| 100000999 |
Jean Martin Home #3 |
030009751 |
B |
22-Feb-13 |
LBQI11 |
6463 |
Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.The following citation was written as a result of an unannounced visit and investigation of an anonymous complaint #CA00200718 regarding an allegation of inappropriate contact between a staff person and client who was a resident in the facility. The complaint was initiated on 9/3/09 with additional on-site investigation on 9/4/09.The Department determined that the facility failed to report an allegation of possible abuse when several staff expressed concern about observed "inappropriate interactions" between Client A and Direct Care Staff 1 (DCS1).Review of Client A's admitting information sheet indicated she was admitted to the facility on 6/1/01 with diagnoses that included "Moderate to Severe MR [Mental Retardation]...Multiple anomalies Syndrome, [and] Pervasive Developmental Disorder." Review of a Functional Assessment dated 8/28/08 indicated for "Social Development-Sexual: [Client A] does not display appropriate sexual behaviors...will masturbate in public." In addition, the assessment indicated Client A was not-verbal, legally blind and has sensorineural deafness (decreased hearing or hearing loss that occurs from damage to the inner ear, the nerve that runs from the ear to the brain, or the brain.)AS 2 (Administrative Staff @) was interviewed on 9/3/09 at 4:20 p.m. regarding the allegation of inappropriate contact between a staff person and a resident in the facility. AS 2 stated "Three different people told me about it...they were not comfortable with Client A sitting on DCS 1's lap." AS 2 was asked if she had completed an investigation or reported the allegation to CDPH when she was made aware of the allegation. She stated she had not and said "I didn't think it was abuse... [Client A] was overly affectionate and [DCS 1] needed training." There was no documented evidence the concern had been investigated after the initial allegation had been reported to the facility.AS 2 was interviewed again on 9/4/09 at 8:35 a.m. She stated Client A had a history of "grinding on people" (inappropriate sexual behavior) and described that DCS 1 would sit down on the couch and Client A would "straddle his leg." When asked when she was told about the concern, AS 2 was unable to give an exact date but thought it may have been toward the end of 2008. AS 2 stated, "I never actually caught it." She also stated DCS 1 was moved to another facility in January, 2009 and had recently returned to the current facility in July, 2009. AS 1 was interviewed on 9/4/09 at approximately 9 a.m. he stated he had heard staff say that DCS 1 was inappropriately interacting with Client A and that he told DCS 1 that allowing a client to sit on his lap was inappropriate and told him to re-direct her in the future. AS 1 could not recall when he was made aware of the concern; In addition, AS 1 stated, "Maybe I did blow it by not reporting and doing an investigation..."DCS 3 was interviewed on 9/4/09 at 9:45 a.m. and stated that she had heard a rumor that DCS 1 had "messed with [Client A] sexually." When asked if there were any changes in Client A's behavior recently, DCS 3 stated Client A had a new problem of "peeing the bed" which started one month ago.DCS 4 was interviewed on 9/4/09 at 10:50 a.m. and was asked if she had witnessed interactions between Client A and DCS 1. DCS 4 stated she had worked with DCS 1 on August 29, 2009 and that she observed DCS 1 seated in a recliner with Client A kneeling on the floor with her head "buried in his lap" as he stroked her hair for approximately 2-3 minutes. DCS 4 stated she felt uncomfortable about it but didn't say anything. She also stated she was surprised at how affectionate they were and that DCS 1 held hands with Client A.DCS 1 was interviewed on 9/4/09 at 11:15 a.m. regarding recent observed interactions with Client A. DCS 1 stated he did recall that on Saturday, August 29, 2009 Client A rested her head above his knees as he stroked her hair and said that the scenario had occurred twice that Saturday. When asked why he allowed Client A to place her head on his lap as he stroked her hair, he stated, "I assumed that's what she wanted...maybe she had a headache."AS 1 was interviewed on 9/8/09 at 12:20 p.m. he stated, "No, he shouldn't have let her put her head on his lap." Review of an investigation, completed by the facility on 9/6/09 (after the initiation of the anonymous complaint submitted to the Department), indicated staff had discussed concerns with AS 2 about "inappropriate interaction" between DCS 1 and Client A. The report indicated specifically that it "May not look good" when Client A stands over DCS 1 "straddling her legs or sitting on his lap."Review of DCS 1's personnel file indicated no evidence of an investigation of the allegation regarding inappropriate interactions with Client A when first reported to the Administrator months ago. In addition, there was no documented evidence that DCS 1 had received additional training regarding appropriate interaction between staff and residents in the facility.Review of the facility's undated policy and procedure titled "PREVENTION OF ABUSE, NEGLECT, AND MISTREATMENT, indicated "The purpose of these procedures is to ensure prompt detection of abuse, neglect, or mistreatment; provide appropriate and thorough investigation; provide resolution for any occurrence of abuse, neglect, or mistreatment; and ensure reporting as specified in federal, state and local law and regulation..." The procedure indicated "...in the event that an employee has been accused of abuse/neglect/mistreatment, the administrator AND on additional management personnel are to be informed ...The accused employee is suspended from working directly with individuals receiving services, pending the completed investigation...Any incident of alleged or suspected abuse...will be reported to the local Department of Health Services Licensing and Certification Office by telephone within 24 hours with a written report sent within 5 days in accordance with H&S code section 1418.91. (a)." This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 050001098 |
JADE HOME |
050009092 |
B |
04-Dec-13 |
5X2M11 |
5346 |
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 persons 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 finds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect.The facility did not comply with the above regulation by failing to ensure Client A was free from unnecessary restraint using duct tape applied tightly to Client A's left arm, impairing circulation and necessitating a trip to the emergency room. The facility failed to follow their own policy and ensure the restraint was applied only upon order of a physician, and that it was not used for the staff convenience in lieu of an effective behavioral program. Client A was a 60 year old woman admitted to the facility with diagnoses including profound mental retardation and psychosis (mental and intellectual disability requiring lifelong pervasive support). Client A was ambulatory and needed staff assistance to complete activities of daily living (toileting, bathing and eating). Client A made her needs known by "grumbling" verbalizations and sometimes displayed temper outbursts, pulling her own hair and picking at her skin, predominantly the skin on the left arm which had white scars on the wrist and forearm.The facility tracked episodes of picking at her skin, resulting in scratches and open areas, documenting five incidents observed from June through August 2010, which increased to 33 episodes in September 2010 and doubled to 67 episodes in October 2010.The written health plan (nursing care plan) for Client A's skin integrity included "Keep her skin clean and dry. Staff will apply bandages/ointment treatment as ordered by MD. Staff will do daily body checks with shower/bath and report any changes of condition to RN (registered nurse)." On October 25, 2010, the RN noted several scratched areas of skin, including a "Quarter