2012, or May 9, 2012, as indicated in the facility?s policy, or when the resident was constantly climbing out of bed on May 12, 2012, at 7 p.m., to prevent falls and/or injuries. The DON could not find documented evidence the physician was notified of Resident 1?s behavior, or that the care plan was updated to include interventions for this behavior to prevent the last fall that resulted in her hip fracture.A review of the facility?s policy and procedure for the Prevention of Falls revised April 16, 2012, indicated as follows: 1. Assess residents and use appropriate measures to prevent falls. 2. Assess risk on admission. If identified at risk according to criteria, an appropriate instrument of prevention is put in place after obtaining consent from responsible party. 3. If there is a need for an instrument? the least restrictive prevention is used, including mattresses on the floor, roll belts while in bed? 4. Every effort is utilized to prevent falls, and if the resident was identified at risk according to the criteria, an appropriate instrument of prevention is put in place after obtaining consent from the resident/responsible party. 5. Residents are routinely monitored by the nursing staff. 6. An interdisciplinary group, including the DON or designee, physical medicine, occupational therapist, RN supervisor, and Social Service will review residents that fall for additional interventions needed. A review of the GACH record dated May 24, 2012, indicated Resident 1 sustained a subcapital [point where the neck of the femur (thigh bone) joins the head or top of the femur] fracture of the left femur. According to the operation report dated May 24, 2012, Resident 1 had hip repair surgery under general anesthesia (medically induced coma). A review of the literature indicated the post-operative risk and complications associated with a surgery under general anesthesia included bleeding, infection, heart attack, pneumonia, kidney failure (during or after an operation), deep venous thrombosis (DVT-occurs when blood clots form in the large veins of the leg. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) and (Savel, Richard H., "Postoperative Care." Hospital Medicine, 2nd Edition, Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261-269). A review of the Nurses Note written May 29, 2012, at 3 p.m., indicated Resident 1 was readmitted to the SNF from the GACH via ambulance with left hip incision that measured 19 centimeters (cm) with 26 staples. A review of the Nurses Note dated June 1, 2012, indicated as follows: At 6 a.m. vital signs were documented, indicating the blood pressure was 122/74, (reference range 90-140/60-90), pulse was 78 beats per minute (reference range is 60-100) temperature was 97.6 (reference is 98.6), and respirations were 20 breaths per minute (reference range is 16 to 20).At 8:30 a.m., Resident 1 had pain of 4 out 10 (pain scale of 0 to 10, with 0 being no pain and 10 being the most severe pain), Tylenol was given, and she was confused. At 8:45 a.m., the CNA reported that the resident was restless, was crying and stating that she was still in pain; had a small bowel movement; had 8 out of 10 pain level. Vicodin (medication for moderate to severe pain) was given, but the resident spit it out, attempted three times, not cooperative. There was no evidence that the physician was contacted regarding the resident?s refusal/spitting out of the Vicodin in an attempt to get further instructions to manage the resident?s pain. There was no documentation that the resident?s pain was relieved.The Nursing Notes indicated even though Resident 1?s pain had not been managed, staff proceeded to get her out of bed, transferred her into a shower chair, and took her to the shower as follows:At 9 a.m., the staff [(licensed vocational nurse 1) LVN 1] had received a phone call from the surgeon?s office for x-ray of the pelvis, no stand or walk until further orders. The resident may be up in a wheelchair or shower chair and may have shower. Staff was educated for safety transfer from bed to shower chair with two person assist (CNA 1 and CNA 2) with licensed staff supervision.At 10 a.m., the CNA (CNA 1) called for help for resident?s changed condition and the resident was put in her room with oxygen administration at 5 liters per minute (Lpm). The resident had difficulty breathing, and her blood pressure was 190/120, her pulse was 122 beats per minute, oxygen saturation (amount of oxygen carried in the blood) level was 85 percent. Oxygen was increased to 15 Lpm via a rebreather mask and oxygen saturation improved to 90 percent.Oxygen saturation in a range of 96 % to 100 % is generally considered normal. Anything below 90 % could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (95-98 %) and respiratory failure is (usually 85-90 %) narrow (AJN, American Journal of Nursing: May 2005 - Volume 105 - Issue 5 - page 72). At 10:15 a.m., the paramedics arrived; the EKG (heart reading) showed Resident 1 had PHC (extra abnormal heart beats). Paramedics did not perform CPR (cardiac pulmonary resuscitation). At 10:30 a.m., the paramedics pronounced the resident?s death. (The resident had a do not resuscitate intensity of care - no CPR to be performed). During an interview with Resident 1?s responsible party (RP) on April 16, 2015, at 2 p.m., she stated that there was only one care plan meeting held. There was no discussion of alternative measures of placing the bed in a ?low? position, applying landing pads to both sides of the bed, or the application of one side rail. The RP stated she was waiting to have the June 1, 2012, care plan meeting, and didn?t know that she could request one sooner, given Resident 1?s care needs.During the interview, the RP stated she never saw landing pads to either side of the bed that she recalls. She stated when she was called about Resident 1 falling out of bed, she was told that the resident fell over the side rails. The RP stated she had requested both side rails to be put up, and didn?t know this was considered a restraint. She said she was in communication with the staff at the SNF often, and asked to have Resident 1 put to bed if she appeared tired, and to apply her head phones with classical music, which Resident 1 loved and which calmed her. She also stated that she was furious when she was telephoned and informed that staff had taken Resident 1 to the shower where she had a change in condition. She said that Resident 1 had numerous falls, and the facility staff didn?t do enough to prevent these falls that led to the resident?s fractured hip and eventual death.A review of a written note dated August 9, 2012, from Resident 1?s surgeon indicated that there were no orders given by him to get Resident 1 out of bed or take her to the shower.A review of the Certificate of Death issued by the County of Los Angeles dated June 22, 2012, indicated that there was no autopsy performed, and the following: 1. Immediate Cause of Death: Arteriosclerotic Cardiovascular Disease (thickening and blockage of artery walls) 2. Other Significant Conditions Contributing to Death: Hip Fracture 3. Operation performed for any condition and date: Total Hip Replacement on May 24, 2012. The manner of death indicated not from natural causes, but from an accident. And the injury was from a ?fall from bed.? Therefore, the facility failed to ensure Resident 1, who was assessed as being a high risk for falls, was provided one-to-one supervision and assistive devices to prevent avoidable accidents, based on the facility?s assessment and care planning to prevent falls and injuries, including but not limited to, failure to:1. Implement the care plans that were developed upon admission to reduce Resident 1?s fall risks and injuries; and 2. Monitor the effectiveness of the care plan interventions and modify them as necessary after each fall incident in accordance with the facility?s policies and procedures. The facility also failed to provide pain management after Resident 1?s fourth fall incident that resulted in a broken hip. Resident 1 subsequently died at the facility on June 1, 2012, after returning from a seven-day hospitalization stay after surgery to repair her broken hip. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 920000068 |
HOLIDAY MANOR CARE CENTER |
920011776 |
AA |
01-Dec-15 |
B6O611 |
15877 |
CFR 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 8/10/15, an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care and Death. Based on interview, and record review, the facility failed to ensure Resident 1, who was assessed as high risk for fall and injury due to confusion, impaired vision, physical limitations, unstable balance, medication use, in need of one-person assistance for transfer and walking with the use of a front wheel walker (FWW), and was at risk for bleeding due to the use of blood thinner, was provided with supervision and assistance to prevent fall and injury by failing to: 1. Ensure Resident 1 was monitored for unassisted transfers and walking. 2. Ensure all nursing personnel caring for Resident 1 were aware of the resident's fall risk and the need to assist her with transfers and walking, re-direct her behavior of unassisted transfers/walking, and remind to call for assistance. 3. Implement the plan of care interventions to provide assistance and monitor Resident 1's gait disturbances. 4. Re-evaluate the plan of care to address Resident 1's continued episodes of independent transfers from the low-height bed and walking unassisted to develop additional interventions, such as bed and chair alarm, and to indicate the frequency of visual checks. 5. Implement the facility's policy and procedure on Prevention of Falls to use appropriate measures and instruments to prevent falls.6. Implement the facility's policy and procedure on Fall, Risk For and Actual Fall to have further assessment, enhance the plan of care, minimize the risk for falls and improve communication with the necessary personnel. On 9/8/14, Resident 1 fell in her room near her bed, sustained a head injury, developed an intracranial hemorrhage (bleeding in the brain), and died on 9/17/14. The immediate cause of death was blunt force head trauma.A review of the closed clinical record indicated Resident 1 was admitted to the facility, on August 22, 2014, and was discharged on September 9, 2014, to a general acute care hospital (GACH). Resident 1's diagnoses included dementia (a progressive decline in memory and at least one other cognitive area, such as attention, orientation, judgement, abstract thinking and personality) with delirium (an acute disorder of attention, memory, and perception), muscle weakness, malaise (a general feeling of discomfort), and atrial fibrillation (irregular heart beat) which was treated daily with the blood thinner (anticoagulant) Coumadin (helps to prevent new blood clots from forming, and helps to keep existing blood clots from getting worse. This medicine increases the risk for bleeding). A care plan developed on August 22, 2014, for Resident 1's risk for falls and injuries related to her mental and physical conditions, included a low bed with half-length side rails, landing pads (fall safety cushion placed at the side of the bed for protection), assistance with transfer activities, monitor gait disturbance, and ambulation as desired with a FWW.A review of the Physical Therapy (PT) Evaluation and Plan of Treatment, dated August 23, 2014, indicated Resident 1 was referred for PT services due to new onset of decreased strength, functional mobility, transfers, ability to safely ambulate, neuro-motor control, and decreased postural alignment. The PT functional assessment indicated Resident 1 required one-person assistance with bed mobility, rolling, bridging, scooting, sitting, transfers, sit to stand, and stand pivot.The Fall Risk Evaluation form, dated August 25, 2014, indicated a score of 18. A total score of 10 or above represented a high risk for falls. A review of the Licensed Nurses Weekly Summary Report, dated August 31, 2014, indicated Resident 1 required supervision with transfers, limited one-person assistance with ambulation and bed mobility, extensive assistance with activities of daily living (ADLs) and toileting.A review of the Minimum Data Set (MDS - standardized assessment and care planning tool), dated September 4, 2014, indicated Resident 1 had severely impaired cognitive skills for daily decision-making, required one-person physical assistance with all her ADLs, including transfers and ambulation.The Fall Care Area Assessment (CAA - used to develop a resident-specific care plan based on identified problems, needs, and strengths), dated September 4, 2014, indicated the following: Resident 1 was prescribed psychotropic medications (mind altering medications) for psychosis (when a person has a break from reality, often involving seeing, hearing, and believing things that are not real - antipsychotic), anxiety (nervousness), and depression (persistent feeling of sadness and loss of interest). Resident 1 had impaired balance during transitions and walking, moving from seated to standing, walking with assistive device (front wheeled walker), moving on and off toilet, turning and facing opposite direction while walking, and doing surface to surface transfers. Resident 1 was considered at risk for injuries due to her diagnoses of dementia, psychosis, anxiety, abnormality of gait, blindness, and generalized weakness. She was described as forgetful, disoriented, and confused.The Psychotropic Medication Use CAA, dated September 4, 2014, indicated Resident 1 was at risk for falls/injuries due to her diagnoses of dementia, psychosis, anxiety, and depression.A review of the PT treatment notes, dated August 25, 26, 27, 28, 2014 and September 1, 2, 3, 4, 5, 2014 indicated there was no change in the resident's bed mobility and transfer abilities; Resident 1 required one-person assistance with bed mobility and transfers throughout her stay in the facility.The nursing Weekly Summary Report, dated September 7, 2014, indicated Resident 1 required supervision with transfers, limited one-person assistance with ambulation and bed mobility, and extensive assistance required with ADLs and toileting. This weekly summary report contradicted Resident 1's mobility and level of assistance from the MDS and PT assessments. There was no documentation by nursing staff to indicate the resident when attempting unassisted walking and transfers was re-directed and reminded to call for assistance to prevent falls.A review of the Nursing Assistant Daily Flow Sheet for August and September 2014 indicated Resident 1 was independent with bed mobility and ambulated on all shifts from August 22 to September 9, 2014. The documentation did not include the level of assistance required with walking/ambulation. For the 7 a.m. to 3 p.m. and the 3 p.m. to 11 p.m. shifts from September 1 to 9, 2015, the documentation indicated the resident was assisted with ADLs, but on the 11 p.m. to 7 a.m. shift documented the resident was independent with ADLs.A Licensed Nurses Progress Note by Staff 3, dated September 8, 2014, timed at 11:45 p.m., indicated Resident 1 was seen on the floor mat moaning, in a sitting position facing the door, noted with a bump on the right temporal (the side of the head behind the eyes), with the skin intact, and a bluish discoloration. The note indicated that with a certified nurse assistant (CNA), the resident was placed back in the bed, ice pack was applied on the right temporal area, and Tylenol 325 mg two tablets were given orally for pain. A complete body check was done and no other injury was found. At 12:10 a.m., Resident 1's physician was notified of the resident's fall and ordered an X-ray of the right temporal area, ice packs, and neurological checks. After the fall, Resident 1 was able to ambulate with a walker with a slow gait to the dining room.According to the following shift Licensed Nurses Progress Note dated September 9, 2014, timed at 7:30 a.m., Resident 1 ate 10% of her breakfast. At 7:45 a.m., the resident was noted with a lump/bump to the back of the head. At 8:30 a.m., the resident complained of pain to the right rib cage area while the X-ray was being taken. The attending physician was notified and ordered an X-ray of the right rib area. The result of a laboratory blood test ordered on September 2, 2014, obtained at 11:45 a.m. on September 9, 2014, indicated Resident 1's international normalized ratio (INR - used to monitor the blood thinning medication) was 5.28 (above the laboratory parameter for atrial fibrillation from 2.0 to 3.0 - an elevated INR indicates the blood is too thin and the person is at greater risk of bleeding). The attending physician was notified and ordered the resident to be transferred to the emergency room (ER) for evaluation.A review of the ER admission report, dated September 9, 2014, indicated Resident 1 was non-responsive on arrival, did not speak or open her eyes, and had some moaning sounds. A computerized tomography (CT scan - combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside the body) indicated the resident had a right-sided subdural hematoma (accumulation of blood on the brain's surface beneath the skull, usually resulting from head injury) with associated subarachnoid hemorrhage (bleeding in the area between the brain and the tissues that cover the brain, hemorrhage in this space can cause coma, paralysis, and death). The CT scan also indicated a left temporal parenchymal hemorrhage (bleeding within the brain itself) with associated left-sided subarachnoid hemorrhage.A review of the GACH discharge summary (from intensive care - ICU) to another hospital unit, dated September 13, 2014, indicated the physician recommended a nasogastric tube (special tube that carries food and medicine to the stomach through the nose) and intravenous nutritional support, but the family declined and decided to place the resident on hospice care for comfort measures only. Resident 1 expired at the GACH on September 17, 2014. A review of the Los Angeles City Coroners Report signed on September 23, 2014, indicated Resident 1 died on September 17, 2014 and the resident's death was caused by intracranial hemorrhage due to blunt force head trauma, resulting from a fall suffered at the facility on September 8, 2014.During an interview with Staff 4, the MDS coordinator, on August 10, 2015, at 4 p.m., she stated Resident 1 required limited assistance, meaning someone had to be with her to assist/guide her with ambulation and transfers. Staff 4 stated Resident 1 was not independent with ambulation and transfers.During an interview with the Director of Nursing (DON), on August 10, 2015, at 4:50 p.m., she stated Resident 1 was independent with ambulation and transfers.On August 31, 2015, at 7:45 a.m., during an interview with Staff 3, the nurse who found Resident 1 on the floor, he stated he made rounds on September 8, 2014, about 11 p.m. and Resident 1 was sleeping in bed. Staff 3 stated shortly after rounds, he heard moaning coming from the resident's room and found the resident sitting on the floor between the beds. Resident 1 had a blue-tinged bump on her right temple. Staff 3 stated Resident 1 was independent with ambulation and transfers and the resident had a low bed with floor mats. Staff 3 stated Resident 1 could not say what happened to her and also stated the resident routinely went to the bathroom by herself, unassisted, and did not use her call light. Staff 3 stated staff tried to provide visual checks frequently. Staff 3 could not explain why the assistance indicated in the MDS and care plan was not provided. Staff 3 did not document the resident was independent with transfers and walking. During an interview with Staff 2 (Physical Therapist), on August 31, 2015, at 11:15 a.m., she stated Resident 1 required minimal assistance with ambulation and transfers, which meant the resident required at a minimum, one-person assistance with ambulation and transfers. Staff 2 stated Resident 1 was not independent with ambulation and transfers.According to the Accident/Incident Investigation form, dated September 10, 2014, on 9/8/14 at 11:45 p.m., the charge nurse (Staff 3) heard a loud 'bang' noise in Resident 1's room, immediately went to check and the resident was on the floor on a sitting position. The investigation report indicated Resident 1 ambulated with a walker, and was able to go to the bathroom independently.During an interview with Staff 5 (CNA), on September 25, 2015, at 11:45 a.m. and a review of the Nursing Assistant Daily Flow Sheets for Resident 1, she explained the forms were incomplete and the CNAs were to document the resident's mobility status and the level of assistance provided.The facility's policy and procedure titled, "Prevention of Falls," revised April 16, 2012, indicated it was the policy of the facility to assess residents for falls and to use appropriate measures to prevent falls. The policy indicated every effort was utilized to prevent falls and, if a resident was identified as at risk for falls, an appropriate instrument of prevention was put in place.The facility's policy and procedure titled, "Falls, Risk For and Actual Fall," revised April 16, 2012, indicated following the completion of the MDS, if a resident triggers a risk for falls, the resident would have further assessment. The plan of care would be enhanced, if indicated, to further minimize the risk for fall and improve communication with the necessary personnel. There was no documented evidence the plan of care was re-evaluated/revised since Resident 1's admission to ensure the staff interventions were appropriate based on the resident's needs. The facility failed to ensure Resident 1, who was assessed as high risk for fall and injury due to confusion, impaired vision, physical limitations, unstable balance, medication use, in need of one-person assistance for transfer and walking with the use of a front wheel walker (FWW), and was at risk for bleeding due to the use of blood thinner, was provided with supervision and assistance to prevent fall and injury by failing to: 1. Ensure Resident 1 was monitored for unassisted transfers and walking. 2. Ensure all nursing personnel caring for Resident 1 were aware of the resident's fall risk and the need to assist her with transfers and walking, re-direct her behavior of unassisted transfers/walking, and remind to call for assistance. 3. Implement the plan of care interventions to provide assistance and monitor the Resident 1's gait disturbances. 4. Re-evaluate the plan of care to address Resident 1's continued episodes of independent transfers from the low-height bed and walking unassisted to develop additional interventions, such as bed and chair alarm, and to indicate the frequency of visual checks. 5. Implement the facility's policy and procedure on Prevention of Falls to use appropriate measures and instruments to prevent falls.6. Implement the facility's policy and procedure on Falls, Risk For and Actual Fall to have further assessment, enhance the plan of care, minimize the risk for falls and improve communication with the necessary personnel. On 9/8/14, Resident 1 fell in her room near her bed, sustained a head injury, developed an intracranial hemorrhage (bleeding in the brain), and died on 9/17/14. The immediate cause of death was blunt force head trauma.The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of death of Resident 1. |
| 970000039 |
Hollywood Premier Healthcare Center |
920012638 |
A |
14-Oct-16 |
IW0P11 |
12202 |