size" open area of skin with a "Yellowish center" (indicating possible infection) on Client A's left arm. On October 26, 2010, the physician diagnosed Client A with "Cellulitis" (a bacterial infection of the skin and soft tissue). Client A's physician prescribed an oral antibiotic and ordered warm compresses be applied to her left arm.On November 4, 2010, the RN documented that a wound on Client A's upper arm was "Healing" and a wound on the lower arm was "Open." The RN noted the open wound was covered with a dressing and Client A was dressed in long sleeves (to discourage picking at the skin). On November 8, 2010, at 8:40 a.m., when Client A arrived at her day program, staff observed duct tape (an adhesive tape usually made of polyethylene, fabric mesh and adhesive, used for repair, constructive and industrial applications) wrapped tightly around the client's left arm, covering more than six inches of her forearm, from wrist to elbow. There were small tears in about 50 per cent of the duct tape, exposing the fibrous layer of tape, indicative of Client A's efforts to try to remove the tape. Client A's left hand, distal to the application of the duct tape, and her forearm, directly above the duct tape, was swollen as a result of constriction by the tape. The tape was stuck to Client A's skin and there was an odor coming from the taped area of Client A's arm. The day program staff sent Client A to a hospital emergency room by ambulance at 10:15 a.m. On October 17, 2011 at 10 a.m., the qualified mental retardation professional (QMRP) indicated the facility manager had applied the duct tape to Client A's arm because Client A was picking at the scab on her wrist. The QMRP confirmed the facility manager had not notified the RN, QMRP or physician, that Client A was "Picking at her skin" and did not consult a licensed professional before using duct tape to cover Client A's arm thus restraining Client A from removing the bandage. The undated facility policy titled, "Task 2 Compliance System to Prevent Abuse/Neglect/Mistreatment," indicated, "Physical restraints will only be used in an emergency situation. Physical restraints are only used upon the order of the physician. If physical restraints are required, a plan of action will be included in the client's Individual Service Plan.Physical restraints are never to be used in lieu of a behavioral management program or for the convenience of the staff."The facility failed to ensure Client A was free from harm, abuse and unnecessary restraint of duct tape applied tightly to her left arm, impairing circulation and necessitating a trip to the emergency room. The facility failed to follow their own policy and ensure the restraint was applied only upon order of a physician, and that it was not used for the staff convenience in lieu of an effective behavioral program. The facility's failure had a direct or immediate relationship to the health, safety or security of the client. |
| 050001098 |
JADE HOME |
050012858 |
B |
3-Feb-17 |
0FN611 |
2050 |
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 a complaint investigation, the Department determined the facility was in violation of the above statute by its failure to report to the Department immediately or within 24 hours an allegation of abuse, when the facility did not report an allegation of abuse for 44 days to the Department.
On September 27, 2016, the Department received a complaint regarding the alleged employee-to-client abuse at the facility.
Record review revealed, Client 1 was a 26 year old male, admitted to the facility on XXXXXXX 2013 with diagnoses including autism, Tourette syndrome (physical -motor tics and at least one vocal-phonic tic), and mood disorder.
During an interview on September 28, 2016 at 1:40 p.m., the day program director (DPD) confirmed on August 15, 2016, Client 1's day program staff reported an allegation of sexual abuse by an employee to Client 1. DPD confirmed, on the same day, August 15, 2016, the allegation of sexual abuse was reported to the executive director (ED) and qualified intellectual disability professional (QIDP) of the facility.
During an interview on September 29, 2016, at 3 p.m., the ED confirmed the facility became aware of the allegation of abuse on August 15, 2016 and conducted an investigation but did not notify the Department or other agencies of the allegation. As of September 27, 2016, 44 days after the facility became aware of the allegation, the facility had not reported the alleged employee to client sexual abuse to the Department.
The facility should know or should have known, they have to report to the Department immediately, or within 24 hours, the allegation of sexual abuse by an employee towards a Client 1 but failed to do so. |
| 110000621 |
Jerold Phelps Community Hospital D/P SNF |
110011473 |
A |
22-Oct-15 |
GOIW11 |
8483 |
F280 ?483.10(d)(3) ?483.20(k)(2) Right to Participate Planning Care-Revise Cp The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment. The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment. The facility violated the above regulation by failing to review and revise the care plan related to swallowing difficulties for Resident 5 who experienced four incidents within the past year of airway obstruction by inhaled material. This failure resulted in four episodes of choking for Resident 5, leading to Resident 5's death due to aspiration (inhaling an item or liquid into the lungs, which impairs normal breathing). Record review on 1/13/15 revealed Resident 5 was admitted to the distinct part skilled nursing facility (SNF). Resident 5's diagnoses included gastroesophageal reflux disease (stomach contents backing up into the esophagus), obesity, and a history of obstructive sleep apnea (blocking of the airway due to relaxation of neck structures during sleep). A nurse's note, dated 12/6/14 at 6:30 p.m., revealed, "At 1445 [2:45 p.m.], a...resident alerted an RN that...resident needed help." The note revealed staff entered the activity room and found Resident 5 "sitting in a chair at the table and appeared in grave distress." The author of the note, Licensed Nurse A, documented that he initiated the Heimlich maneuver [firm, rapid pressure applied below the breast bone to force air out of the lungs and dislodge food or other objects], but was unsuccessful "dislodging unknown object that was obstructing airway." Resident 5's face turned blue, her body went limp, and breath sounds could not be heard. Resident 5 was moved to the floor and her airway suctioned. Staff from the adjacent emergency room, including a physician, responded to the situation. Resident 5 resumed spontaneous breathing and was transferred by gurney to the acute care emergency department. Review of the Emergency Room Report, History of Present Illness, dated 12/6/14, revealed, "Patient had been in the activity room and had choked on pieces of solid food. She was only to eat pureed food [ground or mashed to a soft creamy consistency]; however, there were chunks of crackers in her teeth." Due to Resident 5's Advanced Directive specifying Do Not Resuscitate, aggressive interventions were not initiated. Resident 5's condition deteriorated, and she died at 7 p.m. The emergency room physician listed diagnoses as 1. Aspiration, 2. Aspiration pneumonia, 3. Cardiopulmonary arrest. During a telephone interview on 1/5/15 at 1:50 p.m., a representative of the county medical examiner's office stated the death certificate listed cardiopulmonary arrest secondary to aspiration pneumonia due to food aspiration as the cause of death, with dementia as a contributing factor. Review of Resident 5's record revealed prior incidents of airway obstruction:A nurse's note, dated 4/5/14 at 6 p.m., revealed, "At 1740 [5:40 p.m.], [Resident 5] was sitting [at] bedside eating her dinner....had a mouthful of food and began to choke....Proceeded to administer approx [approximately] 30 abdominal thrusts and resident started to expel chunks of food...." A nurse's note, dated 10/27/14 at 5:40 p.m., revealed, "Called to room by CNA [certified nursing assistant], R [Resident 5] choking, CNA performed Keimlich (sic), airway open. Continued [with] dinner [without] problems." A nurse's note, dated 11/4/14 at 5:35 p.m., revealed, "Called into room by CNA, appears to be choking, unable to speak, gargling noises, Heimlich maneuver (sic) done multiple [times]. Airway cleared...Lungs cleer (sic) to auscultation (listening to breath sounds with a stethoscope)." A physician's order, dated 11/12/14, indicated "Schedule an ST Eval [speech therapy evaluation] for possible diet change (due to swallowing problems and some choking.)" During a telephone interview on 1/21/15 at 2:50 p.m., SNF Nurse Manager stated she was aware of Resident 5's earlier choking episodes. SNF Nurse Manager stated she knew Resident 5 had trouble with some foods like rice "but if it had sauce on it, it wouldn't stick in her throat," and she spoke to the dietary department about it. SNF Nurse Manager stated she recalled trying to contact a speech therapist for evaluation of Resident 5's swallowing, but "had trouble reaching her." A request was made for documentation that the physician order for evaluation by speech therapy was carried out, or that any follow-up related to speech therapy or interventions related to prior incidents of choking was performed. None was provided. During an interview on 4/23/15 at 3:30 p.m., Licensed Nurse B stated she was among staff who responded to Resident 5's choking on 12/6/14. Licensed Nurse B stated Resident 5 had a cup of "what looked like tea" with a few "particles" in front of her in the activity room when she began choking. Licensed Nurse B stated Resident 5 would eat anything put in front of her, including non-food items like flowers and napkins. During an interview on 4/21/15 at 12:30 p.m., Resident 1 stated it was "freaky" the way Resident 5 would eat anything she could get her hands on. Resident 1 stated Resident 5 would ask others for food or take food from their trays. Resident 1 stated he was in the activity room with Resident 5 when Resident 5 choked, and he called for staff to help. He could not recall additional details like what she might have been eating at the time or where she acquired it. Review of Resident 5's care plan Nutritional Status, revised and rewritten on 4/10/12, indicated her need for a mechanically altered diet and her "Attempts to take food when available and accessible (sic)." It did not address her swallowing difficulties or identify her aspiration risk, nor did it reflect reassessment of the resident and changes to the care plan after three previous episodes of choking. The care plan did not reflect any evaluation and treatment by a speech therapist or interventions related to prior incidents of choking, food seeking behavior or consumption of non-food items.Review of facility policy and procedure "Resident Care Planning," dated 10/12/04, "...evaluation and re-assessment of the resident care plan will occur on a continuing basis as needed until the resident is discharged...The resident care plan is a current, written, and personalized plan for the individual resident, which indicates the care he/she needs, how it can best be accomplished and the goals which the interdisciplinary team collectively hope to help the resident achieve." Therefore, the facility failed to review and revise the care plan related to swallowing difficulties for Resident 5 who experienced four incidents within the past year of airway obstruction by inhaled material. This failure resulted in four episodes of choking for Resident 5, leading to Resident 5's death due to aspiration (inhaling an item or liquid into the lungs, which impairs normal breathing). The violation of the regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 110000621 |
Jerold Phelps Community Hospital D/P SNF |
110011925 |
B |
20-Jan-16 |
C8TE11 |
3617 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of staff to resident (Resident 1) abuse to the California Department of Public Health, (CDPH) within twenty four hours. Facility staff was aware of Resident 1's allegation on 11/10/14 and did not report the incident to CDPH until 11/13/14. This failure potentially exposed the resident(s) to risk of further abuse. During a telephone interview, on 11/13/14 at 4:30 p.m., the Skilled Nursing Facility Manager (SNF Manager) stated evening staff reported to her on the morning of 11/10/14 they heard Resident 1 shouting at Licensed Nurse A the prior evening. The SNF Manager stated when she asked Resident 1 what had happened, Resident 1 stated Licensed Nurse A got mad when he joked about Licensed Staff A's girlfriend. Resident 1 described Licensed Staff A as "vicious" and was afraid Licensed Nurse A would "poison" him. The facility's written report of the incident, dated 11/13/14, received via fax on 11/14/15, documented Resident 1 reported Licensed Nurse A "got in my face" and Resident 1 reported he was "scared" of Licensed Nurse A. Clinical records for Resident 1 were reviewed on 11/20/14. Resident 1 had diagnoses that included dementia, anxiety and depression. The most recent Minimum Data Set, a resident assessment tool, dated 8/14/14, indicated Resident 1 had decreased long term memory. Review of Nurse's Notes, dated 11/9/14 at 6:30 p.m., written by Licensed Nurse A, indicated Licensed Nurse A's documentation described Resident 1's questions about his girlfriend as "reflecting animosity" which Licensed Nurse A addressed by direct confrontation, telling Resident 1 he did not appreciate his girlfriend being called "old lady."During an interview, on 11/20/14 at noon, Resident 1 stated he had asked Licensed Nurse A, "How's your old lady?" Resident 1 stated Licensed Nurse A had leaned on the table and "Got in my face." Resident 1 stated Licensed Nurse A asked him, "Did you ever have an old lady?" Resident 1 stated he thought Licensed Nurse A was going to hit him so he told Licensed Nurse A to get out of the room. Resident 1 stated, "I lost my control and yelled at the top of my lungs." Review of facility documentation, "Investigation of [Resident 1] Incident" (undated) indicated the SNF Manager was informed of the incident on 11/10/14 at 0700. The documentation noted CDPH, (California Department of Public Health), and the Ombudsman were notified on 11/13/14. Review, on 11/20/14 at 12:30 p.m., of the facility policy titled, "Prevention and/or Reporting Resident Abuse" indicated notice of alleged abuse would be made to the "Department of Health Services, Licensing and Certification (California Department of Public Health) division as soon as possible after that occurrence of the incident or when the facility learns of the abuse." The facility failed to report an allegation of staff to resident (Resident 1) abuse to California Department of Public Health, (CDPH) within twenty four hours. The State Licensing and Certification Agency (CDPH) received a telephoned report of the alleged incident on 11/13/14 during which the SNF Manager stated staff had notified her of the incident the morning of 11/10/14. A written report of the incident arrived at the Agency on 11/14/14 via facsimile. |
| 630011499 |
Joyce Eisenberg Keefer Medical Center |
930009378 |
A |
03-Jul-12 |
ZOV311 |
7664 |