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) Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 2/17/16, at 12 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1 sustaining a fall at the facility resulting in a hip fracture. Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as risk for falls, received adequate supervision an assistance devices to prevent accidents, including: 1. Failure to implement the plan of care intervention to provide one-person assistance during transfer from bed to a chair (shower chair). 2. Failure to implement the facility?s policy and procedures on Fall Prevention by not educating certified nursing assistant 1 (CNA 1) in safely transferring Resident 1 based on the resident?s assessed functional limitations and needs. 3. Failure to develop a comprehensive plan of care with all interventions to ensure safe transfers and prevent accidents and injury such as the level of assistance the resident needed. 4. Failure to implement the facility?s policy and procedure on Post Falls to evaluate the extent of the injury before moving the resident to prevent complications. On 1/27/16, at 11:35 p.m., CNA 1 allowed Resident 1 to transfer alone from her bed to a shower chair to go to use the restroom while CNA 1 held the shower chair and not the resident. As a result, Resident 1 lost her balance, fell and sustained a fractured left hip which required transfer to a general acute care hospital (GACH) where she underwent surgery. A review of the admission face sheet indicated Resident 1 was originally admitted to the facility on 11/27/13, with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), high blood pressure, and anxiety (nervousness). The physician?s history and physical, dated 2/7/16 indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS- standardized assessment and care planning tool) dated 11/20/15, indicated Resident 1 understood others, was able to make herself understood, required extensive assistance with one person weight-bearing support for transfers between surfaces (bed, chair, wheelchair), and required extensive assistance with one person assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toileting, hygiene, and bathing. The MDS indicated the resident was unsteady and was only able to stabilize with staff assistance when moving from seated to standing position, and transferring between bed and chair or wheelchair. The MDS indicated the resident weighed 185 pounds. The Fall Risk Assessment dated 11/20/15, indicated Resident 1 required assistance with elimination, had a balance problem while standing and walking, and had decreased muscular coordination. The fall risk assessment indicated Resident 1 was unstable when making turns, required use of assistive devices (such as cane, wheelchair or furniture), and the total score on the form was 14, which indicated high risk for falls. A review of the care plan dated 11/20/15 developed for the resident?s needing assistance with activities of daily living (ADLs) indicated Resident 1 required extensive assistance with transfers due to poor balance, poor endurance, poor safety awareness, use of psychoactive medications, and history of stroke with left sided hemiparesis. The care plan interventions included to assist the resident in maintaining proper body alignment, and to observe safety when handling resident. The care plan did not address in the interventions the level of assistance Resident 1 required with transfers or if an assistive device was needed. A review of the care plan titled, "At Risk for Falls Related to: Fall Risk Assessment Score of 14", dated 11/30/15, indicated Resident 1 would have no falls or injuries in the next 90 days. The care plan interventions indicated to adapt the environment to meet resident's safety needs but did not include the level of assistance Resident 1 required with transfers. According to the licensed nurses? notes, on 1/27/16, at 11:35 p.m., the resident sustained a fall. A review of Interdisciplinary Notes, dated 1/28/16, indicated on 1/27/16, at 11:35 p.m., CNA 1 reported to Registered Nurse 1 (RN 1) that (Resident 1) fell on the floor. RN 1 went to the resident's room and found the resident in bed, crying due to severe pain. The physician was called and order transfer to a general acute care hospital (GACH) emergency room. A review of the Investigation for All Incidents form dated 1/28/16, indicated on 1/27/16 Resident 1 stood up while holding the side rail, suddenly lost her balance, fell on the floor, hit her head against the bedside drawer and her left hip against the floor. The investigative form indicated that at the time of the incident, CNA 1 was standing in front of the resident to assist her with the transfer, but was not able to hold her to prevent her fall. A review of the undated documented interview with CNA 1 indicated CNA 1 responded to Resident 1's call light and the resident requested to go to the bathroom. CNA 1 took the shower chair from the bathroom and brought it to the bedside. Resident 1 stood up, shifted to the chair, but started sliding before he could catch her since he had the shower chair in between the resident and him. CNA 1 stated the resident was on the floor lying on her left side in a fetal position and in pain. To make the resident comfortable CNA 1 put the resident back in her bed and left to call the nurse. A review of the undated documented interview with Resident 1, conducted by the administrator while the resident was still in the GACH, indicated Resident 1 stated she wished CNA 1 had not moved her back to bed, but (instead) asked for help. During an interview with Resident 1, on 2/17/16, at 12:15 p.m., she stated the night of the incident, CNA 1 responded to her call light to assist her to the bathroom. Resident 1 stated as she went to sit on the shower chair, the shower chair moved backward away from underneath her legs and she landed on the floor. Resident 1 stated she struck her head on a hard object as she fell. Resident 1 stated during the incident CNA 1 was standing behind the shower chair (the shower chair was between the resident and CNA 1). Resident 1 stated after she fell, she was screaming in pain and CNA 1 picked her up from the floor by placing both his arms under her armpits and put her back in bed. She stated, "It would have been better if he had left me on the floor, because that did not help the situation." During an interview with registered nurse (RN) 1, on 4/21/16, at 6:50 a.m., she stated CNA 1 came to the nurses station frightened and said "Hurry, (the resident) fell." RN 1 stated when she arrived at Resident 1's room, the resident was in bed, crying. RN 1 stated the resident rated her pain at a level of 9 out of 10 (10 being most severe) in the left hip area and she stated she hit her head. RN 1 stated she medicated the resident for pain and assessed the resident per protocol. During an interview with CNA 1, on 4/21/16, at 7:10 a.m., he stated Resident 1 was independent with transferring from bed to chair. CNA 1 stated when he responded to the call light, Resident 1 braced herself on the TV stand next to her bed, stood up unassisted, and when she pivoted to sit in the chair, she slipped and went down on the floor. CNA 1 stated he was holding the shower chair and it did not move. He stated the resident fell and one of her legs was in a very awkward position. CNA 1 stated that when the resident was on the floor, he got behind her, picked her up and flopped her over onto her left (injured area) side on the bed. During an interview with Resident 1, on 4/21/16, at 7:40 a.m., she stated she did not slip, did not lose her balance, did not get dizzy or had any problem except that the shower chair rolled away from her as she was attempting to sit on it. The resident stated she fell and was screaming because the pain was excruciating and the CNA thought he was helping but it was excruciating. Resident 1 stated, "I cannot straighten my leg and they said I will never walk again." A review of the Operative Report from the GACH dated 1/30/16 indicated the preoperative diagnosis was intertrochanteric fracture of the left hip severely comminuted and macerated (the left upper thigh bone was broken into several pieces). The surgical procedure performed, was open reduction and internal fixation (ORIF) of the intertrochanteric fracture (a metallic rod and screws were inserted into the thigh bone). The facility's policy and procedure titled, "Post Falls," revised 6/2012, indicated the intent of the policy was to evaluate the extent of injury and prevent complications. The policy indicated the procedures included to evaluate the resident's condition before moving him. A review of the facility's Job Description for CNAs, revised 9/2011, indicated the CNA?s responsibilities included to report any unusual behavior or observations on any resident immediately to the charge nurse. The facility's policy and procedure titled, "Fall Prevention," undated, indicated the prevention program was to be accomplished by identifying risks, resident assessments, and educating staff. Included in the interventions was to assess the resident's risk of falling on admission. The policy indicated if it was decided the resident was at risk, take steps to reduce the danger. Educate the patient and family about mobility limitations and fall reduction measures. A review of the facility's policy and procedure titled, "Patient Care Plan," undated, indicated the care plan would include but not be limited to the care to be given, methods, approaches (interventions), and expected goals. The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as risk for falls, received adequate supervision an assistance devices to prevent accidents, including: 1. Failure to implement the plan of care intervention to provide one-person assistance during transfer from bed to a chair (shower chair). 2. Failure to implement the facility?s policy and procedures on Fall Prevention by not educating certified nursing assistant 1 (CNA 1) in safely transferring Resident 1 based on the resident?s assessed functional limitations and needs. 3. Failure to develop a comprehensive plan of care with all interventions to ensure safe transfers and prevent accidents and injury such as the level of assistance the resident needed. 4. Failure to implement the facility?s policy and procedure on Post Falls to evaluate the extent of the injury before moving the resident to prevent complications. On 1/27/16, at 11:35 p.m., CNA 1 allowed Resident 1 to transfer alone from her bed to a shower chair to go to use the restroom while CNA 1 held the shower chair and not the resident. As a result, Resident 1 lost her balance, fell and sustained a fractured left hip which required transfer to a general acute care hospital (GACH) where she underwent surgery. 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. |
| 930000575 |
HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF |
930008863 |
B |
17-Jul-12 |
UVXY11 |
4220 |
T22 DIV5 CH3 ART3-72315 (b) Nursing Services- 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. On March 1, 2011, an unannounced investigation was conducted to investigate a complaint regarding Employee B, who screamed at Patient 2 and pushed the patient when she was on her way to the bathroom. Based on record review and interview, the facility failed to ensure Patient 2 was treated with dignity and respect by Employee B, (certified nursing assistant) who screamed at the patient, rushed the patient to get up from bed and pushed the patient when she was on her way to the bathroom. Patient 2 stated Employee B was mean and did not want the mean nurse to be assigned to her again.Findings: On March 1, 2011, a review of the medical record was conducted. The face sheet indicated Patient 2 was admitted to the facility on January 24, 2009 with diagnoses which included chronic respiratory failure, dependent on oxygen, tracheostomy and gastrostomy tube feeding. The Licensed Personnel Progress Notes dated January 27, 2011, identified the patient to be alert, able to make her needs known, and required staff supervision when ambulating to the bathroom.According to the facility's letter to the Department dated February 3, 2011, Patient 2 stated that while she walked to the bathroom, Employee B screamed at her, pushed her and later apologized. The facility's letter indicated this occurred on January 26, 2011.The Licensed Personnel Progress Notes dated January 26, 2011 indicated Patient 2 claimed that Employee B screamed at her and pushed her while she was assisting the patient to the bathroom. Upon interviewing, Employee B denied that she screamed at the patient and pushed the patient. The patient was assured that the CNA would not be assigned to her anymore.According to the facility's investigation (untitled) regarding Patient 2 ' s interview dated January 27, 2011, at 10 a.m., the patient stated the certified nurse assistant came into the room screaming, "Hurry up, hurry up." The CNA rushed the patient to get up from bed and pushed her when she was on her way to the bathroom. Patient 2 stated a family member saw the incident and she did not want the mean staff person assigned to her again. Patient 2 also stated during the interview the certified nurse assistant apologized to her and she accepted it.According to the facility's investigation (untitled) regarding interview with the family member of Patient 2 dated January 26, 2011, he was behind the door getting something from the closet. When the certified nurse assistant came into the room, she pushed the door hard and the door knob hit his mid back and he hit his forehead towards the closet door. The family member stated the certified nurse assistant was screaming to Patient 2, asking her what she wanted and pushed the patient while helping her to the bathroom.During an interview with the Clinical Nurse Director on March 1, 2011 at 1:40 p.m., she stated, they investigated the allegation and concluded to suspend the certified nurse assistant (Employee B) for two days.A review of the Record of Employee Counseling dated January 28, 2011, indicated the certified nurse assistant was assigned to Patient 2 and assisted the patient to the bathroom in a hurriedly manner. The Employee Counseling record indicated the staff member was suspended without pay for two days and further incident would subject Employee B to further disciplinary action including termination.A review of the facility's Mission Statement and Vision dated June 2010 indicated to treat each other, their patients and their partners with respect and dignity. According to the facility ' s policy and procedure on Patients Rights and Responsibilities dated June 3, 2009, the patient had the right to considerate and respectful care, and to be made comfortable.The facility failed to ensure that Patient 2 was treated with dignity and respect by Employee B. The above violation has a direct or immediate relationship to the health, safety and security of Patient 1 and all other patients in the facility. |
| 930000575 |
HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF |
930009022 |
B |
19-Apr-12 |
71MV11 |
6247 |
Title 22 Div 5 Chapter 3 Art 3-72315 (b) Nursing Services Patient Care Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On December 27, 2011, an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Patient A's grievance that he was roughly handled by Employee 2 (Certified Nurse Aide) when he was being transferred from the day room to his bedroom., causing the patient to hit his foot on the wall, door, linen cart and medication cart. As a result, Patient A sustained a cut on his right great toe. Based on record review and interview, the facility failed to ensure Patient A was treated with dignity and respect and was not be subjected to rough handling/physical abuse by Employee 2, who transferred the patient in geri chair in a rough manner and caused the patient's foot to hit the wall, door, linen cart, and medication cart. As a result, Patient A sustained a cut to his right great toe. Findings: On December 27, 2011, a review of the admission face sheet disclosed Patient A was admitted to the facility on January 13, 2006 with diagnoses which included respiratory failure, tracheostomy, spinal cord injury, quadriplegia, and contractures. A review of the quarterly Minimum Data Set (MDS-assessment and care screening tool) dated September 26, 2011, disclosed the patient had clear speech, had the ability to express ideas and wants and had the ability to understand others. The quarterly MDS also indicated the patient was totally dependent on the staff for activities of daily living such as locomotion on and off the unit (moves between his room and activity room/hallway), bed mobility, transferring, dressing and toilet use.A care plan dated December 2, 2011, indicated the patient was totally dependent on staff for activities of daily living (ADL) tasks/needs, requiring assistance from certified nursing assistants) and rehabilitation staff. The approaches included to assist the patient as indicated and provide "schedule routines with ADL care if necessary."During an interview on December 27, 2011 at 9 a.m., Patient A stated he was in a geri chair and told Employee 2 to watch his feet. Patient A stated Employee 2 pushed him in a geri chair from the activity room to his room and "ran my foot on the linen cart, medication cart and the linen cart again."A review of the facility's Investigation Summary Report dated December 13, 2011, indicated Patient A initially filed a grievance on December 9, 2011 at 8 p.m., regarding Employee 2 handling him roughly when being moved from the day room to the patient's bedroom and causing his foot to hit the wall, door and cart. The patient claimed this was done repeatedly and subsequently the treatment nurse came into his room and told him that his foot was bleeding. The patient requested that Employee 2 not be assigned to take care of him anymore. The investigation summary report also indicated Employee 1 (clinical director) had interviewed Patient A on December 12, 2011 at 9:30 a.m. The patient reported his foot hit the wall, the cart and the door and he kept telling Employee 2 (certified nursing assistant) to stop and she "kept on." The investigation report also indicated Employee 2 was suspended. According to the facility's Report of Suspected Dependent Adult/Elder Abuse dated December 12, 2011, Patient A sustained a cut on his right great toe.During an interview with Employee 3 (licensed vocational nurse) on December 27, 2011 at 9:27 a.m., she stated she observed bleeding on the patient's right big toe while she was assisting Employee 4 to transfer the patient back to his bed on December 9, 2011 between 1:30 p.m. and 2 p.m. According to Employee 3, the toenail was partially detached from the patient's right big toe. During an interview with Employee 4 (certified nursing assistant) on December 27, 2011 at 9:45 a.m., she stated she observed 3 drops of blood on the floor of the patient's room while she was assisting Employee 3 to transfer Patient A back to his bed. According to Employee 4, the patient's right big toenail was "about to detach from his toe." The Physician Orders dated December 9, 2011 at 3 p.m., disclosed an order to treat the right great toe with betadine and cover with dry dressing daily and PRN (as needed), if dislodged, for 3 weeks. The Daily Assessment Inquiry in Patient A's electronic medical record, dated December 12, 2011 at 6:03 p.m., disclosed the patient had ointment applied to his right big toe and it was covered with a dry dressing.A review of the treatment record for December 2011, disclosed daily treatment was provided on the patient's right great toe from December 9, 2011 to December 26, 2011. A review of the facility's Record of Employee Counseling dated December 20, 2011, disclosed the subject of the counseling was "Patient Abuse." Employee 2 was assigned to care for Patient A on December 9, 2011 during the 7 a.m.- 3 p.m. shift. Employee 2 transported him back to his room in a rough manner causing the patient's toe to hit the wall, door and cart. Patient A sustained a cut on his right great toe. Upon further investigation by the facility, Employee 2 was discharged due to "willful intent." During an interview with Employee 5 on December 27, 2011 at 10 a.m., it was disclosed on the facility's investigation report that Employee 2 had been terminated.The facility failed to ensure that Patient A was treated with dignity and respect and was not subjected to rough handling/physical abuse by Employee 2. Employee 2 roughly handled Patient A when she was transporting him in a geri chair from the day room to his bedroom and caused his foot to hit the wall, door and medication/linen carts. Patient A sustained a cut on his right great toe that required treatment. Failure of the facility to ensure that Patient A was treated with dignity and respect and was free from rough handling/physical abuse by Employee 2 had a direct relationship to the health, safety and security of Patient A, as well as other patients in the facility. |
| 940000100 |
HARBOR VIEW BEHAVIORAL HEALTH CENTER |
940009293 |
B |
09-May-12 |
Z6LS11 |
5534 |
72527 (a)(9) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public on request. Patients shall have the right:(9) To be free for mental and physical abuse. On 11/16/11, at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity report of Patient 1?s allegation of sexual abuse perpetrated by Employee A and the lack of Employee B to timely report his knowledge of the incident to the administrator.Based on interview and record review, the facility failed to ensure Patient 1 had the right to be free from sexual abuse by failing to: 1. Ensure Patient 1 was not sexually abused by Employee A. 2. Implement the facility?s policies and procedures on abuse prevention that patients shall not be subject to abuse by facility staff. 3. Implement the facility?s policies and procedures of immediately reporting an abuse; however there was a five-day delay in reporting the knowledge of the abuse by Employee B. On 9/29/11, Patient 1 was asked to expose her breast and was kissed on the lips by Employee A, who exposed his genitals. On 11/4/11, Patient 1 reported the incident to Employee A, who waited five days to notify his superiors of the incident. As a result of the incident, the patient felt uncomfortable around Employee A. On 11/16/11, a review of the clinical record revealed Patient 1 was a 15 years old female, admitted to the facility on 9/23/11, with diagnosis that included bipolar disorder unspecified (complex mood disorder characterized by dramatic mood swings) and attention deficit disorder with hyperactivity (problem with inattentiveness, over-activity, impulsivity or a combination). The admission Minimum Data Set (MDS - standardized assessment and care planning tool) dated 10/6/11, indicated the patient was alert and oriented, was able to communicate her needs and was able to perform activities of daily living (ADLs) without assistance. A review of the facility?s investigation of the abuse allegation initiated on 11/9/11 revealed on 9/29/11, before midnight, Employee A asked the patient to expose her breast; the employee went inside the patient?s bathroom (shared with another room) and proceeded to expose his penis to the patient. Later that night, Patient 1 fell asleep and around 1 a.m., awoke with Employee A kissing her lips. Employee A continued making sexual advances after the 9/29/11 incident. Patient 2 (Patient 1?s roommate) had also witnessed Employee A exposing himself.On 11/4/11, Patient 1 informed Employee B of the incident and asked him not to tell anyone. On 11/9/11, Employee B acknowledged the patient had informed him of the incident several days prior and he encouraged Patient 1 to inform her therapist which Patient 1 did on 11/9/11. On that day, the facility made the required agencies notifications, suspended both Employee A and B while investigating and law enforcement initiated a police investigation. On 11/16/11, at 10:30 a.m., during an interview with the patient, she appeared distrubed at having to retell the incident. Patient 1 confirmed the allegation as documented in the facility?s investigation report and stated she felt uncomfortable around Employee A.According to the police department report, Employee A was arrested on 11/21/11, after the allegations were confirmed by the victim, the witness (Patient 2) and by statements made by Employee A. According to the personnel file, Employee 1 was hired by the facility as youth counselor on 4/5/11, and his prior employment was screened for history of abuse. During his employment, Employee A had no documented disciplinary actions related to inappropriate contact with patients.The facility?s policy and procedure on Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 1/2008, indicated staff must not engage in nor permit anyone else to engage in verbal, mental, sexual or physical abuse; neglect; mistreatment, or misappropriation of resident property. The policy defined sexual abuse as including, but not limited to, sexual harassment, sexual contact without the person?s consent, sexual coercion, or sexual assault. The policy also indicated employees are educated in reporting any knowledge of abuse immediately to the administrator and to other officials.The facility failed to ensure Patient 1 had the right to be free from sexual abuse by failing to: 1. Ensure Patient 1 was not sexually abused by Employee A. 2. Implement the facility?s policies and procedures on abuse prevention that patients shall not be subject to abuse by facility staff. 3. Implement the facility?s policies and procedures of immediately reporting an abuse; however there was a five-day delay in reporting the knowledge of the abuse by Employee B. On 9/29/11, Patient 1 was asked to expose her breast and was kissed on the lips by Employee A, who exposed his genitals. On 11/4/11, Patient 1 reported the incident to Employee A, who waited five days to notify his superiors of the incident. As a result of the incident, the patient felt uncomfortable around Employee A. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 940000100 |
HARBOR VIEW BEHAVIORAL HEALTH CENTER |
940009309 |
B |
16-May-12 |
PX4711 |
5702 |