CFR 483.25(h) FREE OF ACCIDENT HAZARD/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on record review and interview, the facility failed to provide a two person assist during transfers for Resident 1, who had a right leg amputation (removal of a right leg) and required a two person assist with transfers. On September 11, 2011 at 4:30 p.m., a certified nursing assistant (CNA 1) transferred Resident 1 from the bathroom (toilet seat) back to the wheelchair without another person assist. Resident 1 fell during transfer and sustained a left leg fracture (broken left leg). The resident required a transfer to the general acute care hospital for surgical intervention. Findings: On November 4, 2011, an unannounced visit was made to the facility to conduct a complaint investigation of Resident 1's fall incident resulting in a fracture.Resident 1's medical record was reviewed on November 4, 2011. The admission record indicated the resident was a 90 year old, re-admitted to the facility on April 23, 2010, with diagnoses of hip amputation due to infected prosthesis, osteoarthrosis (chronic arthritis) and osteoporosis (a disorder in which the bones become increasingly brittle and subject to fracture due to loss of calcium). A review of the Minimum Data Set (MDS) quarterly assessment dated July 24, 2011 indicated Resident 1 required extensive assistance in transfers with a two person assist, where the resident was involved in the activity and the staff provided the weight-bearing support. The MDS also indicated Resident 1 required extensive assistance in locomotion on the unit and was totally dependent on facility staff in toilet use.A review of the Fall Risk Assessment dated July 27, 2011, indicated Resident 1 scored a zero under the ambulatory status parameter. This indicated the resident was fully dependent or non ambulatory, where the person assisting does 100% of the activity. However, the MDS quarterly assessment indicated the resident was involved in ambulating activity and the staff provided weight bearing support. This indicated there was a discrepancy between the MDS quarterly assessment and the fall risk assessment, both completed in July 2011 by the same registered nurse (RN 1). The "Fall Risk Assessment" indicated the resident was assessed as being non-high risk for fall. A review of the care plan dated January 26, 2011 indicated Resident 1 was at risk for falls/injuries related to impaired mobility and non ambulatory status post amputation of the right leg. The goal updated July 27, 2011, indicated the resident was to participate and make decisions regarding activities of daily living as tolerated for 90 days. The staff approaches or interventions included gentle handling with bed mobility and transfers, and observe and report changes to gait, balance and posture. The interventions also indicated Resident 1 completed physical therapy on January 21, 2011 and was able to transfer to the toilet for periodic toilet use. There was no description of how the staff would assist the resident for toilet use (1-person or 2-person assist). However, per the MDS quarterly assessment, a 2-person assist in transfer was required for this resident.A review of the CNA Assignment Worksheet for the 3-11 shift dated September 5 - 11, 2011 indicated Resident 1's Protocol was total care, 2 person assist, with transfers.A review of the Progress Note dated September 11, 2011 at 4:30 p.m., indicated Resident 1 slid down on the floor when CNA 1 was assisting her from the toilet seat. The progress note indicated the CNA could not control the fall, so she slid the resident down on the floor. Resident 1 stated she was having pain in the left upper leg, the on-call physician was notified and ordered to transfer Resident 1 to the emergency room of an acute care hospital for evaluation and rule out fracture.A review of the "Post Fall Assessment" dated September 11, 2011 indicated Resident 1 was found on the bathroom floor in a sitting position next to the shower chair, CNA 1 was with the resident as she was attempting to transfer the resident, however the resident "was not wearing safe shoes" (the facility failed to describe what the "safe shoes" were). The resident stated "I was sliding down from the shower chair." The CNA stated "I lowered her down to the floor on a sitting position." The investigation by RN in the Post Fall Assessment indicated the CNA called the charge nurse to help her. The charge nurse stated he saw the resident sitting on the floor, and the resident's left leg twisted in an angle. The charge nurse and the CNA assisted or carried the resident back to the wheelchair. The charge nurse called the supervisor, and the "head to toe assessment done". The resident was noted with skin tear on the right hand, and the left upper leg was swollen and painful to touch. The investigation section indicated the "CNA did not follow a 2 person assist protocol." During an interview on January 13, 2012 at 3 p.m., the RN Unit Manager stated the CNA "Assignment Worksheet" informed the CNA if the resident was a one person or a two person assist. The RN nurse Supervisor (RN 2) stated "it was missed". A review of the Radiology Exam from the acute care hospital dated September 11, 2011 indicated an angulated displaced fracture (two ends of the broken bone are separated from each other) involving the left femoral shaft (body of the leg), a spiral fracture (broken bone caused by twisting force to the bone) extending from the transverse fracture (broken across the bone) down to the distal left femur (thigh bone), and the impression indicated a left femoral shaft fracture (broken left leg). A review of the Operative Note from the acute care facility dated September 12, 2011, indicated Resident 1 was diagnosed with a displaced left midshaft femur fracture and received a closed reduction, intramedullary rodding (a device used to treat broken bones of the long bones), and a left femur fracture procedure under general anesthesia.A review of the Employee Warning form dated September 12, 2011, indicated CNA 1 was suspended for three days pending an investigation of the incident. The employee warning form indicated CNA 1 was re-educated regarding safe and proper transfers and seeking assistance when necessary. A review of the Certified Nursing Assistant job description dated October 2007, indicated the purpose was to provide each assigned resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as the CNA may be directed by the supervisor. A review of the facility's policy and procedure titled Fall Reduction Program revised November 2011, indicated the fall reduction interventions would be communicated to all relevant staff and responsibility would be assigned. The policy indicated, for example, the CNA assignments would be updated to reflect interventions (i.e. 2 person assist with transfer), and information would be shared during the shift to shift report by charge nurses. The policy indicated the Interdisciplinary Team (IDT) would determine the type and frequency of supervision and this would be included in the care plan and communicated to the rest of the relevant staff.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. |
| 630011499 |
Joyce Eisenberg Keefer Medical Center |
930011726 |
B |
16-Oct-15 |
OTWT11 |
6286 |
CFR 483.13(b) (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. Based on observation, interview and record review, the facility failed to: 1. Protect Resident 1, an 89 year-old, from being slapped on the hand by Resident 2's private companion. On July 22, 2015, the facility activity director witnessed Resident 2's private companion slap Resident 1's hand (the side not indicated). The nurse note dated July 22, 2015, indicated Resident 1 had skin reddish at the back of the left hand measuring 2.5 centimeters (cm) by 0.8 cm. On July 31, 2015, Resident 1's left hand was observed with a red mark. 2. Place Resident 1 at a safe distance from other when in the activity room. 3. Screen Resident 2's private companion upon hiring. 4. Orient and train Resident 2's private companion on "Abuse Prevention/Abuse Training" policy and procedure.On July 31, 2015, at 7:30 a.m., an unannounced visit was made to the facility to investigate an entity report incident (ERI/Intake Number CA000451837) regarding Resident 1 being slapped by Resident 2's private companion.A review of Resident 1's medical record indicated Resident 1 was re-admitted to the facility on May 27, 2014, with diagnoses of pneumonia (a lung infection), hypertension (high blood pressure), and depressive disorder (a persistent feeling of sadness and loss of interest).A review of Resident 1's care plan developed for behavioral symptoms and dated July 8, 2015, indicated one of the approaches was to place Resident 1 at a safe distance from others as to prevent injury, when the resident was in public areas with other residents (during activities, meals, in front of nursing station, etc.). Another care plan developed for cognitive loss/dementia, dated July 8, 2015, indicated Resident 1 had severe cognitive impairment, memory loss, and recall deficit. A review of Resident 1's nurses' note, dated July 22, 2015, and timed at 3:46 p.m., indicated Resident 1 had a reddish discoloration at the back of the left hand measuring 2.5 cm x 0.8 cm, no swelling, with skin intact. The resident denied any pain or discomfort. The resident's range of motion was within normal limits. A review of Resident 1's social services' notes dated July 22, 2015, at 5:25 p.m., indicated "Resident 1 allegedly inappropriately touched on left hand by a private companion that worked for another resident during an activity". A review of the facility's investigative report dated July 23, 2015, indicated on July 22, 2015, the activity director witnessed a private companion of Resident 2 slap the hand of Resident 1. The private companion of Resident 2 stated Resident 1 hit her three times in the left arm and she "tapped her [Resident 1]" for her to stop. During a telephone interview on July 23, 2015, at 11:10 a.m., the facility's administrator stated the private care giver of Resident 2 should not be here at the facility for the well-being of everybody. A review of the nurses' note dated July 31, 2015, at 10:13 a.m., indicated Resident 1's left hand skin discoloration had decreased to a light red ecchymosis (black and blue) area measuring 0.7 cm by 0 .5 cm. No expression of pain noted when the discoloration area was touched. During a tour of the 5th floor, on July 31, 2015 at 10:10 a.m., Resident 1 was sitting in the dining room by herself, and a table was in front of her. The red mark was observed on Resident 1's left hand. An attempt to interview Resident 1 was unsuccessful as Resident 1 did not respond to greetings and did not react to the evaluator who was standing next to her. During an interview on July 31, 2015, at 10:37 a.m., the human resources (HR) manager stated all companions should be screened by HR upon hiring, however the social services did not notify HR of Resident 2's companion being present in the facility. Resident 2's companion had not been screened by the facility's HR department. During a telephone interview on August 6, 2015, at 12:20 p.m., the first floor activity director stated on July 22, 2015, she had to cover the activities on the 5th floor. She stated she brought Resident 1 to the dining/activity room to attend the activity. She placed Resident 1 in the second row, at a square table, located in the middle of the room. There was also another resident on the other side of the table. She noticed the private companion bring Resident 2 into the activity room, and she (the private companion) sat next to Resident 1. While she (activity director) was passing books to other residents for the sing along, she saw Resident 2's companion using her cell phone, then she heard a voice saying "ouch." The activity director turned around, and saw Resident 1's right hand on the companion's left arm. She saw Resident 2's companion hitting Resident 1's right hand once (at the same time a sound with an 8/10 intensity). The companion removed the resident hand from her arm, stood up and left the room. Resident 1 remained calm. The activity director then reported the incident to her supervisor.A review of the facility's policy and procedure, dated September 2010, titled, "Private Duty Companion" stipulated the director of Staff Development and Human Resources, and/or designee shall review qualifications and approve all private companions hired outside the facility. A review of the facility's policy and procedure, dated July 2015, titled, "Abuse Prevention" stipulated each resident/patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. A review of the facility's policy and procedure, July 2015, titled, "Abuse Training" stipulated all employees/caregivers will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in the facility. Annual and as necessary in-service will be provided for review of facility's Policy on Abuse Prevention and Mandated Reporting. The above violation had a direct relationship to the health, safety, or security of patients. |
| 960001896 |
JANRAY |
960011153 |
B |
05-Dec-14 |
EJ6L11 |
4854 |
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 March 8, 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. Ensure Clients 1, 2 and 4 privacy during care of personal needs by closing their bedroom doors while their diapers were being changed. The clinical record for Client 1 was reviewed on March 10, 2014. Client 1 was admitted to the facility May 20, 1997 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), quadriplegia (paralysis in partial or total loss of all limbs and torso) and was dependent on staff for activities of daily living. The clinical record for Client 2 was reviewed on March 10, 2014. Client 2 was admitted to the facility on November 14, 1997 with diagnoses that included severe intellectual disability (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment), cerebral palsy and was dependent on staff for activities of daily living.The clinical record for Client 4 was reviewed March 10, 2014. Client 4 was admitted to the facility January 16, 1997, with diagnoses that included profound intellectual disability, cerebral palsy, quadriplegia and was dependent on staff for activities of daily living.During observations on March 8, 2014, at 6:15 a.m., in Client 1's bedroom, Client 1 was in bed, while Staff A removed his diaper, wiped his groin with wet wipes and put on a new diaper. The bedroom door remained open and Client 1 was exposed to anyone who walked pass his bedroom door. Then Staff A went into the room across from Client 1's room where Clients 2 and 3 were in their beds. Staff A went to Client 2, removed his diaper, wiped his groin and buttocks with wet wipes and applied a new diaper. The bedroom door remained open and Client 2 was exposed to his roommate and anyone who walked past his bedroom door. At 6:25 a.m., Staff A obtained a shower chair and brought it into Client 1's bedroom, then went to Client 1, removed his blankets, removed his pants that were visibly wet, removed the diaper from the client and covered Client 1 with a towel. Client 1 was placed in the Hoyer lift harness and his bare buttocks was exposed as he was lifted onto the shower chair with his genitalia now covered. His bedroom door remained open and anyone who walked past his bedroom had visual access to Client 1.During observation on March 8, 2014, at 8:03 a.m., in Client 4's bedroom, Client 4 was in bed, while Staff A changed her diaper with her bedroom door open exposing the client to anyone in the hallway.During an interview with Staff A, on March 8, 2014, at 8:20 a.m., Staff A stated, he was supposed to provide the clients? with privacy. When asked how you provide the clients privacy, he stated, "You have to close the door." He stated he was the only staff in the house with the clients and he leaves the doors open when he provides care so he can hear the clients.A review of the facility's policy and procedure titled "Privacy and Confidentiality" dated August 1996, stipulated each client will be treated with consideration, respect and full recognition of his dignity as an individual by giving visual privacy during treatment and care of his/her personal needs. Privacy curtains would be used in shared rooms. The facility staff failed to provide Clients 1, 2 and 4 privacy during treatment and care of personal needs by not closing their bedroom doors while their diapers were being changed and they were exposed in view of anyone who walked past the bedroom.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 960002705 |
JADE RANCH |
960013102 |
B |
31-Mar-17 |
REYY11 |
5437 |
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(a) 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: (b) A right to dignity, privacy, and humane care. To the maximum extent possible, treatment, services, and supports shall be provided in natural community settings.