Class B Citation 72319 - Nursing Services ? Restraints and Postural Supports (g) Restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient. On 10/27/09, at 7:45 a.m., an unannounced visit was made to the facility to investigate and entity report regarding Patient 1?s sustaining a fractured clavicle (collar bone) following attempts by facility staff to subdue the patient by manually restraining her. Based on observation, interview and record review, the facility failed to ensure restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient by failing to restrain the patient in a safe manner. As a result, the patient sustained a fractured right clavicle with displacement (bone structure out of alignment). On 10/27/09, a review of the clinical record revealed Patient 1 was a 17 years old female, admitted to the facility on 3/6/09, with diagnoses of mood disorder, psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions), post-traumatic stress disorder (PTSD) and history of poly-substance abuse substance (dependence disorder in which an individual uses at least three different classes of psychoactive substances indiscriminately). The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 9/11/09, indicated the patient was alert and oriented to her surroundings and was independent in her daily living activities. The patient?s behavioral symptoms included verbal and physical abuse, as well as socially inappropriate/disruptive behavior.A physician?s order dated 10/21/09, timed at 1 p.m., indicated to manually restrain the patient using four staff members for three minutes due to severe aggression/agitation, manifested by assaulting staff members. Physician?s orders dated 10/21/09, timed at 1:38 p.m. and at 1:44 p.m., indicated to manually restrain the patient using four staff members for five minutes, for severe agitation and aggression manifested by assaulting and kicking staff members.Another physician?s order on the same day, time at 1:45 p.m., indicated to administer Benadryl (sedative) 50 milligrams (mg), Haldol (anti-psychotic) 5 mg, and Cogentin (to prevent side effects) 2 mg intramuscular (IM) injection, then place the patient in five point restraint, not to exceed one hour.Further record review and a review of the facility?s investigative report revealed on 10/21/09, at 1:30 p.m., the patient became assaultive to staff members, failed to follow verbal directions and cease aggression requiring the Pro-Act (professional assault crisis training) physical floor restraint. The patient?s assaultive behavior continued requiring being restrained two more times and a licensed nurse administered the IM injection as ordered at 1:45 p.m. The patient calmed down at 2:45 p.m., and was released from restraining measures. At 3:25 p.m., the patient complained of pain to the right shoulder/arm area, pain medication was given and the physician was notified. The pain was assessed as severe in a pain intensity scale from zero to four (3/4). An x-ray result reported on the same day at 10:27 p.m. indicated an acute fracture of the right middle third of the clavicle with modest displacement. On 10/22/09, the patient was transferred to an acute care hospital for further evaluation of the fracture and returned on the same day with a sling immobilizer. According to the Pro-Act website (www.proacttraqining.com), Pro-Act containment is a two to four day course in crisis management and teaches principles of crisis communication, evasive techniques, hold breaking and containment. It involves floor or wall restraint for someone who is exhibiting combative behavior. During a floor restraint, the combative person is placed down in a prone position, with each extremity manually secured by three to four staff members. On 10/27/09, at 8:05 a.m., during an interview, Patient 1 appeared pale, with a swollen her right arm, and stated her right shoulder was painful. The patient demonstrated she was unable to raise her right arm more than two to three inches upward and was unable to move the arm in an outward direction. She also stated she was unable to write, due to the pain. The patient indicated on the day of the incident, six or seven staff members had grabbed her and restrained her on the floor. During a second attempt to restrain her, one of the youth counselors jumped on her back, grabbed her left arm, then grabbed her right arm and twisted it at the same time. The patient stated she fell to the floor onto her right side and felt her collar bone snap, which caused a lot of pain. On 10/27/09, at 9:50 a.m., during an interview with the Quality Assurance (QA) Coordinator, regarding Patient 1 statement that one of the counselors jumped on her back, and if that was an acceptable action during Pro-Act containment. The QA Coordinator stated it depended on the level of the patient needing to be safe and it could happen. The QA coordinator stated an acceptable method would be for a staff member to grab a patient?s belt from behind. The facility failed to ensure restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient by failing to restrain the patient in a safe manner. As a result the patient sustained a fractured right clavicle with displacement (bone structure out of alignment). The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 970000115 |
HUNTINGTON HEALTHCARE CENTER |
940009400 |
B |
18-Jul-12 |
0DOF11 |
4127 |
F-323 CFR 483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 7/12/12, an unannounced visit was made to the facility to conduct a standard recertification survey which was completed on 7/14/12. Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from hazards as is possible by failing to: Provide safe hot water temperatures at 120 degrees Fahrenheit (F) or below. Hot water temperatures above 120 degrees F were measured in one shower room and in the hand washing sinks in three restrooms located between Rooms 16-18, 28-30 and 32-34, in the North-East Nursing Station area. The unsafe water temperature placed the residents at risk of burn and scalding. On 7/12/12, between 6:30 p.m. and 8:30 p.m., during the general environmental inspection of the facility, in the presence of the maintenance supervisor, the temperatures of the hot water delivered to plumbing fixtures used by the residents in the North-East Nursing Station area were measured. The unsafe hot water temperatures in the hand washing sinks and in the shower room were as follows:Restroom between Rooms 16 and 18 - 129.8 degrees F. Restroom between Rooms 28 and 30 - 157.3 degrees F. Restroom between Rooms 32 and 34 - 157.1 degrees F. Shower Room S-3- 153.5 degrees F.According to the U.S. Consumer Product Safety Commission (http://www.cpsc.gov/), most adults will suffer third-degree burns if exposed to 130 degrees F for 30 seconds. A temperature of 120 degrees F for five minutes of exposure could result in third-degree burns. The U.S. Consumer Product Safety Commission urges to all users to lower their water heaters to 120 degrees F to prevent scalding, injuries, and death in elderly. There were a total of 18 residents in the affected rooms and five of the 18 residents were able to use the hand washing sink independently. The other 13 residents required assistance by staff to use the hand washing sinks. None of the residents had any concerns regarding the water temperature and had not sustained any injuries related to the unsafe water temperature.On 7/12/12 at 8:30 p.m., during an interview, the maintenance supervisor stated the high temperatures could be related to malfunctioning of the mixing valve (temperature control valve that regulates the temperature of the hot water delivered to the plumbing fixtures used by the residents). The maintenance supervisor explained he kept a record of daily water temperature and had no prior problem with the water temperature. The maintenance supervisor also stated the facility was not equipped with a hot water alarm to alert staff of unsafe water temperatures.A review of water temperature log revealed the temperatures taken daily prior to 7/12/12, were below 120 degrees F. At 8:40 p.m., during an interview, the administrator stated a plumber would be immediately called to assess and evaluate the problem. The facility?s maintenance department policy and procedure on Water Temperature Checking, undated, indicated to check the water temperatures in various locations throughout the building on a regular basis by picking a sink or shower at random; report temperatures above 120 and below 105 to the administrator and make necessary adjustments/repairs or arrange for outside service as necessary. The facility failed to ensure the resident environment remains as free from hazards as is possible by failing to: Provide safe hot water temperatures at 120 degrees F or below. Hot water temperatures above 120 degrees F were measured in one shower room and in the hand washing sinks in three restrooms located between Rooms 16-18, 28-30 and 32-34, in the North-East Nursing Station area. The unsafe water temperature placed the residents at risk of burn and scalding.The above violation had direct or immediate relationship to the health, safety, or security of the residents. |
| 940000100 |
HARBOR VIEW BEHAVIORAL HEALTH CENTER |
940009428 |
B |
07-Aug-12 |
WZ0E11 |
10425 |
F 223 483.13 (b) Free from Abuse/Involuntary SeclusionThe resident has the right to be free from verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion.On 7/10/12, at 11:25 a.m., an unannounced visit was made to the facility to investigate an entity self-reported incident of resident to resident abuse. Based on observation, interview and record review, the facility failed to ensure Resident 1 had the right to be free from verbal and sexual abuse by failing to: 1. Ensure Resident 1 was not sexually and verbally abused by Resident 2. 2. Identify patterns and trends that may lead to abuse. While Resident 1 was in bed asleep, her roommate (Resident 2) sexually assaulted her and after the sexual act threatened to kill her if she reported the incident to anyone. Prior to the sexual assault, Resident 2 used a bobby pin to mark her left hand with Resident 1?s initials and there was no documented evidence the facility investigated the meaning and significance of the initials.On 7/10/12, a review of Resident 1's clinical record revealed the resident was a 16 year-old female admitted to the facility on 6/20/12, with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder which is associated with mood swings that range from the lows of depression to the highs of mania) and post-traumatic stress disorder (a mental health disorder that is triggered by a terrifying event). The resident had a public guardian as the court-appointed conservator. The admission assessment Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/28/12, indicated the resident was able to make her needs known and was independent in performing activities of daily living (ADLs). An interdisciplinary behavioral plan dated 6/20/12, indicated the resident exhibited physical aggressive behavior to self (cutting, inserting foreign objects into rectum, suicidal attempts) and others. The resident's medication regimen included the following psychotropic (mind altering) medications: Seroquel (antipsychotic) 500 milligrams (mg) by mouth daily scheduled at 8 p.m. and Depakote (mood stabilizer) 1000 mg by mouth daily also scheduled at 8 p.m.A review of Resident 2's clinical record revealed the resident was a 17 year-old female initially admitted to the facility on 1/26/12, and was re-admitted on 5/7/12, with diagnoses that included unspecified episodic mood disorder, post-traumatic stress disorder, obsessive-compulsive disorder [an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions)] and combinations of drug dependence excluding opioid type drug currently in remission. The resident was a ward of the state (dependent of Court). The resident was placed in a three bed-room residing with Residents 1 and 3. The admission MDS assessment dated 5/20/12, indicated the resident was able to make her needs known and was independent in performing ADLs. A Child/Adolescent Assessment - Short Format form dated 2/1/12, indicated Resident 2 had persistent hyperactivity, poor attention span and inability to focus, poor impulse control, poor social skills, poor boundaries, poor insight, recurrent anger outburst, persistent agitation and restlessness, persistent obsessive thoughts/impulses, and physical aggression to peers and caregivers. In addition, the resident had a history of a sexual assault on a female roommate in 2009. Resident 2's daily psychotropic medications included Depakote (mood stabilizer) 1000 mg by mouth at bedtime for unspecified mood disorder, the antidepressant Trazodone Hydrochloride 100 mg by mouth at bedtime for problematic sleep and Seroquel 100 mg by mouth twice a day every day for unspecified episodic mood disorder. According to the Interdisciplinary Behavioral Plan dated 6/20/12, the interventions included one on one counseling/therapy twice a week for 30 minutes and group therapy sessions that included education on anger management, behavior control, emotional conflicts/frustrations tolerance and triggers and impulse control.According to a Change of Condition (COC) Documentation form dated 6/26/12, at 6:10 p.m., Resident 2 used a bobby pin to create markings on her own skin, two-letter initials on the left hand and a cross on the right forearm. Staff redirected the resident to stop using the bobby pin. The resident's physician was informed and a topical treatment was ordered to the affected areas. There was no documented evidence the facility investigated the meaning or significance of the two-letter initials the resident marked on her left hand. A review of Resident 1's COC Documentation form dated 7/2/12, timed at 1 p.m., Resident 1 closed the door of the room, pushed Resident 2 against the wall and placed her hand on Resident 2's neck. Staff intervened, opened the door and initiated an investigation regarding the assault.The facility?s investigation of the physical assault led to expose a sexual assault that took place on 7/1/12, against Resident 1 committed by Resident 2. According to the facility's investigation and the clinical record documentation, Resident 2 was assaulted by Resident 1 as a result of Resident 2 on 7/1/12, at approximately 11 p.m. sexually abusing Resident 1. While Resident 1 was asleep, Resident 2 removed Resident 1's scarf from her head, used the scarf to tie Resident 1's wrists together with palms facing each other above her head and against the wall. Resident 2 used her other hand to lift Resident 1's shirt up to kiss, lick and gently bite Resident 1's chest and stomach. Resident 2 then proceeded to insert three fingers inside Resident 1's vagina. During the incident, Resident 1 reported she attempted to fight off Resident 2 and yell, but Resident 2 prevented her from doing this by holding her down while putting her hand around Resident 1's neck/throat. At the end of the assault Resident 2 threatened to kill Resident 1 and her family if she reported the incident to staff. Resident 2 returned to bed after completing the assault and in the morning of 7/2/12, Resident 2 disposed of the scarf in the day room trash can to prevent people from finding out about the incident. The sexual assault was witnessed by Resident 3. The staff did not witness the incident because it occurred in between the every 15-minute supervision/safety/security rounds.On 7/2/12 at 6:15 p.m., Resident 2 was discharged to the custody of the police department after the facility reported the incident to law enforcement. On 7/10/12 at 11:50 a.m., during an interview, Resident 1 was observed alert, oriented, was able to communicate and had no emotional expression. She stated Resident 2 was obsessed with her, she could feel and see Resident 2 staring at her and Resident 2 had marked her name initials on Resident 2?s left hand. Resident 1 stated before the incident she had reported (no specific date given) to staff (no specific staff identified) that Resident 2's attention made her uncomfortable and during their group sessions, staff would talk to Resident 2 about maintaining social boundaries. Resident 1 stated Resident 2 sexually assaulted her after she told her she was just a friend to her. Resident 1 refused further interview.On 7/10/12, at 12:10 p.m., during an interview, the assistant administrator stated Resident 1 told staff that Resident 2's action towards her made her uncomfortable. The assistant administrator stated this concern was not specifically documented in the clinical record but instead addressed through a plan of care addressing Resident 2's behavior manifested by physical aggression with interventions that included group counseling sessions about maintaining social boundaries and therapy sessions with a licensed therapist two times per week. When asked about protecting Resident 1, and allowing the two residents remain roommates, the assistant administrator explained a room change was counter therapeutic for both residents because the residents are assisted to work through their problems and they needed to try to work out their issues. The assistant administrator acknowledged there was no investigation of the meaning of the two-letter mark Resident 2 made on her left hand which could have led to further interventions. On 7/10/12, at 4:05 p.m., during an interview, Resident 3 confirmed witnessing the sexual assault and explained she could not scream for help because she was very sleepy.A review of Resident 3's clinical record revealed the resident was admitted on 6/21/12, with diagnoses that included unspecified episodic mood disorder and drug dependency. The resident was able to make her needs known, had no memory problems and was able to perform ADLs independently. According to the facility's policy and procedure titled "Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property," dated 1/2008, residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, visitors legal guardians, friends, or other individuals. The administrator/designee educates staff on strategies to identify, correct and intervene in situations in which abuse, neglect, or misappropriation of resident property is more likely to occur. The administrator/designee identifies events such as suspicious bruising of resident, occurrences, patterns and trends that may constitute abuse, to determine the direction of the investigation.The facility failed to ensure Resident 1 had the right to be free from verbal and sexual abuse by failing to: 1. Ensure Resident 1 was not sexually and verbally abused by Resident 2. 2. Identify patterns and trends that may lead to abuse. While Resident 1 was in bed asleep, her roommate (Resident 2) sexually assaulted her and after the sexual act threatened to kill her if she reported the incident to anyone. Prior to the sexual assault, Resident 2 used a bobby pin to mark her left hand with Resident 1?s initials and there was no documented evidence the facility investigated the meaning and significance of the initials.The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000100 |
HARBOR VIEW BEHAVIORAL HEALTH CENTER |
940012198 |
B |
27-Apr-16 |
09XU11 |
6447 |
Health and Safety (H&S) Code 1418.91Reports of incidents of alleged abuse or suspected abuse of Residents (a) A long ?term health care facility shall report all incidents of alleged abuse or suspected abuse of a Resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class ?B? violation. On 1/27/2016 at 7:17 a.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident regarding an alleged Resident to Resident physical abuse.The facility failed to: 1. Report an alleged abuse to the Department of Health (DPH, Licensing and Certification) immediately, or within 24 hours.Resident 1 was sleeping in her bed on 1/17/16 when Resident 2 went into her room, put her hand on Resident 1?s neck and attempted to choke her. The facility did not report the incident to the Department until 1/19/16, at 12 p.m., two days after.On 1/27/2016 at 8:00 a.m., Resident 1 was observed sleeping on her bed without bed linen and pillow cases. At 8:09 a.m., Resident 2 was observed in her room making her bed.A review of the Admission Record indicated Resident 1 was admitted to the facility on 1/29/15, with diagnoses that included schizoaffective disorder, a mental condition that causes both of loss of contact with reality (psychosis) and mood problems (depression or mania). A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/21/15, indicated Resident 1 had the ability to make self-understood and understand others. Under the Brief Interview for Mental Status (BIMS) indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 had hallucinations (seeing, hearing, feeling, smelling, or tasting that does not exist in reality) and delusions (a belief held with strong conviction despite clear and obvious evidence that isn?t true or false belief). Resident 1 was independent in all activities of daily living.A review of the Admission Record indicated Resident 2 was admitted to the facility on 10/28/15, with diagnoses that included schizoaffective disorder. A review of the MDS dated 11/10/15, indicated Resident 2 had the ability to make self-understood and understand others. Under the Brief Interview for Mental Status (BIMS) indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 had hallucinations and delusions. Resident 2 was independent in all activities of daily living. On 1/27/2016 at 9:30 a.m., during an interview, in reference to the incident allegation on 1/17/2016 at 2:45 a.m., Resident 2 stated, ?I don?t know what happened that day. I just heard a voice telling me to hurt someone and do all those things.? At 9:33 a.m., Resident 1 refused to be interviewed.On 1/27/2016 at 9:34 a.m., during an interview, the license vocational nurse (LVN 1) stated that, on 1/17/2016 at 2:45 a.m., LVN 1 who was in the medication room heard someone screaming from Resident 1?s room. When LVN 1 went in the room, a certified nurse assistant was already in the room and Resident 2 was seen walking towards the bathroom (joined/shared bathroom between two rooms) and went back to her bed. LVN 1 talked to Resident 2 and the Resident stated, ?I?m the devil. Someone told me to do it.? LVN 1 gave Resident 2 one dose of Chlorpromazine 25 milligrams orally as ordered as needed for psychotic behavior (psychosis is a mental disorder involving loss of contact with reality). Afterward, LVN 1 stated Resident 2 went to sleep and was monitored closely. LVN 1 assessed Resident 1 for any injury, there was no injury noted.Resident 1 told LVN 1 that Resident 2 ?tried to kill her.? Resident 1 was temporarily relocated to the cabana room to sleep and the room change was done the next day.A review of the facility?s Event Summary Report indicated that on 1/17/16, at 2:45 a.m., staff heard screaming from Resident room (Resident 1). Staff noted that peer (Resident 2) had gone into adjoining bathroom. Staff noted peer standing next to Resident?s bed with hands on Resident 1?s neck area. The staff initiated ?crisis communication? and the peer responded positively by following staff direction and left Resident 1?s room. Resident 1 was assessed without redness to the neck and denied pain. When interviewed, peer stated, ?I?m the devil and I want to kill everyone? ?The voices in my head are telling me to do these things.?On 1/27/2016 at 2:36 p.m., during an interview, the administrator (ADM) stated the staff called her on 1/17/16 while she was ?half sleep? regarding the incident. When asked who was responsible for reporting the abuse incident? The ADM stated the director of nursing (DON) would report the incident in the absence of the ADM. If both ADM and DON were not available, then the program director (PD) would report. When asked why this abuse allegation was not reported within 24 hours, the ADM gave no reason. The ADM stated that she knew about it on 1/17/16 while she was ?half sleep? and reported the incident on 1/19/2016. The ADM stated the PD came to work on 1/18/2016 (holiday) but the PD thought the ADM took care of it already that was the reason why it was not reported to the Department within 24 hours.On 1/27/2016 at 3 p.m., during an interview, the PD stated Resident to Resident altercation should be reported to DPH within 24 hours after the incident occurred. The PD stated the ADM was responsible for reporting abuse incident because she was the abuse coordinator. If both ADM and DON were not available, then PD would report. The PD stated she was aware that staff already reported the incident to the ADM on 1/17/16. The PD stated she thought the ADM took care of it and reported it that was the reason why she did not follow-up and reported it. A review of the facility?s policy and procedure titled, ?Abuse Prohibition-State of California? revised on 10/15/15 indicated if no serious bodily injury: provide a written report to local ombudsman, the L&C (Licensing and Certification) Program District Office, and the local law enforcement agency within 24 hours.The facility failed to: 1. Report an alleged abuse to the Department of Health (DPH, Licensing and Certification) immediately, or within 24 hours.The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000115 |
HUNTINGTON HEALTHCARE CENTER |
940012769 |
B |
23-Nov-16 |
MJQ911 |
12190 |
F203. 42 CFR 483.12(a)(4)(5)(6) Notice Before Transfer
Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section.
Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged.
Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days.
The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.
F205. 42 CFR 483.12(b)(1)(2) Notice of Bed-Hold Policy and Readmission
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.
F206. 42 CFR 483.12(b)(3) Permitting Resident to Return to Facility
A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services.
On 6/15/16 at 8:35 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding the facility refusing to readmit Resident 1 from a general acute care hospital (GACH).
Based on interview and record review, the facility failed to establish a policy and procedure regarding providing a written notice before transfer and failed to follow its bed hold and readmission policy and procedure by failing to:
1. Give Resident 1?s legal representative a written notice of proposed transfer/discharge before transferring Resident 1 to a GACH.
2. Notify Resident 1?s legal representative in writing of the facility's seven-day bed hold policy at the time of the resident?s transfer (the second bed hold notice) to a GACH.
3. Readmit Resident 1 to the facility immediately upon the first availability of a bed if the resident required the services provided by the facility.
Resident 1, who did not have the capacity to make decisions, was transferred to GACH on XXXXXXX16. The resident's legal representative was not provided in writing a notice of proposed transfer/discharge and the facility did not have a policy and procedure regarding providing in writing the notice of proposed transfer/discharge to a resident and/or legal representative. The resident?s legal representative was not notified in writing at the time of transfer of the facility's seven-day bed hold policy.
After being hospitalized for more than seven (7) days, the social worker from the GACH communicated with the facility on 5/31/16 that Resident 1 would be discharged back to the facility. The facility refused to readmit the resident.
This deficient practice resulted in the violation of Resident 1?s rights to receive information regarding appealing a transfer if believed to be inappropriate or involuntary and securing a facility?s bed hold during the resident?s hospitalization, and to return to the facility to occupy the first available bed.
A review of the Admission Record indicated Resident 1 was a 58-year-old female, who was admitted to the facility on XXXXXXX 11 and was readmitted on XXXXXXX16, with diagnoses that included hypertension (high blood pressure), end stage renal failure (the kidneys were nonfunctioning), and hyperglycemia (high blood sugar). The resident's pay type was Medicaid (a State's health insurance coverage).
According to Resident 1?s Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/18/16, the resident was severely impaired (never/rarely made decisions) in cognitive skills for daily decision-making, and was totally dependent on staff with transfer, dressing, and eating with one person assist.
A review of the Interdisciplinary Team Meeting, dated 5/17/16, indicated Resident 1 had a legal representative.
A review Resident 1's Bedhold Informed Consent for her re-admission date of XXXXXXX16 indicated it is the policy of the facility to provide the residents the right to secure a bed hold during hospitalization. The consent indicated the resident/legal representative have the option of requesting a seven (7) day bed hold to keep a bed vacant and available to return to the facility as provided under the State Medicaid plan.
A review of the nursing note, dated 5/18/16 at 8:24 p.m., indicated the licensed vocational nurse (LVN 1) documented that Resident 1 was transferred to GACH by ambulance at 8:15 p.m.
A review of Resident 1's Second Notice of Bedhold, which was to be completed at the time of transfer, indicated the resident was transferred on XXXXXXX 16. There was no signature of the facility personnel on the form that Resident 1's legal representative was notified in writing of the duration of the facility's bed hold policy. The sections on the form, which indicated "How notified: phone, person, and copy given," were not answered by a facility personnel.
A review of Resident 1's Notice of Proposed Transfer/Discharge indicated that effective XXXXXXX16, the resident was transferred to a GACH. There was no signature of the Resident 1's legal representative on the notice. There was no documented evidence the legal representative was notified of the transfer in writing before the transfer or as soon as practicable.
A review of the hospital?s CM/SW (case manager/ social worker) Note, dated 5/25/16 (seven days after the transfer from the facility) indicated a case manager (CM 1) called the facility and spoke with the administrator and per the administrator, Resident 1 could not return to the facility due to the facility staffs were not competent to care for residents with a "line like PICC (peripheral inserted central catheter), Quinton (a name for a central line catheter used for dialysis), Permacath (a name for a central line catheter used for dialysis), etc." The CM/SW Note indicated Resident 1's anticipated hospital discharge back to the facility was early next week according to the hospital's registered nurse (RN).
A review of the hospital?s CM/SW Note, dated 5/31/16 (13 days after the transfer from the facility), indicated CM 1 re-referred Resident 1 to the facility for placement. CM 1 documented that the facility's personnel (Staff 1) was informed that Resident 1's attending physician at the facility would be informed by the resident's attending physician at the hospital regarding the resident's discharge back to the facility. CM 1 documented that Resident 1's legal representative was agreeable of the resident's return to the facility. CM 1 documented that Staff 1 stated that according to the facility's administrator, "the administrator does not hold the facility from reaccepting the patient."
On 6/15/16 at 9:20 a.m., during an interview with the director of nursing (DON), the DON stated she was competent in providing Permacath and central line dressing care and changes.
On 6/15/16 at 10 a.m., during an interview, the administrator stated all communications with the acute care hospital was done verbally over the phone, and readmission for residents with central line catheters was dependent on the DON?s approval.
On 6/15/16 at 3:15 p.m. during a concurrent interview and record review of Resident 1's bed hold notification and Notice Of Proposed Transfer/Discharge with the assistant director of nursing (ADON) and in the presence of the social services designee (SS 1), the ADON stated there was no documentation found in the clinical record that Resident 1's legal representative was notified in writing of the facility's seven-day bed hold policy and of the proposed transfer to the GACH.
On 6/17/16 at 2:10 p.m., during an interview, Resident 1's legal representative stated, "No" when asked regarding receiving a notification in writing of the facility's seven-day bed hold policy at the time the resident was transferred to the GACH. Resident 1's legal representative also stated, "No" when asked regarding getting a notification in writing of the proposed transfer to the GACH.
A review of the facility's census, from 5/24/16 to 6/14/16, indicated the facility had a bed available to permit the readmission of Resident 1.
On 7/29/16 at 10 a.m., during a telephone interview, a registered nurse (RN 1) stated the facility had a bed capacity of 99 beds and there were 73 residents currently in the facility. RN 1 stated Resident 1 was not in the list of residents currently in the facility
The facility submitted a policy and procedure titled, "Bed Hold Policy, Notice of Proposed Transfer/Discharge," revised on 6/21/16, which indicated that a copy of the second notice of bed hold will be provided to the resident or representative. The policy did not indicate procedures in providing a notice of proposed transfer/discharge to the resident and/or legal representative.
The facility failed to establish a policy and procedure regarding providing a written notice before transfer and failed to follow its bed hold and readmission policy and procedure by failing to:
1. Give Resident 1?s legal representative a written notice of proposed transfer/discharge before transferring Resident 1 to a GACH.
2. Notify Resident 1?s legal representative in writing of the facility's seven-day bed hold policy at the time of the resident?s transfer (the second bed hold notice) to a GACH.
3. Readmit Resident 1 to the facility immediately upon the first availability of a bed if the resident required the services provided by the facility.
The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 970000115 |
HUNTINGTON HEALTHCARE CENTER |
940013460 |
A |
31-Aug-17 |
0F5P11 |
18143 |
CFR 483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
F309 CFR 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
F323 CFR 483.24 (d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
F279 CFR 483.21(b) Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at ?483.10(c)(2) and ?483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
(ii) Any services that would otherwise be required under ?483.24, ?483.25 or ?483.40 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(c)(6).
On 5/17/17, at 10:10 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care.
Based on observation, interview, and record review, the facility failed to provide the care and services to prevent falls for one of two sampled residents (Resident 1), who was assessed to have poor trunk control (the ability to control and hold up the body upright when sitting or moving) and the tendency to lean forward when in a sitting position, in accordance with assessments, care plans, and physician's orders. The facility failed to:
1. Recline the back of the reclining wheelchair to prevent Resident 1 from falling forward.
2. Provide a wedge seat cushion (a cushion used to help prevent wheelchair-bound individuals from sliding forward) in the reclining wheelchair to prevent Resident 1 from leaning forward.
3. Ensure two-persons assistance to Resident 1 when transferring (how resident moves between surfaces including to or from bed, chair, wheelchair, and standing position), dressing (how resident puts on, fastens and takes off all items of clothing), and providing personal hygiene (how resident maintains personal hygiene, including combing hair).
These deficient practices resulted in Resident 1 sustaining a fall with a right frontal scalp laceration (a deep cut or tear in skin) and was sent out to the hospital for suture (stitches used by doctors and surgeons to hold the skin together) procedure of the laceration. Resident 1 was diagnosed to have subdural hemorrhage (bleeding under the skull and outside the brain that is caused by traumatic head injury).
A review of Resident 1's record titled, "Record of Admission," indicated Resident 1 was admitted to the facility on XXXXXXX11, and was re-admitted on XXXXXXX12, with diagnoses that included cerebrovascular disease (a disorder in which an area of the brain is temporarily or permanently affected by lack of blood flow or bleeding), disorder of muscle, and contractures (a condition of shortening and hardening of muscles and tissues that cause deformity and rigidity of joints) of the left elbow and left hand.
A review of Resident 1's record titled, "SBAR ([Situation, Background, Assessment, and Request], a form of communication between healthcare members for changes in resident's conditions), dated 4/12/13, at 6:18 p.m., indicated Resident 1 slid down from her wheelchair and hit the left side of her forehead on the floor. The SBAR indicated Resident 1 complained of pain on the left side of her forehead above the eye and had skin discoloration and swelling on the left forehead area.
A review of Resident 1's record titled, "Physician Orders," dated 3/17/15, at 5 p.m., indicated, "May get up resident in reclining wheelchair every day (QD) as tolerated per family request for poor trunk control."
A review of Resident 1's SBAR, dated 4/5/15, no time, indicated Resident 1 had a fall. The SBAR indicated Resident 1 slid down from her reclining wheelchair and hit her left forehead on the floor. The SBAR indicated Resident 1 had a laceration (a deep cut or tear in skin) on the left forehead with bleeding. The SBAR indicated a Certified Nurse Assistant (unidentified) stated, "Resident slid down from chair and within blink of seconds, resident was on floor on left side."
A review of Resident 1's Physician Orders, dated 4/5/15, at 4:20 p.m., indicated, "Wedge cushion when on reclining wheelchair as tolerated for safety and positioning due to (D/T) poor trunk control."
A review of Resident 1's record titled, "Physical Therapy Evaluation and Discharge Status," indicated the following:
1. On 4/8/15, to improve safety and positioning in wheelchair, recline the wheelchair and use cushion (wedge).
2. On 4/28/15, dependent with two-person assist with transfers from bed to wheelchair and poor balance for static sit (seating is rigid or not moving) and dynamic sit (seating allows or encourages the seated individual to move). "Wheelchair management: Wheelchair with reclining back for positioning and pommel wedge cushion for safety and comfort."
A review of Resident 1's record titled, "Interdisciplinary Team (a group of health care professionals from diverse fields who work toward a common goal for the resident)/Care Plan Meeting," dated 5/18/15, indicated Resident 1 was at risk for falls with precautions/interventions for the use of a wedge cushion and reclining chair due to poor trunk control.
A review of Resident 1's record titled, "History and Physical (H&P)," dated 9/19/16, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's record titled, "Resident Care Plan," dated 1/25/17, indicated Resident 1 was at risk for falls due to history of falls with the last fall on 4/5/15, impaired cognition (the ability to think and reason), and osteoporosis (a medical condition in which the bones become brittle and fragile). The Resident Care Plan indicated Resident 1 was totally dependent on staff with transfers, dressing, bathing, and personal hygiene. The Resident Care Plan indicated Resident 1 had the tendency to lean forward and had poor trunk control with the intervention of keeping the wheelchair in a tilt position (reclined) while in the wheelchair. The Resident Care Plan did not indicate the physician's order for a wedge cushion to be placed in Resident 1's reclining wheelchair.
A review of Resident 1's record titled, "Minimum Data Set ([MDS], a resident assessment and care screening tool), dated 1/27/17, indicated Resident 1 had short- and long-term memory problems and had severe impairment in cognitive skills for daily decision-making. The MDS indicated Resident 1 was totally dependent requiring two-person physical assistance with transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, and standing position) and dressing (how resident puts on, fastens and takes off all items of clothing), and personal hygiene (how resident maintains personal hygiene including combing hair). The MDS indicated Resident 1 used a wheelchair as a mobility device.
A review of Resident 1's record titled, "Progress Notes," dated 3/18/17, the physician indicated Resident 1 was non-ambulatory and had partial contractures of joints in both hips and knees.
A review of the facility's document titled, "Incident Report," dated 4/15/17, indicated Resident 1 had a witnessed fall and sustained a laceration to the right side of the forehead by the right eye. The incident report included a Certified Nursing Assistant's (CNA 1) written declaration that on 4/15/17, at 9:35 a.m., CNA 1 transferred Resident 1 from bed to the wheelchair. CNA 1 turned around to get a comb from Resident 1's drawer and "not even 5 seconds," later, CNA 1 heard a "drop" and quickly turned back and saw the resident on the floor facing down, bleeding. CNA 1's written declaration did not indicate that another staff was present during transfer. CNA 1's written declaration did not indicate Resident 1's wheelchair was reclined and a wedge cushion was placed in the seat of the wheelchair.
A review of Resident 1's untitled physician's order, dated 4/15/17, at 9:45 a.m., indicated to transfer Resident 1 to the emergency room for head laceration and further evaluation.
A review of Resident 1's hospital record titled, "Transmission Log," indicated Resident 1 was admitted to the hospital on XXXXXXX17, no time, with an admitting diagnosis of head trauma with subacute (a condition that is not sudden [acute] or happened a long time [chronic]) versus chronic subdural hemorrhage (SDH).
A review of Resident 1's untitled hospital record of the CT scan (computed tomography scan, a diagnostic tool that uses x-rays to make detailed pictures) of the head, dated 4/17/17, indicated, "Stable 3 millimeter (mm) left inferior frontal (lower front) convexity (surface of the brain) extra-axial fluid suggestive of subacute hemorrhage.
A review of Resident 1's record titled, ?History and Physical (H&P)," dated 4/21/17, indicated Resident 1 was admitted to the hospital from XXXXXXX17, until XXXXXXX 17. The H&P indicated, "Patient (Resident 1) admitted to the hospital secondary to a mechanical fall from the wheelchair. Patient has a large right frontal scalp laceration, status post (condition after) suture, and also the patient sustained subdural hemorrhage." The H&P indicated Resident 1 was transferred to an acute long-term care hospital (a transitional care hospital that provides long-term acute care to medically complex patients who require an extended stay in a hospital setting) for continuation of treatment.
During an interview on 5/17/17, at 12:45 p.m., CNA 2 stated there should be two persons assisting Resident 1 with transfers. CNA 2 stated Resident 1 was weak and could not stand or walk. CNA 2 stated whenever Resident 1 sits in the wheelchair, the seat of the wheelchair should be adjusted so that Resident 1 would lean back and would not be sitting up straight because Resident 1 was at risk for leaning forward and falling.
During an interview on 5/17/17, at 1:20 p.m., the Restorative Nurse Assistant ([RNA 1], a CNA who received training for expanded role to restore and maintain resident's strength, coordination and ADL skills) stated Resident 1 was confused and quiet. RNA 1 stated Resident 1 was not one to resist care and did not have a behavior of attempting to get out of bed or wheelchair. RNA 1 stated Resident 1 had the tendency to lean forward in the wheelchair.
During an interview on 5/17/17, at 2:30 p.m., the Licensed Vocational Nurse (LVN 1) stated she had been taking care of Resident 1 and that Resident 1 had the tendency to lean her body to one side or forward due to poor trunk control.
During an interview on 5/17/17, at 3 p.m., the Director of Nursing (DON 1) stated Resident 1 was confused, calm and quiet. DON 1 stated Resident 1 did not have the behavior of trying to get out of bed or wheelchair unassisted and was totally dependent on staff with care. DON1 stated that there should be two staff assisting Resident 1 with transfers.
During a telephone interview on 6/27/17, at 10:50 a.m., CNA 1 stated she had taken care of Resident 1 for over a year and did not have behaviors of trying to get up from the bed or wheelchair on her own. CNA 1 stated Resident 1 had the tendency of leaning forward when in the wheelchair so she would place Resident 1 in front of a table. CNA 1 stated on 4/15/17, at 9 a.m., she transferred Resident 1 from the bed to a wheelchair by herself. CNA 1 stated in detail, step-by-step, the process of transferring Resident 1 from the bed to the wheelchair the day of 4/15/17, was as follows:
1. Placed Resident 1's wheelchair next to the bed and locked the wheelchair.
2. Transferred Resident 1 from the bed to the wheelchair and placed Resident 1's feet on the foot rest.
3. While Resident 1 was sitting in her wheelchair at the foot of the bed, CNA 1 went to get Resident 1's comb from the drawer located next to Resident 1's bed.
4. CNA 1 turned her back to Resident 1 then she heard a sound.
5. CNA 1 saw Resident 1 on the floor lying on her right side, had a cut that was bleeding from above her eyebrow.
During an interview on 6/27/17, at 2:39 p.m., the Registered Nurse Supervisor (RN 1) stated CNA 1 should have asked another staff to assist her in transferring Resident 1 from bed to the wheelchair. RN 1 stated if CNA 1 had another staff to assist her, then the additional staff could have monitored Resident 1 and prevented the fall as CNA 1 was getting Resident 1's comb.
During an observation of a reclining wheelchair on 8/1/17, at 1:50 p.m., RNA 2 stated the reclining wheelchair was the same as Resident 1's reclining wheelchair. RNA 2 demonstrated and stated the reclining wheelchair could be adjusted from a 90 degree angle (resident sitting upright) to a flat position. RNA 2 stated staff could adjust the reclining wheelchair seat using the levers on each side of the wheelchair handle.
During an observation of a reclining wheelchair on 8/2/17, at 9:20 a.m., CNA 1 stated Resident 1 used the same type of reclining wheelchair on 4/15/17. In the presence of DON 2 and the Regional Operations (RO) staff, CNA 1 provided a return demonstration of how she transferred Resident 1 from the bed to the reclining wheelchair on 4/15/17, using RO to represent Resident 1.
1. RO was lying in bed.
2. CNA 1 moved the reclining wheelchair next to the foot of the bed.
3. CNA 1 moved RO's legs down from the bed and then she used her arms to sit up RO from the bed.
4. RO was sitting at the edge of bed and CNA 1 wrapped RO's arms around her (CNA 1) body.
5. CNA 1 assisted RO stand up from the bed and then transferred RO to the reclining wheelchair.
6. CNA 1 unlocked the reclining wheelchair.
7. CNA 1 placed RO's feet on the foot rest of the reclining wheelchair.
8. CNA 1 stated Resident 1 was leaning and resting her head and upper body on CNA 1's chest as CNA 1 was putting Resident 1's vest (an article of clothing).
9. CNA 1 positioned RO to sit back on the wheelchair positioned at 90 degrees.
10. CNA 1 turned around to get a comb from the drawer.
11. CNA 1 stated within 5 to 6 seconds, she heard a drop then saw Resident 1 face down forward on the floor.
During an interview on 8/2/17, at 9:50 p.m., CNA 1 stated on 4/15/17, she should have reclined the wheelchair more to prevent Resident 1 from falling forward from the reclining wheelchair.
During an interview on 8/2/17, at 1:03 p.m., and concurrent review of Resident 1's care plan, DON 2 stated Resident 1's care plan did not indicate the fall precautions/interventions of placing Resident 1 in front of a table to prevent from leaning forward and a wedge cushion in the reclining wheelchair for safety due to poor trunk control. DON 2 demonstrated and stated a wedge cushion would be placed in the wheelchair, the straps of the wedge cushion would go around the reclining wheelchair and it would be buckled together and straps were adjusted as needed. DON 2 demonstrated and stated it was difficult for her to slide off from the wedge cushion.