On February 3, 2017 at 6:25 a.m., an unannounced visit was made to the facility to conduct an investigation of a complaint regarding Client 1's hair being cut close to the scalp without first securing permission from the mother.
The facility failed to ensure:
Client 1?s hair was not cut without first obtaining the parent?s permission. The licensee cut Client 1's (young female child) hair (braids) off completely without getting her mother's permission.
During a review of Client 1's clinical record on February 3, 2017, the face sheet indicated Client 1 was admitted to the facility XXXXXXX 2016 with diagnoses of severe intellectual disability (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment), cerebral palsy (disorder that includes: poor coordination, stiff muscles, weak muscles, trouble swallowing or speaking, tremors, problems with sensation, vision, and hearing. Difficulty with the ability to think or reason, and symptoms worsen over time), and failure to thrive (a pronounced lack of growth in a child because of inadequate absorption of nutrients or a serious heart or kidney condition, resulting in below-average height and weight). Client 1 was non-verbal and wheelchair bound.
During an interview with the complainant, on February 3, 2017 at 6:15 a.m., she stated she was angry and offended by the way the facility treated her daughter. She stated although her daughter was placed in the facility?s care she makes decisions regarding her health and other matters in her life. She stated she did not give permission to the administrator, licensee, QIDP, or the nurse to cut her daughter?s hair. The complainant stated there was no discussion regarding the cutting of her daughter?s hair and she was angry and mad when she arrived to visit her daughter and observed her hair cut off on January 28, 2017.
During an observation on February 3, 2017, at 6:30 a.m., Client 1 was observed in bed. Client 1?s hair was cut low to her scalp and her cut resembled a little boy.
During an interview with Staff A, on February 3, 2017 at 7:03 a.m., she stated she worked the night shift and was responsible for dressing Client 1. Staff A stated it was difficult combing Client 1's hair because she was not acquainted with Client 1's hair texture. Staff A stated Client 1's hair was matted and thick and she could not get a brush through the strands of her hair, and as a result the client's hair looked messy most of the time. Staff A stated the qualified intellectual disabilities professional (QIDP) did not teach her how to care for Client 1's hair neither did the licensee provide hair care training. Staff A stated she understood why the mother was upset because nobody asked her permission before cutting Client 1's hair low to her scalp.
During an interview with the licensee, on February 3, 2017 at 7:22 a.m., she stated she took the client to the barber to get her hair cut without the permission of the mother and she made a mistake.
During an interview with the QIDP, on February 3, 2017 at 7:52 a.m., she stated the facility failed to secure permission from the mother before cutting Client 1's hair and the facility made an error in judgement. The QIDP stated the school teacher complained about her hair and also complained that Client 1 putting her hair in her mouth. When asked for documentation to substantiate the claim of Client 1 putting her hair in her mouth and the school staff requesting Client 1's hair be cut, the QIDP stated she did not document any conversations she had with the school teacher. The QIDP stated she had not documented any incidents regarding Client 1's hair issue particularly her putting her hair in her mouth. The QIDP stated the facility did not have a policy and procedure in the facility that governed client's hair care. The QIDP stated she did not have any policies and procedures in the facility that governed client?s rights.
The Nurses? Admission Record dated December 10, 2016, did not identify Client 1 having a behavior of putting her hair in her mouth.
The facility failed to ensure Client 1?s hair was not cut without first obtaining the parent?s permission. The licensee cut Client 1?s hair (braids) completely off without getting her mother?s permission.
The above violations caused or occurred under circumstances likely to cause significant humiliation, or other emotional trauma. |
| 630004921 |
Janray Home II |
960013259 |
A |
20-Jun-17 |
CXFS11 |
8396 |
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 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:
(d) a right to prompt medical care and treatment
On February 10, 2017 at 6:02 a.m., an investigation of an Entity Reported Incident (ERI) was initiated regarding the death of Client 1 in the facility.
The facility failed to:
1. Effectively administer cardiopulmonary resuscitation (CPR) to Client 1. Direct Care Staff (DCS A) provided chest compressions to Client 1 while in bed on a soft surface (mattress) after she was found to be unresponsive in her bed. Failure of the staff to perform CPR as mandated by the American Red Cross, potentially contributed to the death of Client 1.
Review of Client 1's clinical record, indicated Client 1 was admitted to the facility XXXXXXX 2007 with diagnoses of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care), and seizure disorder (an episode of abnormal brain activity resulting in uncontrollable jerking movements of the body).
The Daily Care Flow Sheet for February 2017, indicated on February 4, 2017 Client 1 had a bath, and urinated two times.
The latest physician's progress record, dated December 30, 2016, indicated Client 1 was doing well with a good appetite, with no new orders to follow.
The latest nurse's progress note, dated December 30, 2016, indicated Client 1 was doing well with a good appetite and no new orders written by the physician to follow.
The Nursing Quarterly Assessment, dated December 30, 2016, indicated Client 1 was stable, up to date with her immunizations, the flu shot was given, and an audiology assessment was performed March 19, 2016 which showed mild to moderate hearing loss in one ear. The dental exam was performed August 30, 2016 with moderate gingivitis. The vision exam dated March 17, 2016, indicated eye exam results same as last year. The mammogram dated July 15, 2015 indicated normal findings. The skin integrity was intact and normal. Circulation was within normal limits.
The Nursing Care Plan dated March 1, 2016; indicated staff was to ensure regular re-positioning such as getting out of the wheelchair upon return from the day program and spend time on a mat or lying supine to redistribute her weight bearing surfaces.
The Vital Signs Record, dated February 4, 2017, indicated a blood pressure of 123/73, temperature of 97.6, pulse of 69, and respirations were 19.
The Occupational Therapy (OT) annual evaluation, dated June 2, 2016, indicated Client 1 was dependent on staff for all self-care, was non-ambulatory and non-verbal.
During an interview with DCS J, on February 10, 2017 at 6:10 a.m., he stated on February 4, 2017 he fed Client 1 a soft diet at 11:30 a.m., and put her in bed to relieve pressure from her bottom and promote circulation as directed by the nurse. DCS J stated the next time he saw Client 1 in the bed was at 1:00 p.m., when DCS A was yelling for help. DCS J stated he observed DCS A was providing chest compressions to her chest while she was lying in bed on top of the mattress. DCS J stated he did not see DCS A give mouth to mouth breaths, only chest compressions.