During the same interview, DON 2 stated during CNA 1's return demonstration, CNA 1 did not verbalize or demonstrate that the reclining wheelchair was reclined and a wedge cushion was placed in the reclining wheelchair. DON 2 stated Resident 1's fall could have been prevented if CNA 1 reclined the reclining wheelchair and/or reclined the reclining wheelchair enough to prevent the fall and used a wedge cushion in the reclining wheelchair.
A review of the facility's policy and procedures titled, "Fall Prevention and Reduction," dated October 2010 indicated the facility was responsible to prevent falls to the extent possible and within the control of the facility.
A review of the facility's undated policy and procedures titled, "Moving a Resident, Bed to Chair/Chair to Bed," indicated the facility was responsible for providing safe transferring of a resident and the transfer procedure may require two persons.
Therefore, the facility failed to provide the care and services to prevent falls for Resident 1, who was assessed to have poor trunk control and the tendency to lean forward when in a sitting position, in accordance with assessments, care plans, and physician's orders. The facility failed to:
1. Recline the back of the reclining wheelchair to prevent Resident 1 from falling forward.
2. Provide a wedge seat cushion in the reclining wheelchair to prevent Resident 1 from leaning forward.
3. Ensure two-person assistance to Resident 1 when transferring, dressing, and providing personal hygiene.
These deficient practices resulted in Resident 1 sustaining a fall with a right frontal scalp laceration and were sent out to the hospital for suture procedure of the laceration. Resident 1 was diagnosed to have subdural hemorrhage.
The above violations jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result to Resident 1. |
| 950000062 |
HUNTINGTON DRIVE HEALTH AND REHABILITATION CENTER |
950012815 |
A |
14-Dec-16 |
DKN811 |
8569 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision and physical assistance in accordance with Resident 5?s comprehensive assessment which indicated that Resident 5 required a one-person assistance when walking and stand-by assist while standing. While Resident 5 used the front wheel walker (FWW) to the bathroom, Resident 5 fell when CNA 1 left her unattended and unsupervised, and sustained a left hip fracture. As a result, Resident 5 had severe pain needing pain medications, was transferred to an acute hospital where surgery was performed (four screws were placed on the left femoral neck fracture) that required anesthesia, and was hospitalized for four days. On 10/13/2015, during a recertification survey conducted at the facility, an interview with Resident 5 prompted the investigation into Resident 5?s fall who had sustained a left hip fracture as the result of the fall. On October 13, 2015, at 10:50 a.m., during the initial tour of the facility, Resident 5 stated she fell at the facility, was unable to remember the date. She stated a CNA (certified nursing assistant) left her unattended at the foot of her bed. The CNA had to move the roommate's wheelchair that was blocking the doorway to the bathroom. Resident 5 stated she broke her left hip because of the fall. A review of Resident 5's clinical record indicated she was admitted to the facility on July 27, 2015, with diagnoses that included Parkinson's disease (progressive disease marked with tremors, muscular rigidity and slow imprecise movement) and unstageable pressure ulcers of the right and left buttocks, and right heel. On October 14, 2015, a review of Resident 5's Fall Risk Assessment dated July 27, 2015, indicated Resident 5 was unable to independently come to a standing position, exhibited loss of balance while standing, and had a decrease in muscle coordination. The assessment indicated the resident had a predisposing condition of vertigo (lightheadedness or dizziness). A review of the "Minimum Data Set" (MDS-an assessment tool), dated August 31, 2015 indicated Resident 5 required one-person assistance. Staff is to provide guided maneuvering of limbs or other non-weight-bearing assistance when standing, and participating in activities. The record indicated the resident used an assistive device such as a front wheel walker (FWW). A review of a "Change of Condition" (SBAR - Situation Background Appearance Request) dated September 3, 2015, at 7:17 p.m., indicated the resident had a fall while walking with a FWW (front wheel walker). The CNA was assisting the resident to the bathroom, and suddenly the resident lost balance and fell, landing on her buttocks. The physician was on site and ordered X-ray for the left hip on September 3, 2015 at 9:17 p.m. A review of the pain assessment dated September 3, 2015 at 9:41 p.m., indicated the resident was restless, crying in pain from the left hip. Percocet 5/325 mg was given for pain. On September 4, 2016 at 3:57 a.m., the X-ray result indicated acute left hip fracture. At 4:20 a.m., the physician was notified and gave an order to transfer the resident to the emergency room via ambulance. A review of the admission records dated September 4, 2015, from the acute hospital, indicated another X-ray was done and disclosed a subcapital fracture (an extracapsular fracture of the neck of the femur [thigh bone], at the point where the neck of the femur joins the head) of the left hip from a fall at the nursing home. A review of the acute hospital CT (computed tomography-special X-ray tests) hip images results dated September 4, 2015, indicated the resident had an impacted subcapital fracture of the left femoral neck. The operative report dated September 5, 2015, from the acute hospital indicated surgery was performed where four (4) screws were placed on the left femoral neck fracture. On October 15, 2015, at 8:20 a.m., during an interview with Resident 5, she stated CNA 1 got her up from the bed to go to the bathroom and left her unattended at the foot of the bed holding on to the front wheel walker (FWW), while CNA 1 went to move the roommate?s wheelchair, which was blocking the bathroom door. The resident further stated she lost her balance and fell to the floor between the television set and the foot of the bed. Resident 5 stated she was in the "worst pain ever" and could not walk around in the facility with her friends anymore. On October 15, 2015, at 9:02 a.m., during a telephone interview with CNA 1, she stated on September 3, 2015, she took Resident 5 out of bed to take her to the bathroom, using a FWW. CNA 1 stated she left Resident 5 unattended and unsupervised (unable to tell how long), in order to move a wheelchair belonging to Resident 5's roommate which was blocking the door to the bathroom. CNA 1 stated Resident 5 fell on the floor. She stated she was about six to 10 feet away from Resident 5, when Resident 5 fell. CNA1 stated she should have put the resident back in bed before leaving, and never should have left her by herself, or should have called another CNA or charge nurse to help her. On October 15, 2015, at 1:40 p.m., during an interview with Employee C, she stated that the nursing staff should not have left Resident 5 standing up holding on to the FWW unattended. Employee C stated Resident 5 required close stand-by assistance (assistance should have been within reach and readily available). The physical therapist stated it is not a stand by assist if the CNA was six to 10 feet away from the resident. The physical therapist stated she would have had the resident sit down first, and then move the equipment (wheelchair) as a preventive measure to prevent falls or accidents. On October 15, 2015, at 10:25 a.m., during an interview with Employee A, he stated CNA 1 should have asked a co-worker for help or clear the pathway before helping Resident 5 to the bathroom. He stated CNA 1 should have sat the resident back to bed before moving the wheelchair as prevention for falls and or accidents. On October 15, 2015, at 2:55 p.m., during an interview with Employee B, she stated that the CNA 1 should have called someone for help or let the resident sit down first before leaving the resident unattended to prevent falls. On October 16, 2015, at 2:45 p.m., during an interview with CNA 2, she stated she was called to Resident 5's room by CNA 1 on September 3, 2015, to help CNA 1 and the charge nurse to lift Resident 5 off the floor and into the wheelchair. CNA 2 stated CNA 1 and the charge nurse took the resident to the bathroom after the fall. CNA 2 stated if she was providing care for Resident 5, she would have Resident 5 sit back down on the bed before clearing the pathway to the bathroom to prevent falls or accidents. The facility's policy and procedures regarding Falls and Fall Risk, Managing, revised December 2007, stipulated: Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). The facility failed to provide adequate supervision and physical assistance in accordance with Resident 5?s comprehensive assessment which indicated that Resident 5 required a one-person assistance when walking and stand-by assist while standing. While Resident 5 used the front wheel walker (FWW) to the bathroom, Resident 5 fell when CNA 1 left her unattended and unsupervised, and sustained a left hip fracture. As a result, Resident 5 had severe pain needing pain medications, was transferred to an acute hospital where surgery was performed (four screws were placed on the left femoral neck fracture) that required anesthesia, and was hospitalized for four days. The violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 960001553 |
HOLY HILL HOME CARE/BENFIELD HOME |
960009826 |
B |
02-Apr-13 |
7LGC11 |
8119 |
WIC 4502 (h) Class B CitationPersons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.It is the intent of the Legislature that persons with developmental disabilities have rights including, but not limited to, the following:(h) A right to be free from harm, including unnecessary physical restraints, or isolation, abuse, or neglect.Based on interview and record review the facility staff failed to: 1. Ensure the safety and the right to be free from harm for 2 clients (Client 1 and 2) who were reported to have bruises of unknown origins.Failure of the facility's administrative staff to follow up regarding bruises of unknown origin placed Client 1 and Client 2 at risk for abuse and harm. On February 22, 2013 at 10:00 a.m., an unannounced visit was made to the facility to conduct a complaint investigation of abuse. According to the facility's report the incident occurred February 14, 2013 and the Qualified Mental Retardation Professional (QMRP)/Registered Nurse (RN), the Administrator, and the Regional Center were made aware of the incident of bruising under Client 1 and Client 2's eyes.On February 22, 2013 at 4:30 p.m., during a review of Client 1?s health record ?Face sheet? it was revealed the client was admitted to the facility June 30, 1995, with the diagnosis of profound mental retardation. According to Client 1?s behavioral assessment, dated December 3, 2012, the client is non-verbal, and uses gestures and facial expressions to communicate her needs. Client 1 had a history of Pica (picking small pieces of trash from the floor and putting it into her mouth). She was able to follow directions and was able to dress and undress her. Client 1 was documented by the behaviorist to have had no inappropriate behaviors targeted for intervention.On February 22, 2013 at 4:50 p.m., during a review of Client 2's health record, face sheet, it was revealed the client was admitted to the facility February 24, 1993, with the diagnosis of severe mental retardation. According to Client 2's behavioral assessment dated December 3, 2012 the client had targeted behaviors that included self injurious behavior defined by the behaviorist as banging her head on the wall, stealing, defined as taking belonging from others and refusing to return them, and temper outbursts defined as yelling, screaming, and pacing.On February 22, 2013 at 10:22 a.m., during an interview with the day program staff, (Staff D) and a signed declaration, he stated, on February 14, 2012, Client 1 and 2 arrived to program with bruises. Client 1 arrived to the day program with a bruise under the left eye, and Client 2 had a bruise under the right eye that was reddish in color. Staff D stated and documented calling the facility?s Registered Nurse and informing her of both Client 1?s and 2?s bruises; however, the registered nurse allowed the client to remain at the day program. Staff D stated the clients often arrived to the program with bruises, and each time they have bruises they phone the staff at the facility and notify them of the concerns. Staff D stated he was concerned about the clients and proceeded to disclose documented evidence of the clients arriving to the day program with bruises.The following represents documentation from the day program regarding Client 1?s multiple bruises: 1. On February 14, 2012, Client 1 had a 2 inch bruise to the lower part of her left eye. 2. On February 22, 2012, Client 1 arrived to the day program with red marks on the right side of her chin. 3. On July 3, 2012, Client 1 arrived to the day program with redness to the right side of her cheek. 4. On July 23, 2012, Client 1 arrived to the day program with a bruise on the right arm and a finger cut 5. On September 17, 2012, Client 1 arrived to the day program with a quarter size bruise on the left upper part of the arm, greenish in color. The following represents documentation from the day program regarding Client 2?s multiple bruises: 1. On February 14, 2013, Client 2 arrived to the day program with a 2 inch bruise on the upper and lower part of her right eye. 2. On June 13, 2012, Client 2 arrived to the day program with a bruise on the right upper calf.3. On June 15, 2012, Client 2 arrived to the day program with bruise to the lower chin. 4. On June 28, 2012, Client 2 arrived to the day program with a bruise on the left upper leg.5. On July 18, 2012, Client 2 arrived to the day program with a bruise on the right thigh. 6. On August 8, 2012, Client 2 arrived to the day program with redness below her right and left eyes.7. On December 14, 2012, Client 2 arrived to the day program with a dime size bruise on the left side of her mouth; documentation also indicated the client did not have the bruise the day before. On February 22, 2013 at 4:00 p.m., during an interview and a signed declaration regarding the incident on February 14, 2013, Staff A (morning shift staff) stated he assisted Clients 1 and 2 to the bus and neither clients had bruises on their faces. On February 22, 2013 at 4:09 p.m., during an interview and a signed declaration regarding the incident on February 14, 2013, Staff B (morning shift staff) stated on February 14, 2013, she assisted Client 1 and 2 to the bus and neither client had bruises on the faces.On February 22, 2013 at 4:11 p.m., during an interview and a signed declaration regarding the incident on February 14, 2013, Staff M stated on February 14, 2013 at 2:30 p.m., Client 1 and 2 both exited the bus, and were both observed to have bruises under their eyes. Staff M documented not knowing how the bruises occurred.On February 22, 2013 at 4:15 p.m., during an interview and a signed declaration regarding the incident on February 14, 2013, Staff L stated on February 14, 2013, when she reported to work, she noted bruises under both Client and 2 eyes. She documented not knowing how the clients received the bruises.On February 23, 2013 at 2:11 p.m., during an interview with the bus driver he stated, he did not know how the bruises came about to both Clients 1 and 2. The bus driver stated when he retrieved the clients for program from the facility on February 14, 2013 the clients did not have bruises on their faces.On February 22, 2013 at 4:45 p.m., during an interview with the Registered Nurse she stated, on February 14, 2013 at 9 a.m., she received a call from the day program staff who informed her that both Clients 1 and 2 arrived to the day program with bruises on their faces. The RN stated at 4 p.m., when the clients returned from the day program, she examined the clients and found them both to have bruises on their faces. When asked why did the staff not immediately retrieve the client after being notified of the bruises, she stated she was not told to pick up the clients. The RN further stated, she was made aware of both Clients 1 and 2 arriving to the day program with bruises on different occasions and was sure the incidents did not happen in the facility which led her to believe the incidents must have taken place while the clients were transported to the day program on the bus. The RN stated she reported the incidents to the regional center but nothing has been done to secure Client 1 and 2's safety.Based on interview and record review the facility staff failed to: 1. Ensure the safety and the right to be free from harm of 2 clients who were reported to have bruises of unknown origins.Failure of the facility's administrative staff to follow up regarding bruises of unknown origin placed Client 1 and Client 2 at risk for abuse and harm. The above violation had a direct relationship to the health, safety and security of both clients. |
| 960000973 |
HARBOR HEALTH CARE, INC. - DESTINO DIVISION |
960011154 |
B |
05-Dec-14 |
H1IW11 |
3772 |
? 76918 Client's Rights Each client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550, Title 17. California Administrative Code. Welfare and Institution Code 4502 (b) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:(b) A right to dignity, privacy, and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports shall be provided in natural community settings.On May 23, 2014, an unannounced visit was made to the facility to conduct a fundamental survey.Based on observation, interview and record review, the facility staff failed to:1. Provide Clients 2 and 5 with privacy during morning care. Client 2 was admitted to the facility March 20, 2003 with diagnoses that included profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care), Down syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21) and was dependent on staff for activities of daily living. Client 5 was admitted to the facility January 2, 2003 with diagnoses that included profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care), Cerebral palsy (a group of disorders that effect a person's ability to move and maintain balance and posture related to the brains ability to control the body) and was dependent on staff for activities of daily living. During an observation on May 23, 2014, at 6:10 a.m., Staff A had Client 2 standing near her bed wearing her bra and panty while her roommate, Client 5 was in the room watching Staff A and Client 2. The bedroom door was wide open and there was no privacy curtain to keep her out of view and anyone who passed by the door had full view of Client 2.During an interview with Staff B, on May 23, 2013, at 6:15 a.m., she stated, "I have explained to her several times, she has to have a privacy screen up. You have to excuse us, we have two new staff."During an observation on May 23, 2014, at 6:30 a.m., Client 5 was standing near her bed in her pajamas with the bedroom door opened. Staff A assisted her removing her pajama pants then had her remove her underwear, revealing her genitalia to anyone who passed by the open door. There was no privacy curtain observed. During an interview with the qualified intellectual disability professional (QIDP), on May 24, 2014, at 2:35 p.m., she stated staff were supposed to close the doors or use a privacy curtain while changing, showering, and use a privacy screen between the clients. She stated clients have the right to privacy.The facility policy and procedure titled "Resident Rights" dated August 21, 2006, stipulated each client had the right to dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. The facility staff failed to provide Clients 2 and 5 with privacy during morning care. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 960001841 |
HOLY HILL HOME CARE/BELLFLOWER HOME |
960011774 |
B |
08-Oct-15 |
OF7H11 |
3090 |
Health & Safety Code 1265.5 (f) Upon the employment of a person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall submit fingerprint cards to the department for the purpose of obtaining criminal record check.On September 12, 2014 at 5:30 a.m., an unannounced visit was made to the facility, to conduct an annual Fundamental survey. The facility failed to obtain a criminal clearance (pre-employment background check) for a direct care staff (Staff A). Staff A?s fingerprints were not cleared through the Department of Justice, prior to allowing the staff to provide care to Clients 1, 2, 3, 4 and 5, which placed the clients at risk for potential harm.During an interview on September 13, 2014 at 11:05 a.m., Direct Care Staff A stated she has been working at the facility for seven years, on week-ends only.On September 14, 2014 at 2:00 p.m., a review of the employee files indicated Direct Care Staff A had no documented evidence of criminal clearance through the Department of Justice. The employee file of Direct Care Staff A only included chest x-ray result and W4 (tax form); most of the documents in her employee file, like her job application was missing. During an interview on September 14, 2014 at 2:15 p.m., the Administrator said Direct Care Staff A has been working at the facility for seven years and he does not know why her employee file was missing. He indicated Direct Care Staff A will obtain copy of the criminal clearance from the hospital?s Human Resources on Monday, September 15, 2014.On September 15, 2014 at 10:30 a.m., a call was made to the automated registry verification of the California Department of Justice for criminal background clearance of CNA (Certified Nursing Assistant) and ICF/DD (Intermediate Care Facility for the Developmentally Disabled) Direct Care Staff. The automated response system disclosed Direct Care Staff A has no record on file.On September 15, 2014 at 6:34 p.m., the Administrator sent a copy of the Department of Health and Human Services, Office of Inspector General, Fraud Prevention and Detection search result dated May 16, 2011, for Direct Care Staff A. The search indicated there were no results found for Staff A. The date of the search was four years after Direct Care Staff A started to work with clients at the facility.A review of the clients? medical records indicated Clients 1, 2, 3, 4, and 5 have diagnoses that include severe and profound intellectual disabilities. The clients depended on staff for assistance with activities of daily living (walking, transferring, eating, bathing, toileting). A review of the facility?s undated policy titled, ?Staff Orientation Procedure? indicated the staff are responsible to have fingerprint clearance.Failure of the administrative staff, to ensure Direct Care Staff A had criminal clearance, placed the facilities five clients at risk for potential harm and abuse. The above violation had a direct relationship to the safety and security of the clients residing in the facility. |
| 960000976 |
HARBOR HEALTH CARE, INC. - BRIAR DIVISION |
960013096 |
B |
29-Mar-17 |
XWRR11 |
4488 |
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 March 14, 2017 at 3:10 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI) regarding Staff L hitting Client 1.
The facility staff failed to:
Follow the facility?s policy regarding staff treatment of clients. Staff L hit Client 1 on the hand during snack time when Client 1 grabbed another client?s clothing protector.
During a review of the clinical record for Client 1 on March 14, 2017, the face sheet (identifying form) indicated Client 1 was admitted to the facility XXXXXXX 1985 with diagnoses of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care), visual and hearing loss, and hypothyroidism (thyroid gland does not make enough thyroid hormone, this condition is often called underactive thyroid). Client 1 was dependent on staff for self-care needs.
During an interview with the house leader (HL), on March 14, 2017 at 3:10 p.m., regarding the incident that occurred on Sunday March 12, 2017, she stated she received a text from Staff L who informed her that she was told to leave work early on Sunday. The HL stated that Staff S told the qualified intellectual disabilities professional (QIDP)-2 on call that she (Staff L) hit Client 1 on the hand. The HL stated Staff L admitted to her that she hit Client 1 on the hand because Client 1 grabbed Client 2?s clothing protector.