During an interview with DCS A, on February 10, 2017 at 6:45 a.m., he stated on February 4, 2017 at approximately 1:00 p.m., he entered the bedroom of Client 1 to provide peri-care (change her diaper). DCS A stated he touched the client on the shoulder and informed her that he was going to change her diaper but was alarmed when she did not move and failed to respond to him as she typically does. DCS A stated Client 1 was very pale, not breathing, and without a pulse. DCS A stated he removed the pillows from under her head and gave one breathe then 10 compressions for a total of 4 times and directed DCS J to call 911. DCS A stated he only gave a total of 4 breaths and continued with chest compressions for 17-20 minutes. DCS A stated he gave all compressions on a soft mattress without a board under Client 1's chest. DCS A stated he should have placed the client on a hard surface and then proceeded with CPR. DCS A stated when the paramedics arrived they said the client was dead. DCS A stated he was trained to perform CPR and he was supposed to placed Client 1 on a hard surface and continue compressions. During an interview with DCS A, on April 20, 2017 at 8:30 a.m., he stated since Client 1 died he has felt bad, and that he should have performed compressions on a firm surface.
During an interview with the Administrator, on February 10, 2017 at 7:11 a.m., he stated the staff had not received training from the facility but did have training from an outside service and were certified to do CPR. The Administrator stated there was a cheat sheet posted on the wall in the kitchen just in case of an emergency which requires CPR, and the regional center left books in the office for the staff to refer to at any time. The Administrator stated on April 19, 2017 at 8:35 a.m., Client 1 was well and was up to date with all of her immunizations, her monthly physician assessments, as well as her annual consultations. The Administrator stated he was saddened and surprised by the event.
During an interview with the registered nurse (RN), on February 10, 2017 at 7:50 a.m., she stated DCS J called her around 1:15 p.m., and informed her that
DCS A found Client 1 unresponsive in bed and 911 had been called. The RN stated when she arrived; the rescue department was there and pronounced Client 1 dead. She stated she called the primary physician, and Client 1?s sister requested she allow her to come to the facility to say her goodbyes because Client 1 was going to be cremated. The RN stated she was saddened by the event which took place and that DCS A should have placed Client 1 on the floor to do the chest compressions to ensure perfusion to the heart was achieved.
On February 10, 2017 a review of the facility's policy and procedure manual, indicated there was no CPR policy.
Review of the document titled ?Prehospital Care Report Summary,? dated February 4, 2017, indicated a call was received at 1:38 p.m., emergency services was dispatched at 1:39 p.m. The paramedics arrived on the scene at 1:44 p.m., the dispatch reason was cardiac arrest prior to arrival, last seen normal at 11:30 a.m. and death determined at 1:45 p.m. Further review indicated no apparent injury or trauma, rigor and lividity (a purple coloration of dependent parts, except in areas of contact pressure, appearing within 30 minutes to 2 hours after death, as a result of gravitational movement of blood within the vessels) present. The total run time was 11 minutes.
According to American Red Cross First Aid CPR/AED participant?s manual, CPR is a combination of chest compressions and rescue breaths. For chest compressions to be the most effective, the person should be on his or her back on a firm, flat surface. If the person is on a soft surface like a sofa or bed, quickly move him or her to a firm flat surface before you begin. The following represents the appropriate steps of CPR.
The facility failed to:
1. Effectively administer cardiopulmonary resuscitation (CPR). DCS A provided chest compressions to Client 1 while in bed on a soft surface (mattress) after she was found to be unresponsive in her bed. Failure of the staff to perform CPR as mandated by the American Red Cross, potentially contributed to the death of Client 1.
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.
4 |
| 110000621 |
Jerold Phelps Community Hospital D/P SNF |
110012138 |
A |
1-Nov-17 |
U56W11 |
13114 |
483.25(l) DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above.
Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
The facility failed to monitor for increased potential of adverse consequences for Resident 1 by failing to monitor for the potential for increased bleeding and immediately notify a physician of Resident 1's bruising, an indicator of excessive bleeding, after administration of medications with potential interactions (Warfarin and levofloxacin) that can cause excessive bleeding. Resident 1 died of multi-organ failure and acute blood loss.
Review of Resident 1's face sheet (a document that summarizes resident's information) on 7/8/2015, revealed Resident 1 was admitted to the facility on 8/1/14.
Review of Resident 1's physician orders for the month of June 2015 revealed Resident 1's medication regimen included an order, dated 6/2/15, for Warfarin (also known by the brand name Coumadin), an anticoagulant [blood thinner] medication commonly used to prevent formation of blood clots in people with artificial heart valves (Retrieved 10/28/15 from www.nlm.nih.gov/medlineplus/druginfo/meds). Resident 1's care plan reflected anticoagulation therapy since March of 2013.
Resident 1's care plan, last revised May 2015, included an entry "Anticoagulant Therapy." The problem identified Resident 1 was at risk for bleeding, bruising related to use of: Coumadin related to heart valve replacement. The goal was "Resident / patient would not have covert or overt bleeding or injury x 90 days." Interventions included "Staff will Observe for signs/symptoms of bleeding (e.g. tarry stool, blood in urine, bruising, petechiae [pinpoint red or purple spots on the skin due to bleeding]); Monitor drug regime for drugs that increase effects...; Observe for adverse reactions (e.g. fever, skin lesions, anorexia, nausea, vomiting, cramps, diarrhea, hemorrhages, hemoptysis [coughing blood])."
Record review revealed a Physician's Progress Note, dated 6/6/15 at 10 a.m., and signed by Physician A, indicating "pt.[patient] reported to be coughing repeatedly vigorously with phlegm and small amount of blood yesterday." Physical examination revealed "[bilateral] rhonchi, few coarse sounds" in her lungs. (Rhonchi are abnormal sounds heard when listening to the lungs, often indicating secretions in the airways.) Physician A's assessment was bronchitis (inflammation of the airways), and the plan included Levaquin (an antibiotic) 750 milligrams daily.
A handwritten Physician Order, dated 6/6/15 at 10:30 a.m., and signed by Physician A, reflected Levaquin 750 milligrams orally every day for 10 days. There were no new orders related to increase monitoring of Resident 1's INR.
Warfarin therapy is monitored by measuring the amount of rise in the international normalized ratio (INR). The target therapeutic increase in patients receiving Warfarin is 2 to 3 in most cases, or 3.5 in those with heart valve replacements. Bleeding is the most common adverse effect of Warfarin. Levofloxacin - also known by the brand name Levaquin is an antibiotic used to treat pneumonia (inflammation of the lungs sometimes caused by infection) among other things. Levofloxacin can interact with Warfarin resulting in an increase in the effect of Warfarin as reflected by an increase in the INR. An INR above 5 is normally considered to be a significant increase, requiring immediate reevaluation of therapy. (DiPiro et al., Pharmacotherapy: a pathophysiologic approach, third edition, Ch. 19 Thromboembolic Disorders, p. 414; Koda-Kimble and Young, Applied Therapeutics: The Clinical Use of Drugs, seventh edition, Ch. 14 Thrombosis, p. 14.5)
The U.S. Food and Drug Administration website documents Levaquin may enhance the effect of Warfarin. "Patients should also be monitored for evidence of bleeding." Patient Counseling Information reveals, "Patients should be informed that concurrent administration of Warfarin and Levaquin has been associated with increases...clinical episodes of bleeding." (Retrieved 10/28/2015 from www.accessdata.fda.gov)
During an interview on 2/16/16 at 5 p.m., Physician B stated, "It's usual to increase monitoring the INR when antibiotics are given."