During an interview with Staff L, on March 15, 2017 at 8:30 a.m., she stated on March 12, 2017 she was working the evening shift and observed Client 1 attempting to remove Client 2's clothing protector while they were seated at the table eating snacks. Staff L stated she hit Client 1 on the wrist to stop her from grabbing Client 2's clothing protector. Staff L stated she made a mistake in hitting the client and did not think but reacted too fast.
During a telephone interview with Staff S, on March 16, 2017 at 7:53 a.m., she stated she worked on Sunday March 12, 2017. Staff S stated she observed Client 1 remove another client's clothing protector and sat down at the table. Staff S stated suddenly, Staff L entered the room and that was when she witnessed and heard Staff L slap Client 1 on her hand 4 times. Staff S stated she went into the back room with another client and called the QIDP on-call who immediately called Staff L and demanded she leave the premises.
During an interview and a review of a Special Incident Report (a documented detailed account of events) with the qualified intellectual disabilities professional (QIDP) 1, on March 14, 2017 at 4:10 p.m., he stated it was reported to him from QIDP 2 on call, that on Sunday March 12, 2017 at 3:35 p.m., Staff S observed and heard Staff L slap Client 1 on the wrist 4 times. QIDP 1 stated he interviewed Staff L on March 13, 2017 and she admitted to tapping Client 1 on the hand.
During an interview with the QIDP, on March 15, 2017 at 1:45 p.m., he stated the facility has a "Zero Tolerance Policy" for abuse and Staff L was terminated for striking Client 1.
A review of the facility?s policy and procedure undated titled ?Abuse,? indicated abuse is not tolerated.
The facility failed to follow the facility?s policy regarding staff treatment of clients. Staff L hit Client 1 on the hand during snack time when Client 1 grabbed Client 2?s clothing protector.
The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 630013124 |
Heart to Heart Health Care, Inc. |
980010567 |
B |
24-Mar-14 |
Z90211 |
5834 |
72527. Patient?s Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. (1) To be fully informed, as evidenced by the patient?s written acknowledgement prior to or at time of admission and during stay, of these rights and of all rules and regulations governing patient conduct.On 3/3/14, at 1:40 p.m., an unannounced visit was made to the facility to investigate an allegation the facility did not allow Patient 1 to return from a general acute care hospital (GACH) to the facility.Based on observation, interview and record review, the facility failed to ensure Patient 1?s right to be fully informed of the facility?s rules was not violated by failing to: 1. Honor a contract titled, ?Notice of Bed Hold,? signed by Family Member 1 and a staff member on admission and another one signed by Employee 3 on 12/19/13, which indicated the patient had the right to exercise a bed?hold for seven days should the patient be transferred to a GACH.Patient 1 was transferred to a GACH on 3/2/14, for evaluation of a swollen right leg. On the same day, 3/2/14, the GACH had a physician?s order for the patient to be discharged to the facility but the facility refused to readmit the patient. On 3/3/14, a review of the clinical record indicated Patient 1 was admitted to the facility on 5/15/13, with diagnoses including chronic respiratory failure, dependent on a ventilator (a machine designed to provide the mechanism of breathing for a patient who is unable to breath) and quadriplegia (inability to move/feel both hands and legs as a result of an injury). The current certification period was dated from 1/10/14 to 3/10/14. A form titled, ?Notice of Bed Hold Policy,? was signed and dated on admission (5/15/13) by Family Member 1 and a staff member (name not legible). A second form titled ?Notice of Bed Hold Policy,? with the patient?s name was signed by Employee 3 on 12/19/13. Both forms indicated it was to inform the patient of the right to exercise a bed-hold for seven (7) days should the patient be transferred to a GACH. According to the facility?s Nursing Flow Sheet dated 3/1/14, timed at 7 p.m. the patient?s right leg was swollen, the physician was notified and ordered to transfer the patient to a nearest GACH, but the patient refused to be transferred. On the same evening, 3/1/14, at 9 p.m., the note indicated the patient was shivering and the temperature was 102 degrees Fahrenheit (normal body temperature ranges from 97 to 99 degree Fahrenheit). On 3/2/14 at 2 a.m., the patient agreed to be transferred to a GACH. A review of the GACH Emergency Room record dated 3/2/14, timed at 2:20 a.m. indicated Patient 1?s had a duplex ultrasound (diagnostic test to check how the blood moves through veins and arteries) performed on the right leg and showed a venous thrombosis. On the same day, 3/2/14, at 12:29 p.m., a physician ordered the patient to be discharged from the acute hospital. A GACH nursing note dated 3/2/14, timed at 3:30 p.m., indicated the patient was given discharge instructions and the nurse (Employee 1) from the facility wanted the patient to have a MRSA (Methicillin-Resistant Staphylococcus Aureus ? contagious bacterial infection) result, but was told the test takes three days for the result). A GACH physician?s progress note dated 3/2/14, timed at 7:20 p.m. indicated the patient had absolutely no signs of acute or sub-acute infection, was cleared medically to be discharged, and the facility was required to take the patient back. A GACH laboratory test result of the right nares (nostril) dated 3/3/14 indicated not MRSA. On 3/3/14, at 2:10 p.m., during an interview, Employee 2 stated the patient returned to the facility on 3/2/14, at 4 p.m. (14 hours after the patient was transferred to the GACH) but the facility did not accept the patient because there was no evidence the patient was clear from the infectious disease MRSA. Employee 2 further explained that on 3/3/14, at 11 a.m. (after the patient was cleared from MRSA by the GACH) the facility decided not to accept Patient 1 from the GACH after a group meeting with all patients and staff was held. Employee 2 indicated all (patients and staff) agreed they did not want Patient 1 in the facility due to the patient?s verbally abusive behavior such as yelling and using foul language towards patients and staff) and his socially inappropriate behavior, such as spitting at staff, turning the call light on all day and night, and having loud music all night, disturbing other patients? sleep.On 3/3/14, at 3:30 p.m., a visit to Patient 1 was conducted at the GACH. The patient was observed lying in a bed and stated during an interview he wanted to go back to the facility.The facility failed to ensure Patient 1?s right to be fully informed of the facility?s rules was not violated by failing to: 1. Honor a contract titled, ?Notice of Bed Hold,? signed by Family Member 1 and a staff member on admission and another one signed by Employee 3 on 12/19/13, which indicated the patient had the right to exercise a bed?hold for seven days should the patient be transferred to a GACH.Patient 1 was transferred to a GACH on 3/2/14, for evaluation of a swollen right leg. On the same day, 3/2/14, the GACH had a physician?s order for the patient to be discharged to the facility but the facility refused to readmit the patient. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 910000049 |
Hyde Park Convalescent Hospital |
910013624 |
B |
17-Nov-17 |
E95Y11 |
6630 |
F223
?483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
The Department received an entity reported incident (ERI) that a resident (Resident 1) reported to the social services that his money was missing out of his account.
An unannounced investigation was conducted on 7/27/17.
Based on interview and record review, the facility failed to:
Ensure Residents 1 and 3 were free from fiduciary (pertaining to assets, such as cash) abuse.
This deficient practice resulted in Residents 1 and 3 having financial loss and expressing distress.
a. A review of Resident 1's Admission Face Sheet indicated the resident was a 64 year-old male who was admitted to the facility on 6/8/17. Resident 1's diagnoses included generalized muscle weakness, chronic obstructive pulmonary disease ([COPD] a disease that causes difficulty breathing), suicidal ideation (thoughts of committing suicide), and osteoarthritis (joint disease causing pain and stiffness).
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 7/24/17, indicated Resident 1 was able to understand and be understood by others. Resident 1's Brief Interview for Mental Status [(BIMS) cognition assessment score was 15 (a score of 9 and above means the resident was interviewable). According to the MDS, Resident 1 required assistance with activities of daily living (ADLs) and was receiving medications for depression (feelings of sadness) and anxiety (feeling of worry, nervousness, and unease).
On 7/27/17 at 5:20 p.m., during an interview, Resident 1 stated on 6/26/17, he gave his debit card (plastic payment card that can be used instead of cash) and pin number to Certified Nursing Assistant 1 (CNA 1) to go buy him some potato chips. Resident 1 stated CNA 1 returned to the facility with his debit card two hours later with no potato chips. During the interview, Resident 1 became emotional as he spoke, his voice quivered (shaking with a slight rapid motion) and he paused intermittently while stating, "I'm suffering here. I have no money." Resident 1 stated the facility's Social Services Designee (SSD) promised to reimburse the stolen money on 8/1/17.
During an interview, on 7/27/17, at 5:07 p.m., the Director of Staff Development (DSD) stated CNA 1 texted her a resignation letter on 6/30/17, before Resident 1's funds were discovered missing. The DSD stated Resident 1's missing funds were not discovered until 7/12/17, after Resident 1 asked the SSD to call the bank to check his account balance. The DSD stated she called CNA 1 to inquire if she had ever helped Resident 1 with his debit card and CNA 1 replied, "Why are you asking me." The DSD stated CNA 1 did not answer the question.
On 7/28/17, at 8:10 a.m., during a concurrent interview and record review, the SSD stated on 7/12/17, after calling Resident 1's bank, she was informed the balance was $137.00. The SSD stated Resident 1 stated he had more money than that in his account before he gave his debit card and pin number to CNA 1 on 6/26/17 to withdraw $200.00 for him. The SSD stated, Resident 1 stated CNA 1 was the only one who had his debit card and pin number. The SSD stated the bank transactions were done on different days and that a police report was filed regarding the alleged missing funds.
A review of Resident 1's bank transaction details were as follows:
1. 6/19/17 - four withdrawals totaling $209.00
2. 6/26/17 - nine withdrawals totaling $530.00
3. 6/27/17 - two withdrawals totaling $204.50
4. 7/3/17 - two withdrawals totaling $204.50
5. 7/5/17 - two withdrawals totaling $205.00
6. 7/10/17 - eight withdrawals totaling $618.00
For a sum total of $1971.00
On 7/28/17 at 8:45 p.m., during an interview, Resident 1 stated on 6/26/17 was the first time he had given his debit card to CNA 1 to buy cigarettes and chips. Resident 1 stated CNA 1 returned his card hours later and stated she did not have time to go to the store.
A review of CNA 1's employee file indicated CNA 1 was hired by the facility on 12/16/16. The file indicated CNA 1 had no prior disciplinary actions.
During an interview and concurrent record review, on 7/28/17, at 8:59 a.m., the Director of Nursing (DON) stated Resident 1 should be given his money back right away. A review of a letter addressed to the Department of Public Health from the facility's Administrator, dated 7/18/17, indicated Resident 1's money would be reimbursed once the investigation was completed. As of date, 7/28/17, Resident 1 had not been reimbursed of his money.
b. A review of Resident 3's Admission Face Sheet indicated the resident was a 76 year-old male who was admitted to the facility on 5/16/17. Resident 3's diagnoses included hypertension (high blood pressure), muscle weakness, and depression (feelings of sadness).
A review of Resident 3's MDS, dated 5/28/17, indicated the resident was able to understand and be understood by others.
During an interview, on 7/28/17, at 10:05 a.m., Resident 3 stated the SSD took him to the bank whenever he needed money and Resident 3 would send employees to buy cigarettes. Resident 3 stated his money had been stolen three times in the past and he suspected CNA 1 did it, but did not report the incidents to anyone in the facility. Resident 3 stated the employee (CNA 1) who stole the missing funds was fired.
On 7/28/17 at 10:19 a.m., during an interview, the DSD stated after an in-service training on 7/12/17, the staff was told to stop buying things for the residents.
A review of the facility's policy and procedure titled, "Abuse Prevention Program," with a revision date of 8/2006, indicated the residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. According to the policy, the facility would protect residents from abuse by anyone including facility staff, other residents, consultants and volunteers.
Upon further review, the facility did not have a policy regarding reimbursing resident funds.
The facility failed to:
Ensure Residents 1 and 3 were free from fiduciary (pertaining to assets, such as cash) abuse.
The above violation had a direct relationship to the health, safety, or security of the residents in the facility. |
| 910000048 |
HERITAGE REHABILITATION CENTER |
910013611 |
A |
13-Nov-17 |
C6QE11 |
7108 |
F323
483.25 (d) Accidents.
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(2) Each resident receives adequate supervision and assistance devices to prevent accidents
The Department received an Entity Reported Incident (ERI), dated 7/17/17 alleging a resident (Resident 1) was left unattended while in the bathroom, lost her balance and fell. Resident 1 sustained a non-displaced fracture (broken bone) to the cervical spine (bones of the neck), laceration (skin cut) to the left cheek (face) and left upper eye.
On 7/28/17 at 10 a.m., an unannounced complaint investigation was conducted.
Based on observation, interview and record review, the facility failed to adhere to Resident 1?s plan of care by not:
1. Providing adequate supervision and close monitoring to prevent accidents and injuries for Resident 1, who was assessed as a risk for falls
2. Utilizing the chair alarm device (Tab Alarm) to prevent falls.
3. Maintaining a safe environment for Resident 1 who was assessed as a high risk for falls and had a history of falls.
This deficient practice resulted in Resident 1 falling while in the bathroom unsupervised and sustained a non-displaced fracture (broken bone) to the cervical spine (bones of the neck), laceration (skin cut) to the left cheek (face) and left upper eye that required a 911 transfer to the hospital for wound closure, evaluation and treatment.
A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 1/17/17. Resident 1's diagnoses included chronic atrial fibrillation (irregular heartbeat), muscle atrophy (wasting of the muscle), difficulty in walking, lack of coordination, and abnormal posture.
A review of a "Fall Risk" assessment, dated 1/17/17, indicated Resident 1 was assessed as a high risk for fall, had problems balancing while standing and walking, decreased muscular coordination, jerking with an unstable gait when making turns and required the use of an assistive device while walking.
A review of Resident 1's plan of care titled, "High Risk for fall," dated 1/18/17, the listed staff interventions included to apply a tab alarm (a pressure alarm placed under specific body areas to detect movement for the purpose to prevent falls) while the resident was in the toilet and to monitor the resident's whereabouts at all time.
A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 5/2/17, indicated the resident required extensive assistance with transferring, toileting, bed mobility, dressing, and hygiene.
A review of the facility's undated investigation report indicated on 7/14/17 at approximately 4:30 p.m., the resident was assisted to the toilet by a Certified Nursing Assistant 1 (CNA 1) and CNA1 left Resident 1 unattended with the door ajar. CNA 1 was assisting another resident in the adjacent room when she heard a banging noise and went and found the resident on the floor bleeding from the left facial area. The report indicated first aid was provided and 911 was called for further evaluation and treatment. Resident 1 returned to the facility on 7/15/17 with the diagnoses of C-spine fracture, facial laceration with swelling and sutures.
A review of the general acute care hospitals (GACH) history and physical (H/P), dated 7/18/17 (four days after the resident fell), indicated the resident was transferred to the GACH after a fall with cervical spine fracture, facial laceration requiring four sutures (used to close open wounds) to the left temple area. The H/P indicated the resident was required to wear the neck collar at all times and to follow up with the neurosurgeon (a physician who specializes in the care and treatment of the nervous system, the brain and/or spine) in six weeks.
A review of the GACH?s Emergency room (ER) notes indicated Resident 1 presented to the ER on 7/14/17, due to a mechanical ground level fall, falling forward striking her forehead. Resident 1 complained of neck, back and shoulder pain and had a pain level of 9 on a scale of 1-10 (1 = mild, 5 = moderate, 10 = severe). Resident 1 received 650 mg of Tylenol (pain medication) for pain. Resident 1 had a head/c-spine [neck area] Computerized Tomography Scan ([CT scan] detailed x-ray pictures of parts and the structures inside your body), which indicated a non-displaced fracture through the base of the cervical spine. According to the GACH?s discharge summary, Resident 1 was evaluated by the neuro-surgeon and diagnosed with a non-displaced cervical spine fracture. The resident was required to wear a cervical collar at all times for six weeks and required a follow-up evaluation by the Neurosurgeon.
During an interview on 7/28/17 at 12:10 p.m., Resident 1 stated she fell in bathroom after attempting to stand from the commode and did not call for the staff's assistance. The resident stated as a result of the fall she has to wear a neck collar (used to stabilize a neck fracture) due to the fall.
On 7/28/17 at 1:30 p.m., during an interview, Certified Nurse Assistant 1 (CNA1) stated she assisted Resident 1 to the bathroom, but was called by another resident for help. CNA 1 stated she left Resident 1 and gave her the call button and instructed the resident to call when she was ready to get off the commode. CNA 1 stated while assisting the resident in the next room, she heard Resident 1 call for help and fall. CNA 1 stated she accompanied the Charge Nurse into the resident's bathroom and observed Resident 1 lying on her left side on the bathroom floor bleeding from the left side of the eye and cheek. CNA 1 stated that she did not apply the Tab Alarm to Resident 1 while she was on the toilet, as per the resident's plan of care and should have.
During an interview on 8/14/17 at 4:46 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 should not have been left alone in the bathroom because she had the tendency of getting up without calling for help, and all the CNAs who had provided care for the resident were aware of the behavior.
A review of the facility's undated policy titled "Falls-Clinical Protocol," indicated frail elderly individuals are often at a greater risk for serious adverse consequences of falls, thus the interventions should be followed.
The facility failed to adhere to Resident?s 1 plan of care by not:
1. Providing adequate supervision and close monitoring to prevent accidents and injuries for Resident 1, who was assessed as a risk for falls
2. Utilizing the chair alarm device (Tab Alarm) to prevent falls.
3. Maintaining a safe environment for Resident 1 who was assessed as a high risk for falls and had a history of falls.
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. |
| 250001502 |
HEMET VALLEY HEALTHCARE CENTER |
250013563 |
AA |
1-Nov-17 |
DF9O11 |
14254 |
Health & Safety Code Section 1424(c)
Class "AA" violations are violations that meet the criteria for a class "A" violation and that the state department determines to have been a direct proximate cause of death of a patient or resident of a long-term health care facility. Class "A" are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom.
Title 42 of the Code of Federal Regulations ?483.24 Quality of Life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
22 CCR ? 72311. Nursing Service - General.
(a) Nursing service shall include, but not be limited to, 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.
(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.
22 CCR ? 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.
Based on observation, interview, and record review, the Department determined that the facility failed to provide the necessary care to maintain Resident A's highest practicable physical, mental, and psychosocial well-being by failing to ensure fall interventions (and nursing assessments regarding anti-anxiety and sleeping medications) were implemented (in accordance with Resident A's fall risk assessment).
This failure resulted in the resident falling and striking his head, which required acute care hospitalization. Resident A subsequently died three days after his fall due to an intracranial hemorrhage (bleeding inside the skull) extending from the right frontal lobe to the right temporal lobe.
An unannounced visit to the facility on December 20, 2016 and a review of Resident A's medical record were conducted. The review revealed that Resident A was admitted to the facility on December 7, 2016, with diagnoses of chronic obstructive pulmonary disease (a progressive lung disease) and depression.
A review of Resident A's Morse Fall Scale (a numerical scale indicating a resident's risk for falls), dated December 7, 2016 at 10:31 p.m., indicated that Resident A's Morse Fall Scale score was 65. Resident A's Morse Fall Scale score of greater than 46 placed Resident A at a high risk of falling.
Resident A's Morse Fall Scale dated December 7, 2016 further indicated the following fall precautions were initiated: "Wheels locked bed in low position, call system in reach, keep floor clear of clutter, offer frequent toileting."
According to the facility's Policy and Procedure entitled, "Fall Prevention/Risk Assessment," revised date April 4, 2016, fall precautions are safety interventions initiated to decrease the potential for a resident's exposure to harm.
A review of the medical record indicated Resident A was prescribed Plavix and aspirin, both blood thinners. In addition, Resident A was receiving Xanax and Lorazepam (both anti-anxiety medications) A review of comments printed on the resident's medication administration record indicated Xanax and Lorazepam increase the risk of cognitive impairment, falls, and fractures.
Review of the "Medication Administration Record" (MAR) indicated Restoril 15 milligrams (mg) was prescribed for Resident A on December 7, 2016, at bedtime as needed for insomnia. A review of comments printed on the physician's order for Resident A, dated December 7, 2016, reflected: "Caution, Geriatric or debilitated patients: Decrease dose to 7.5 mg. po (orally) 30 minutes before bedtime. The risk of over sedation, dizziness, confusion, ataxia (lack of muscle coordination) and falls increases significantly with larger doses of benzodiazepines (a class of drugs to treat anxiety and insomnia) in elderly or debilitated patients."
The MAR indicated Norco 5/325 mg. was ordered for Resident A on December 9, 2016, to be given orally every six hours as needed for pain. Norco, according to the U.S. National Library of Medicine (2016) is a narcotic pain medication with side effects including lightheadedness, dizziness and fainting.
A review of the physician document entitled "Progress Notes," dated December 12, 2016, at 3 p.m., indicated a physician order for Resident A as "Fall precautions." The "Fall Risk Evaluation" completed by Charge Nurse (CN) 1, on December 7, 2016, at 10:31 p.m., indicated Resident A was a "High Risk" for falls. Fall interventions initiated included: "Wheels locked, bed in low position, call system in reach, keep floor clear of clutter, offer frequent toileting."
The MAR indicated, on December 12, 2016 at 5:06 p.m., Resident A received the medication Lorazepam 0.5 mg.
The MAR also indicated, on December 12, 2016 at 7:20 p.m., Resident A received the medication Xanax 0.5 mg.
A review of the Nursing Progress Notes, dated December 12, 2016 at 11:27 p.m., indicated that on December 12, 2016at 7:45 p.m., Resident A had an unwitnessed fall and was found on the floor next to the bed.
The "Daily Focus Assessment Report," dated December 12, 2016 at 7:45 p.m., indicated, "Post Fall Interventions, Physical body assessment, call light in reach, direct observation by staff, frequent orientation, wheels locked, bed position low, call system in reach."
The Nursing Progress Notes, dated December 12, 2016 at 11:27 p.m., further indicated, "Pt's [Resident A's] bed alarm turned on and all staff made aware".
The medical record revealed that Resident A continued to receive Lorazepam on December 13, 14, 15, and 16, 2016. The medical record failed to include documentation that indicated Resident A was reassessed to include monitoring his response to the Lorazepam or Xanax after his fall on December 12, 2016. Further, there was no update to the resident's care plan to include the addition of any additional fall interventions after the first fall.
A review of the Morse Fall Scale assessment dated December 14, 2016, at 5 p.m., indicated Resident A was assessed as being a high fall risk with a score of 95. Fall interventions in place were documented as: "Wheels locked bed position low, call system in reach." Though Resident A's Morse Fall Scale score had increased from 65 to 95, there were fewer fall interventions documented on December 14, 2016 than were previously documented on December 7, 2016.
A review of the Nursing Progress Notes dated December 15, 2016, at 11 p.m., (three days after Resident A's first fall), indicated Resident A sustained a second fall, and was found on the floor next to the bed with a laceration to his left forehead. The MAR reflected that prior to the resident's second fall on December 15, 2016, Resident A received Lorazepam 0.5 mg. at 6:31 p.m. (five hours and nine minutes prior to falling), Norco 5/325 mg. at 9:03 p.m. (two hours and 57 minutes prior to falling), and Restoril 15 mg, at 9:04 p.m., (two hours, 56 minutes) prior to his fall at 11 p.m. that night.
A review of the medical record failed to show documentation that indicated Resident A was reassessed for his response to the medications Lorazepam or Restoril following the December 15, 2016 fall.
Resident A was transferred to the Emergency Room (ER) following his fall on December 15, 2016, at 11:35 p.m. The ER record indicated Resident A had a laceration above his left eyebrow which was repaired with steri-strips (surgical tape).
The medical record indicated Resident A returned to the facility on December 16, at 2:15 a.m. The document entitled, "Progress Notes Reported," indicated on December 16, 2016, at 6:05 a.m., Resident A began to "shake down the left side and 911 was called." The document indicated the resident was transported to the ER on December 16, 2016, at 6:25 a.m. The acute care facility record indicated that Resident A, who was unconscious upon arrival, underwent numerous tests, including a cat scan of the brain. The CAT scan results, dated December 16, 2016, at 8 a.m., indicated there was a "Large acute hemorrhage" on the right side of Resident A's brain with a "mass effect." The record indicated Resident A was admitted to the medical/surgical unit on December 16, 2016, at 2:25 p.m. with the diagnosis of "Persistent seizure disorder, intracranial hemorrhage." The progress notes from the acute care facility indicated Resident A died on December 18, 2016, at 2:35 p.m., from an intracranial hemorrhage, three days following his fall at the facility on December 15, 2016.
An interview was conducted with the facility Charge Nurse (CN 1) on December 20, 2016, at 11 a.m. During the interview, CN 1 stated that the certified nurse assistant (CNA 1) assigned to Resident A on December 15, 2016, at 7 a.m., told the CN 1 that after CNA 1 changed Resident A's linen on December 15, 2016, prior to the patient's second fall, she forgot to put the bed alarm back on.
An interview was conducted with the Interim Director of Nurses (IDON) on December 20, 2016, at 10:35 a.m. The IDON stated that during her interview with CNA 1 on December 15, 2016, CNA 1 told the IDON that she had forgotten to turn the bed alarm on after CNA 1 was finished changing the resident's linen. The IDON stated that a care plan to address Resident A's high risk of fall was not initiated when the resident's fall risk assessment indicated he was at high risk for falls. The IDON further stated that there were no additional interventions implemented for Resident A after his initial fall on December 12, 2016.
A review of the facility policy entitled, "Fall Prevention/Risk Assessment (Revised/Reviewed 4/2016)," indicated: "Purpose: To identify residents at risk for falls and to establish guidelines for prevention of resident falls. Goals: To apply fall prevention interventions to all residents admitted to the facility to ensure a proactive, standardized approach to resident safety that decreases the potential for a resident's exposure to harm. 3. The licensed Nurse will institute a plan of care that identifies the fall risk score and the interventions for that fall risk score. 5. C. A High (fall) Risk- score of 46 and above."
The policy and procedure further indicated "Required documentation: 2. Patient care plan. Procedures: 2.The following will be considered as possible interventions based upon the resident's Morse Risk Score, and resultant risk status:
Low Risk-score 0-24
-Assess fall risk status on admission, quarterly and any time the resident fall status changes.
-Discuss fall prevention measures with the patient (use call light for assistance with transfers, not to get out of bed without assistance, etc.)
-Call light in reach and working
-Answer call light in a timely manner
-Reposition patient at least every two hours and more often as needed.
-Offer bed pan at least every two hours or take to the bathroom as per patient's request.
-Monitor patient's response to medication-notify MD as appropriate.
-Encourage to sit up in wheel chair or attend activity of his/her choice
-If necessary/appropriate, place patient closer to the station for better monitoring.
-Notify MD/Family of any falls or injury.
B. Moderate Risk-Score 25-45
-Apply all interventions for low risk status, and:
-provide assistance with toileting, hydration, and repositioning at least every two hours and more often as necessary.
-provide resident with yellow non-skid slipper/socks is ambulating.
C. High Risk -Score 46 and above:
-Apply all interventions for low and moderate risk status, and:
-Obtain order for low bed if appropriate for patient's diagnosis.
-If tab monitor is ordered and is not working, consult with DON or Nurse Manager for alternative fall prevention method.
-Refer to rehab/DT for more assessment.
-Fall risk arm band.
-Fall risk sign posted by door."
Resident A died December 18, 2016, three days after his second fall at the facility.
A telephone interview with a Representative from the County Coroner's office was conducted on December 22, 2016. The Representative stated the cause of death for Resident A was from an intracranial hemorrhage due to blunt force trauma.
The facility failed to ensure additional nursing interventions and adequate monitoring were implemented for Resident A, assessed as being at a high risk for falls, after he sustained an initial fall at the facility. Following the initial fall, Resident A's fall interventions were not increased, but rather they were decreased, even though Resident A's Morse Fall Scale score went from 65 to 95. The facility also failed to reassess Resident A for his response to multiple drugs following both falls. This failure to reassess was both a failure to adequately monitor the resident's drug regimen and a failure to implement the facility's fall prevention policy and procedure, which called for monitoring a resident's response to medication. This failure to implement the facility's fall prevention policy and procedure resulted in the resident falling from his bed a second time, striking his head.
In violation of the above-cited licensing standards, the facility also failed to provide Resident A with necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with comprehensive assessment and plan of care. The facility also failed to ensure Resident A's drug regimen was free from unnecessary drugs by failing to adequately monitor the use of those drugs.
These violations were the direct proximate cause of Resident A's death. |
| 930000575 |
HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF |
930013650 |
A |
29-Nov-17 |
JI0S11 |
9151 |
?483.25(c) Mobility.
(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident?s clinical condition demonstrates that a reduction in range of motion is unavoidable.
On October 14, 2017 during recertification survey Resident 17?s range of motion (ROM - full movement to a joint) was investigated.
Based on observation, interview, and record review, the facility failed to ensure a resident who enters the facility without limited ROM does not experience reduction in ROM unless it is unavoidable due to the medical condition, including:
1. Failure to refer Resident 17 to rehabilitation therapy for evaluation upon re-admission to the facility on November 23, 2016, to ensure ROM exercises were provided to prevent functional decline in ROM.
2. Failure to evaluate Resident 17's need for Restorative Nursing Assistant (RNA - nursing assistant program that help residents maintain any progress made after therapy intervention to maintain their function) services for ROM when Resident 17 was identified with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to left wrist and fingers on March 30, 2017 and a splint to the left hand was ordered.
3. Failure to implement the physician?s order by not providing Resident 17 with passive ROM (PROM - amount of motion at a given joint when moved by another person) to the left wrist, hand and fingers before application of a splint (a device used for support or immobilization of a limb).
4. Failure to implement the Joint Mobility/ROM Care Plan dated June 1, 2017, for Resident 17's high risk for developing contractures due to physical limitations by not referring to rehabilitation staff for evaluation of any changes in the ROM status.
As a result, Resident 17 developed contractures to the left wrist/hand/fingers and losing the ability to flex the right fingers (unable to close the hand) requiring a special call light button. Resident 17 was no longer able to type on a keyboard.
On October 14, 2017 at 6:20 p.m., during an interview, Resident 17 stated he had not been receiving physical therapy (PT) for his hands and fingers and could not extend his left fingers and could not close his right hand (unable to flex the fingers). Resident 17 was observed wearing a splint to his left hand. Resident 17 stated he received a new call light the day prior (October 13, 2017), because he could not press on the call light button to call for assistance.
A review of the Admission Record indicated Resident 17 was admitted to the facility on August 19, 2016 and re-admitted on November 23, 2016, with diagnoses including muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), systemic lupus erythematosus (disease where the body's immune system mistakenly attacks healthy cells), and multiple sclerosis (a disease where the immune system attacks the protective sheath that covers nerve fibers and causes communication problems between your brain and the rest of the body).
A review of the Joint Mobility Assessment dated August 24, 2016, indicated left and right finger extensions were within functional limits (WFL).
Upon re-admission on November 23, 2016, there was no documented order for RNA to provide Resident 17 with ROM exercises to the hands and wrists.
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated November 29, 2016 and September 1, 2017 indicated Resident 17 was cognitive (memory and thinking skills) impaired and required total care. The MDS indicated Resident 17 had functional limitation in the ROM to both sides of the upper and lower extremities (hands, arms, legs and feet).
A review of the Physician's Order dated March 30, 2017 indicated Restorative Nursing Assistant (RNA) to apply left wrist and fingers flexion splints two to four hours, five times a week. Release and re-apply every two hours for 15 minutes. Check skin integrity and circulation for contracture management.
Further review of the physician?s orders indicated no documented order for RNA to provide Resident 17 with ROM exercises to the right and left hands.
A review of the Joint Mobility/ROM Care Plan with a review date of June 1, 2017, for Resident 17's high risk for developing contractures due to physical limitations, indicated as goals to minimize further decline in ROM and maintain the current joint mobility status. The interventions included assessing Resident 17's joint mobility status when giving care, referring to rehabilitation staff if any decline, and applying a left wrist and hand finger flexion splint as ordered.
A review of the Physician's Order dated August 24, 2017 indicated RNA to apply left wrist, hand and fingers splint three to six hours after passive ROM (PROM). Monitor for circulation and skin integrity before and after splint application.
There was no evidence the order for RNA to provide Resident 17 with PROM exercises was implemented.
A review of the Interdisciplinary Team (IDT - several disciplines of the health care team including the resident and/or representative) Conference Notes dated September 6, 2017, indicated Resident 17's responsible party attended the meeting and requested PT evaluation.
A review of the Joint Mobility Assessment dated September 14, 2017, indicated the ROM of the left finger extension had moderate (50% to 75%) limitation and the right finger extension had minimal (75% to 100%) limitation. There was no documented order for RNA to provide Resident 17 with ROM exercises. There was no documented evaluation by PT as requested by Resident 17's responsible party on September 6, 2017.
On October 15, 2017 at 2:07 p.m., during an interview with RNAs 1 and 2, RNA 1 stated RNAs were not providing PROM exercises to Resident 17 because there was no order for it. RNA 2 confirmed there was no order for PROM.
On October 16, 2017 at 4:45 p.m. during record review with the MDS Nurse, no order for PROM exercise was found. The MDS Nurse confirmed there was no ROM exercises ordered since re-admission on November 23, 2016 or on March 30, 2017 when the resident was identified with left hand contractures.
On October 15, 2017 at 5:10 p.m., during a telephone interview, Physical Therapist 1 (PT 1) stated Resident 17 was in and out of the hospital and a new order had to be placed upon re-entry but this was not done. PT 1 explained WFL (within functional limits) indicated the fingers were able to spread out and there were no obvious or visible contractures. Moderate limitation meant, "Half of what the full ROM should be."
On October 16, 2017 at 5:45 p.m., during an interview, the Administrator stated when Resident 17 was re-admitted on November 16, 2016, and PT was not notified of the need to evaluate Resident 17.
On October 16, 2017 at 6 p.m., during a follow-up interview, Resident 17 stated he used to type on a keyboard before he was admitted to the facility, but now he could not, which made him feel bad.
A review of facility's policy and procedures titled "Inpatient Physical Therapy Evaluation" revised on April 2016 and approved on May 25, 2016 indicated physical therapy evaluation shall document the resident's ability to complete tasks that included range of motion and gross strength: assessment of active/passive range of motion all extremities, neck and trick, joint mobility, soft tissue limitations and indicate joints with limitations outside normal functional limits.
The facility failed to ensure a resident who enters the facility without limited ROM does not experience reduction in ROM unless it is unavoidable due to the medical condition, including:
1. Failure to refer Resident 17 to rehabilitation therapy for evaluation upon re-admission to the facility on November 23, 2016, to ensure ROM exercises were provided to prevent functional decline in ROM.
2. Failure to evaluate Resident 17's need for RNA services for ROM when Resident 17 was identified with contractures to the left wrist and fingers on March 30, 2017 and a splint to the left hand was ordered.
3. Failure to implement the physician?s order by not providing Resident 17 with passive PROM to the left wrist, hand and fingers before application of a splint.
4. Failure to implement the Joint Mobility/ROM Care Plan dated June 1, 2017, for Resident 17's high risk for developing contractures due to physical limitations by not referring to rehabilitation staff for evaluation of any changes in the ROM status.
As a result, Resident 17 developed contractures to the left wrist/hand/fingers and losing the ability to flex the right fingers requiring a special call light button. Resident 17 was no longer able to type on a keyboard.
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 17. |
| 930000575 |
HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF |
930013651 |
B |
29-Nov-17 |
JI0S11 |
11792 |
?483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
On October 12, 2017 during recertification survey, the facility?s infection control program was investigated. There were 18 residents of the total census of 76 residents in the facility on contact isolation precautions (measures to help stop spread of germs from person to person) for ESBL producing bacteria [extended spectrum beta (รก) lactamase, an enzyme produced by many species of bacteria which destroy one or more antibiotics] infection, and for Elizabethkingia meningoseptica infection (rare and unusual gram-negative aerobic bacteria found in fresh water, salt water, or soil that is causing fulminant hospital infections and exhibit intrinsic resistance for most antimicrobial agents).
Based on observation, interview, and record review, the facility failed to implement infection control precautions to prevent the spread of infections, including:
1. Failure to ensure Resident 7, who had no ESBL infection, was not placed in the same room with Resident 6 who had ESBL infection.
2. Failure to ensure Certified Nursing Assistants 1, 3 and 4 (CNAs 1, 3, and 4), and Respiratory Therapist 3 (RT 3) implemented the Centers for Disease Control and Prevention (CDC) Guidelines on isolation by contaminating environmental surfaces such as privacy curtains, door handles, oxygen equipment, and suction devices, when touching them with soiled gloves.
3. Failure to ensure RT 4 and LVN 4 implemented the facility?s policy and procedure on Isolation Precautions - Infection Prevention and CDC Guidelines on Hand hygiene.
As a result, all 76 residents the facility, staff, and visitors were placed at a high risk of cross contamination and spread of infections.
a. On October 12, 2017, at 6:25 p.m., during the initial tour of the facility, accompanied by LVN 1, Resident 6?s two-bed room was observed. Resident 6 was sharing the room with Resident 7. LVN 1 stated Resident 6 was on contact isolation precautions due to ESBL producing bacterium infection of the sputum (mixture of saliva and mucus coughed up from the respiratory tract).
At the time of the observation, CNA 4 was providing care to Resident 6 wearing disposable gloves. CNA 4 pulled the privacy curtain with the contaminated gloves she provided care to Resident 6.
A review of the Admission Record, indicated Resident 6 was admitted to the facility on April 24, 2017, with diagnoses including ESBL, tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and ventilator (machine that supports breathing) dependence.
The Minimum Data Set (MDS - standardized assessment and care planning tool) dated July 4, 2017 indicated Resident 6 had severe cognitive (ability to think, remember, reason, understand, and learn) impairment and was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene.
A review of the Physician's Order dated September 27, 2017, indicated contact isolation for Resident 6 due ESBL infection in the sputum. Resident 6 could share the room with other resident with same infection.
A review of the Admission Record of Resident 7 (Resident 6's roommate) indicated an admission dated September 6, 2017, with diagnoses including chronic respiratory failure, tracheostomy, and ventilator dependence.
The MDS dated September 16, 2017, indicated Resident 7 had severe cognitive impairment and was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene.
There was not documented evidence Resident 7 had ESBL infection.
On October 14, 2017, at 12 p.m., during an interview, the Clinical Coordinator (CC) and the Infection Preventionist (IP) both stated Resident 7 should not be sharing the room with Resident 6 because Resident 7 did not have an infection. Both CC and IP stated staff must observe strict hand hygiene before and after resident care. CC stated the physician was not notified of Resident 7's potential exposure to ESBL bacteria.
According to the CDC website https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html:
-During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surface Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination.
-Determine patient placement based on the following principles: ?Route(s) of transmission of the known or suspected infectious agent
?Risk factors for transmission in the infected patient
?Availability of single-patient rooms
?Patient options for room-sharing [e.g., cohorting (imposed grouping of people) patients with the same infection].
?Avoid placing patients on Contact Precautions in the same room with patients who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission (e.g., those who are immunocompromised, have open wounds, or have anticipated prolonged lengths of stay).
-In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis, balancing infection risks to other patients in the room, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized patient.
b. Resident 8 was admitted to the facility on February 19, 2017, with diagnoses including head trauma and anoxic (lack of oxygen) encephalopathy (damage of the brain functions).
The MDS dated July 20, 2017, indicated Resident 8 was in vegetative (without apparent brain activity or responsiveness) state and was totally dependent on staff for care.
On October 15, 2017 at 8 a.m., CNA 3 was observed, wearing gloves, providing incontinent care to Resident 8 who had a bowel movement. CNA 3, wearing the same gloves, disconnected Resident 8's cool aerosol oxygen device. CNA 3 wearing the same gloves, wheeled Resident 8 to the shower room, touched the shower door knob, and showered Resident 8. CNA 3, using the same gloves, touched the restroom door handle, wheeled Resident 8 back to the room, pulled the privacy curtain transferred Resident 8 back in bed, and wiped dry Resident 8.
On October 15, 2017, at 9 a.m., during an interview, CNA 3 stated she should have changed gloves after providing incontinence care and washed her hands before disconnecting and reconnected Resident 8 from and to the cool aerosol oxygen therapy.
A review of the facility's policy and procedure titled, "Hand hygiene," dated August 24, 2017, indicated to perform hand washing with plain soap and a hand rub (if hands not soiled) before and after routine patient (resident) care activities and non-patient care activities.
c. Resident 15 was admitted to the facility on May 30, 2017, with diagnoses including chronic respiratory failure, tracheostomy and ventilator dependence.
The MDS dated September 9, 2017, indicated Resident 15 consistently and reasonably made independent decisions regarding tasks of daily life.
On October 14, 2017, at 1:35 p.m., Resident 15 requested for his tracheostomy to be suctioned. RT 4 was observed with a cell phone on her hand, proceeded to get gloves, dropped one, picked it up from the floor, discarded it, put on gloves, and then suctioned Resident 15. RT 4 did not wash hands after using the cell phone, prior to put on the gloves.
After finishing the procedure, at 1:40 p.m., during an interview, RT 4 stated she should have performed hand hygiene before resident care to prevent spread of infection.
A review of the facility's policy and procedure titled, "Isolation Precautions Infection Prevention," dated March 22, 2017, indicated contact precautions in addition to standard precautions are used on patients with multi-drug (several medications) resistant organisms such as extended-spectrum beta lactamase (ESBL) producing organisms. Hand hygiene must be performed by either a 15-20 second hand wash or by use of a alcohol hand sanitizer between all patients contacts, after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by these fluids.
d. Resident 18 was admitted to the facility on September 29, 2017, with diagnoses not limited to chronic respiratory failure and ventilator dependence.
The MDS dated October 9, 2017, indicated Resident 18 had severe cognitive impairment and required total care.
During an observation on October 14, 2017, at 6:15 a.m., CNA 1 was wearing gloves, picked up a small blue plastic sheet on the floor and performed partial bed-bath on Resident 18. CNA 1, wearing the same gloves, picked up clean linen from a clean linen cart.
During an observation on October 14, 2017, at 6:30 a.m., RT 3 was observed suctioning Resident 18 with gloves on, and proceeded to turn off Resident 18's suction machine wearing the same gloves.
A review of Resident 18's Laboratory Detail dated October 10, 2017, indicated Resident 18's sputum was positive for ESBL infection.
e. During wound care observation on October 14, 2017, at 8:50 a.m., LVN 4 was observed putting on partially (just over the arms) a coat apron with thumb hole sleeves and done gloves on both hands. LVN 4 removed the right hand glove, pumped and quickly rubbed hand gel sanitizer with the right hand for less than five seconds. LVN 4 was further observed removing both gloves, quickly applying and rubbing hand gel sanitizer on both hands for less than 10 seconds, wear gloves and cover the wound with a dressing.
A review of the Admission Record, indicated Resident 23 was admitted to the facility on May 30, 2017, with diagnoses including chronic respiratory failure and right trochanter (hip bone) pressure sore (localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear).
The MDS dated June 27, 2017, indicated Resident 23 had severe cognitive impairment and required total care.
On October 14, 2017, at 11:15 a.m., during an interview, LVN 4 acknowledged it was important to remove both gloves and pull back the apron to thoroughly perform hand hygiene.
According to the CDC Guidelines on Hand hygiene, when using alcohol-based hand sanitizer:
?Put product on hands and rub hands together
?Cover all surfaces until hands feel dry
?This should take around 20 seconds.
The facility failed to implement infection control precautions to prevent the spread of infections, including:
1. Failure to ensure Resident 7, who had no ESBL infection, was not placed in the same room with Resident 6 who had ESBL infection.
2. Failure to ensure CNAs 1, 3 and 4 and Respiratory Therapist 3 did not contaminate environmental surfaces such as privacy curtains, door handles, oxygen equipment, and suction devices, when touching them with soiled gloves.
3. Failure to ensure RT 4 and LVN 4 implemented the facility?s policy and procedure on Isolation Precautions - Infection Prevention and CDC Guidelines on Hand hygiene.
As a result, all 76 residents the facility, staff, and visitors were placed at a high risk of cross contamination and spread of infections.
The above violation had a direct or immediate relationship to the health, safety, and security of all residents in the facility. |
| 960000984 |
HARBOR HEALTH CARE, INC. - BAYLOR DIVISION |
960013661 |
B |
1-Dec-17 |
D3EI11 |
7397 |
California Code of Regulations, Title 22, ?76880
(b) There shall be comprehensive treatment services for all clients which include:
(1) Provision for dental treatment.
(2) A system that will assure annual reexamination in accordance with the client?s needs.
On August 30, 2017 at 6:10 AM, an unannounced annual Extended Recertification Survey was conducted.
The facility administration failed to:
Provide comprehensive diagnostic and dental treatment services for Client 4 by dental professionals on an annual basis, as needed, and as recommended by the dentist. This deficient practice had the potential for the client to experience a decline in oral health and have diseases including oral cancer.
A review of the clinical record for Client 4 was reviewed on 9/1/17. The face sheet indicated Client 4 had a diagnosis of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care).
A review of the Physician's Orders for Client 4, dated 8/1/17, indicated he has a diagnosis of adult periodontal disease. There was an order for dental evaluation annually. The original order was 2/3/14.
According to the National Institute of Dental and Craniofacial Research (or NIDCR, an institute of the National Institutes of Health, or NIH) publication, titled "Periodontal (Gum) Disease: Causes, Symptoms, and Treatments," NIH Publication No. 13-1142, the NIDCR indicates periodontal disease is gum disease. The publication indicates, "Periodontal diseases range from simple gum inflammation to serious disease that results in major damage to the soft tissue and bone that support the teeth. In the worst cases, teeth are lost." The publication indicates periodontal diseases begins with gingivitis (inflammation of the gums) and can advance to the severe form of the disease known as periodontitis (inflammation around the tooth). The publication indicates, "In Periodontitis, gums pull away from teeth and form spaces ... that become infected ... If not treated, the bones, gums, and tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed." The publication indicates periodontitis is treated between deep cleaning (performed by a dental professional such as a dentist, periodontist, or dental hygienist), medications, and even surgical interventions. The Publication also indicates to "Visit the dentist routinely for a check-up and professional cleaning."
A review of the dental records for Client 4 indicated the last time Client 4 received dental services was on 8/13/14. The dentist indicated Client 4 has periodontal disease (IV), gingival hyperplasia (overgrowth of the gums), and gingivitis on all tissue. The dentist indicated Client 4 should return in 6 months.
A review of Client 4's nurses notes, dated 6/30/17, indicated the last dental visit was on 8/13/14. The nurse findings from the last dental visit on 8/13/14 indicated "no dental caries (tooth decay)."
During an interview with the Qualified Intellectual Disability Professional (QIDP)/Administrator and Registered Nurse (RN), on 9/1/17, at 11:54 AM, the QIDP stated there were no further dental exams or services provided to the clients in the facility since the last exam indicated in their dental records.
During an interview with the QIDP and RN, on 9/1/17, at 2:06 PM, the RN stated there currently were no dental providers. She stated the facility has been unable to find a dentist to provide services and anesthesia since the clients last saw the dentist. The QIDP stated the facility does not have termination letters from the dentist used by the facility to indicate services would no longer be provided to the clients.
During an interview with the QIDP, on 9/1/17, at 3:42 PM, he was asked when was the last time the clients had received any dental services from a dentist and dental hygienist. The QIDP stated, "Whatever you see, that is the last." He confirmed there were no visits by a dentist or dental hygienist since the date the dentist last saw each client as indicated in their dental records.
The facility's policy and procedure titled "Dental Services" dated 8/21/06, indicated, "Dental services are those services provided by dental staff for the purpose of maintaining daily oral health through preventive measures and for the correction of existing oral diseases ... There shall be comprehensive diagnostic services for all clients which include a complete extra-oral and intra-oral examination, utilizing all diagnostic aids necessary to properly evaluate the client's oral condition ... (1) There shall be comprehensive treatment services for all clients which includes: (a) Provision for dental treatment. (b) A system that will assure that each client is re-examined at specified intervals in accordance with his/her needs, but at least annually. (2) There shall be education and training through a dental hygiene program to maintain oral health conducted twice each year which includes: (a) Giving information regarding nutrition and diet control measures to staff. (b) Instruction of clients and staff in each living unit in proper methods of oral hygiene. (c) Instructions of parents or authorized representatives in the maintenance of proper oral hygiene, where appropriate (as in the case of clients leaving the facility) ... There shall be available qualified dental personnel, and necessary supporting staff to carry out the dental services program. "
According to the NIDCR publication, titled "Practical Oral Care for People With Intellectual Disability," NIH Publication No. 09-5194, updated 11/3/14, the NIDCR indicates, "In general, people with intellectual disability have poorer health and oral hygiene than those without this condition. Data indicate that people who have intellectual disability have more untreated caries and a higher prevalence of gingivitis [inflammation of the gums] and periodontal diseases than the general population."
According to the NIDCR publication, titled "Dental Care Every Day: A Caregiver's Guide" NIH Publication No. 12-5191, dated February 2012, the NIDCR indicates, "Dental care is just as important to your client's health and daily routine as taking medications and getting physical exercise. A healthy mouth helps people eat well, avoid pain and tooth loss, and feel good about themselves." The NIDCR's publication indicates there are three steps to a healthy mouth by brushing teeth every day, flossing every day, and visiting a dentist regularly. The publication indicated, "Your client should have regular dental appointments. Professional cleanings are just as important as brushing and flossing every day. Regular examinations can identify problems before they cause unnecessary pain."
This was a repeat deficiency from the 5/20/16 recertification survey, included in the recertification survey dated 9/1/17.
The facility administration failed to provide comprehensive diagnostic and dental treatment services for Client 4 by dental professionals on an annual basis, as needed, and as recommended by the dentist. This deficient practice had the potential for the client to experience a decline in oral health and have diseases including oral cancer.
The above violation had a direct relationship to the health, safety and security of the clients residing in the facility. |
| 960000984 |
HARBOR HEALTH CARE, INC. - BAYLOR DIVISION |
960013663 |
B |
1-Dec-17 |
D3EI11 |
7221 |
California Code of Regulations, Title 22, ?76880
(b) There shall be comprehensive treatment services for all clients which include:
(1) Provision for dental treatment.
(2) A system that will assure annual reexamination in accordance with the client?s needs.
On August 30, 2017 at 6:10 AM, an unannounced annual Extended Recertification Survey was conducted.
The facility administration failed to:
Provide comprehensive diagnostic and dental treatment services for Client 3 by dental professionals on an annual basis, as needed, and as recommended by the dentist. This deficient practice had the potential for the client to experience a decline in oral health and have diseases including oral cancer.
The clinical record for Client 3 was reviewed on 9/1/17. The face sheet indicated Client 3 had a diagnosis of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care).
A review of the Physician's Orders for Client 3, dated 8/1/17, indicated dental evaluation annually and as needed. The original order was dated 6/9/00 and recapped yearly.
A review of the dental records for Client 3 indicated the last time Client 3 received dental services was on 8/13/14. The dentist indicated Client 3 needs an extraction for one of his teeth and a root canal for one of his teeth. The dentist indicated Client 3 should return in 6 months.
According to an article published by Mouth Healthy, a resource from the American Dental Association (ADA), titled "extractions," the article indicates, "An extraction means to have a tooth removed, usually because of disease, trauma, or crowding."
According to the American Association of Endodontists (AAE), in an article titled "Root Canals," the article indicates a root canal is an endodontic treatment, where the inside of a tooth is treated. Root canals are performed to treat the soft tissue within the tooth, known as pulp, becomes infected or inflamed. The article indicates, "If pulp inflammation or infection is left untreated, it can cause pain or lead to an abscess." During a root canal, the article indicates the dental professional drills into the tooth's root canal where the pulp is located, removes the affected pulp, cleans the tooth, and then fills the space. The dentist will then apply a crown or use a different tooth restoration practice to restore the tooth to a normal, functional level on another visit after the root canal is filled.
Client 3's Nursing Assessment Update, dated 7/26/17, indicated under Physical/Medical Review, Client 3 last had dental services on 8/13/14. The nurse indicated the recommendation from the dental visit on 8/13/14 included an extraction of Client 3's teeth.
During an interview with the Qualified Intellectual Disability Professional (QIDP)/Administrator and Registered Nurse (RN), on 9/1/17, at 11:54 AM, the QIDP stated there were no further dental exams or services provided to the clients since the last exam indicated in their dental records.
During an interview with the QIDP and RN, on 9/1/17, at 2:06 PM, the RN stated there currently were no dental providers. She stated the facility has been unable to find a dentist to provide services and anesthesia since the clients last saw the dentist. The QIDP stated the facility does not have termination letters from the dentist to indicate services would no longer be provided to the clients.
During an interview with the QIDP, on 9/1/17, at 3:42 PM, he was asked when was the last time the clients have received any dental services from a dentist and dental hygienist. The QIDP stated, "Whatever you see, that is the last." He confirmed there were no visits by a dentist or dental hygienist since the date the dentist last saw each client as indicated in their dental records.
The facility's policy and procedure titled "Dental Services" dated 8/21/06, indicated, "Dental services are those services provided by dental staff for the purpose of maintaining daily oral health through preventive measures and for the correction of existing oral diseases ... There shall be comprehensive diagnostic services for all clients which include a complete extra-oral and intra-oral examination, utilizing all diagnostic aids necessary to properly evaluate the client's oral condition ... (1) There shall be comprehensive treatment services for all clients which includes: (a) Provision for dental treatment. (b) A system that will assure that each client is re-examined at specified intervals in accordance with his/her needs, but at least annually. (2) There shall be education and training through a dental hygiene program to maintain oral health conducted twice each year which includes: (a) Giving information regarding nutrition and diet control measures to staff. (b) Instruction of clients and staff in each living unit in proper methods of oral hygiene. (c) Instructions of parents or authorized representatives in the maintenance of proper oral hygiene, where appropriate (as in the case of clients leaving the facility) ... There shall be available qualified dental personnel, and necessary supporting staff to carry out the dental services program. "
According to the National Institute of Dental and Craniofacial Research (or NIDCR, an institute of the National Institutes of Health, or NIH) publication, titled "Practical Oral Care for People With Intellectual Disability," NIH Publication No. 09-5194, updated 11/3/14, the NIDCR indicates, "In general, people with intellectual disability have poorer health and oral hygiene than those without this condition. Data indicate that people who have intellectual disability have more untreated caries and a higher prevalence of gingivitis [inflammation of the gums] and periodontal diseases than the general population."
According to the NIDCR publication, titled "Dental Care Every Day: A Caregiver's Guide" NIH Publication No. 12-5191, dated February 2012, the NIDCR indicates, "Dental care is just as important to your client's health and daily routine as taking medications and getting physical exercise. A healthy mouth helps people eat well, avoid pain and tooth loss, and feel good about themselves." The NIDCR's publication indicates there are three steps to a healthy mouth by brushing teeth every day, flossing every day, and visiting a dentist regularly. The publication indicated, "Your client should have regular dental appointments. Professional cleanings are just as important as brushing and flossing every day. Regular examinations can identify problems before they cause unnecessary pain."
This was a repeat deficiency from the 5/20/16 recertification survey, included in the recertification survey dated 9/1/17.
The facility administration failed to provide comprehensive diagnostic and dental treatment services for Client 3 by dental professionals on an annual basis, as needed, and as recommended by the dentist. This deficient practice had the potential for the client to experience a decline in oral health and have diseases including oral cancer.
The above violation had a direct relationship to the health, safety and security of the clients residing in the facility. |
| 960000984 |
HARBOR HEALTH CARE, INC. - BAYLOR DIVISION |
960013659 |
B |
1-Dec-17 |
D3EI11 |
6314 |
California Code of Regulations, Title 22, ?76880
(b) There shall be comprehensive treatment services for all clients which include:
(1) Provision for dental treatment.
(2) A system that will assure annual reexamination in accordance with the client?s needs.
On August 30, 2017 at 6:10 AM, an unannounced annual Extended Recertification Survey was conducted.
The facility administration failed to:
Provide comprehensive diagnostic and dental treatment services for Client 1 by dental professionals on an annual basis, as needed, and as recommended by the dentist. This deficient practice had the potential for the client to experience a decline in oral health and have diseases including oral cancer.
The clinical record for Client 1 was reviewed on 9/1/17. The face sheet indicated Client 1 had a diagnosis of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care) and seizure disorder (a brain disorder involving repeated, spontaneous movements of the body).
A review of the Physician's Orders for Client 1, dated 6/6/17, indicated, "Dental evaluation annually." The original order was dated 11/19/86.
A review of the dental records for Client 1 indicated the last dental services were on 10/16/14. Client 1 was provided with general anesthesia (a procedure using medications that places clients in a sedative, sleep-like state, to perform dental procedures or other surgeries) for x-rays, a dental exam, cleaning, and root planning (a procedure to help reattach the gums to the tooth after deep cleaning). The dentist indicated Client 1 should return in 6 months.
A review of Client 1's Nursing Assessment Update, dated 8/21/17, indicated under Physical/Medical Review, Client 1 last had dental services on 10/16/14.
During an interview with the Qualified Intellectual Disability Professional (QIDP)/Administrator and Registered Nurse (RN), on 9/1/17, at 11:54 AM, the QIDP stated there were no further dental exams or services provided to the clients in the facility since the last exams indicated in their dental records.
During an interview with the QIDP and RN, on 9/1/17, at 2:06 PM, the RN stated there currently were no dental providers. She stated the facility has been unable to find a dentist to provide services and anesthesia since the clients last saw the dentist. The QIDP stated the facility does not have termination letters from the dentist used by the facility to indicate services will no longer be provided to the clients.
During an interview with the QIDP, on 9/1/17, at 3:42 PM, he was asked when was the last time the clients had received any dental services from a dentist and dental hygienist. The QIDP stated, "Whatever you see, that is the last." He confirmed there were no visits by a dentist or dental hygienist since the date the dentist last saw each client as indicated in their dental records.
The facility's policy and procedure titled "Dental Services" dated 8/21/06, indicated, "Dental services are those services provided by dental staff for the purpose of maintaining daily oral health through preventive measures and for the correction of existing oral diseases ... There shall be comprehensive diagnostic services for all clients which include a complete extra-oral and intra-oral examination, utilizing all diagnostic aids necessary to properly evaluate the client's oral condition ... (1) There shall be comprehensive treatment services for all clients which includes: (a) Provision for dental treatment. (b) A system that will assure that each client is re-examined at specified intervals in accordance with his/her needs, but at least annually. (2) There shall be education and training through a dental hygiene program to maintain oral health conducted twice each year which includes: (a) Giving information regarding nutrition and diet control measures to staff. (b) Instruction of clients and staff in each living unit in proper methods of oral hygiene. (c) Instructions of parents or authorized representatives in the maintenance of proper oral hygiene, where appropriate (as in the case of clients leaving the facility) ... There shall be available qualified dental personnel, and necessary supporting staff to carry out the dental services program. "
According to the National Institute of Dental and Craniofacial Research (or NIDCR, an institute of the National Institutes of Health, or NIH) publication, titled "Practical Oral Care for People With Intellectual Disability," NIH Publication No. 09-5194, updated 11/3/14, the NIDCR indicates, "In general, people with intellectual disability have poorer health and oral hygiene than those without this condition. Data indicate that people who have intellectual disability have more untreated caries and a higher prevalence of gingivitis [inflammation of the gums] and periodontal diseases than the general population."
According to the NIDCR publication, titled "Dental Care Every Day: A Caregiver's Guide" NIH Publication No. 12-5191, dated February 2012, the NIDCR indicates, "Dental care is just as important to your client's health and daily routine as taking medications and getting physical exercise. A healthy mouth helps people eat well, avoid pain and tooth loss, and feel good about themselves." The NIDCR's publication indicates there are three steps to a healthy mouth by brushing teeth every day, flossing every day, and visiting a dentist regularly. The publication indicated, "Your client should have regular dental appointments. Professional cleanings are just as important as brushing and flossing every day. Regular examinations can identify problems before they cause unnecessary pain."
This was a repeat deficiency from the 5/20/16 recertification survey, included in the recertification survey dated 9/1/17.
The facility administration failed to provide comprehensive diagnostic and dental treatment services for Client 1 by dental professionals on an annual basis, as needed, and as recommended by the dentist. This deficient practice had the potential for the client to experience a decline in oral health and have diseases including oral cancer.
The above violation had a direct relationship to the health, safety and security of the clients residing in the facility. |