Record review revealed a Nurses Note written by Licensed Nurse C, dated 6/9/15 at 3:47 a.m., three days after starting Levaquin, indicating "Several areas of ecchymosis [bruising] of various size found on [left] lateral [side] aspect of [patient's] back of unknown origin." There was no documentation in Resident 1's record that Licensed Nurse C notified a physician of the bruising on 6/9/15.
During an interview, on 10/22/15 at 8:15 p.m., the author of the note, Licensed Nurse C, stated the bruises were approximately 1 to 1 1/2 inches across, and were dark purple in color. Licensed Nurse C stated the bruises "looked new." Licensed Nurse C confirmed she did not notify a physician of the bruises.
A Nurses Assessment Report written by Licensed Nurse D, dated 6/9/15 at 5:47 p.m., revealed Resident 1 was currently receiving Levaquin 750 milligrams by mouth daily for treatment of a possible upper respiratory infection, "No ASE's (adverse side effects) noted at this time." Licensed Nurse D documented Resident 1's skin as "Intact, Rash (See comments)" and skin color as "Appropriate for race." The "Comments" section included no documentation about the bruising or discoloration to Resident 1's left flank or back noted by Licensed Nurse C earlier that morning. There was no documentation that Licensed Nurse D notified the physician of Resident 1's bruising on 6/9/15.
During an interview, on 7/16/15 at 8:50 a.m., Resident 1's family member (Family H) stated she asked Licensed Nurse D about the combination of Levaquin and Warfarin on 6/9/15. Family H stated Licensed Nurse D said she "wondered about that" when she saw the order and agreed to call the physician.
A Nurses Note, dated 6/10/15 at 12:40 p.m., indicated "CNAs point out a bruise on left side of patient's torso, mildly painful to touch. [Physician B] notified of pt.'s BP [blood pressure] and of the bruise."
Record review of a Patient Lab (Laboratory) Results Report, dated 6/10/15 at 12:01 p.m., revealed Resident 1's INR was critically high at 6.6. The report also revealed the critically high value was phoned by lab staff to facility staff on 6/10/15 at 12:02 p.m. A Patient Results Report, dated 6/10/15 at 11:56 a.m., revealed a critically low value for Resident 1's hemoglobin (the oxygen carrying component of red blood cells) and a low value for Resident 1's hematocrit (the volume percentage of red blood cells in the resident's blood), both indicators of possible bleeding. The report documented these hemoglobin and hematocrit values were phoned by lab staff to facility staff on 6/10/15 at 11:55 a.m. The nurse's notes reflected no documentation that facility staff notified a physician of these values, nor clarification of continuing the medications as ordered.
Review of Resident 1's Medication Administration Record, dated 6/1/15 through 6/18/15, revealed the Levaquin was discontinued on 6/10/15. The MAR reveals a stop date of 6/21/15 for the Warfarin. The MAR also reflected Resident 1 received Warfarin 5 mg. on 6/10/15 at 8:37 p.m., more than eight hours after the lab notified a licensed nurse of critical lab values.
During an interview, on 10/22/15 at 2:40 p.m., when asked if she had contacted a physician about administering levofloxacin to Resident 1 while Resident 1 received Warfarin, Licensed Nurse D stated she asked Physician B when she saw him "if he wanted to continue the Warfarin," but Physician B gave no response other than a shrug. Licensed Nurse D could not recall what date she spoke to Physician B. Licensed Nurse D also stated, "I know there was a delay in stopping the Warfarin and getting labs." Licensed Nurse D stated she told the night shift licensed nurse taking over Resident 1's care, "I would hold the Warfarin if I were you."
During an interview, on 10/23/15 at 9:15 a.m., Administrative Staff G was asked how staff was expected to "monitor drug regime" as reflected in Resident 1's care plan. Administrative Staff G stated she "expected them to look it up" if not familiar with medication interactions. If a potential interaction was identified, Administrative Staff G stated staff should contact the ordering physician, and not give the medication until clarification can be obtained.
During an interview, on 10/23/15 at 10 a.m., Licensed Nurse F stated he was not aware of interactions between Warfarin and Levaquin, and had not looked the medications up in a medication book or online resource.
During an interview, on 10/23/15 at 10:45 a.m., the manager of the off-site pharmacy that dispensed the Levaquin (Manager H) stated resident medication profiles only showed medications dispensed by her pharmacy, although notes could be added to the profile if the pharmacy is notified of medications from other sources. Manager H stated Resident 1's profile did not reflect Resident 1's Warfarin.
During an interview, on 10/27/15 at 2:10 p.m., Consultant Pharmacist I stated he was not aware that Levaquin was added to Resident 1's medication regimen, had not been alerted to the medication when it was ordered 6/6/15, and did not review Resident 1's medication regimen at the time it was added. Pharmacist I stated, "That's a terrible combination. When I hear those two together, I immediately think of skyrocketing [lab tests indicating slowed blood clotting]...If I'd seen that [Warfarin and Levaquin] I would have called, emailed, done everything to alert somebody."
Review of Resident 1's Certificate of Death, dated 6/23/15, revealed Resident 1 died on 6/18/15 of multi-organ failure (the immediate cause of death) with an acute blood loss of unknown cause leading to the multi-organ failure.
During an interview, on 11/2/15 at 11:15 a.m., Physician A stated, "I'm not going to remember anything from June." When asked about prescribing Levaquin for a patient on Warfarin, Physician A stated, "I know that combination [Levaquin and Warfarin] is a problem." Physician A stated, "I may or may not have looked at what medications [Resident 1] was on" at the time he prescribed the Levaquin.
During an interview, on 2/16/16 at 5 p.m., Physician B stated he was Resident 1's primary care provider in the community clinic, and followed her in the skilled nursing facility. Physician B stated he was notified of Resident 1's increasing fatigue and bruising on 6/10/15, and saw her in the skilled nursing facility on that date.
Physician B's note, dated 6/11/15, for the visit on 6/10/15 revealed Resident 1 had, "a bruise at the anterior axillary line [front of the arm pit] on the left extending around the level of T5 [thoracic vertebra, midback] to the patient's pelvis" and an "elevated INR, acute blood loss." The plan included comfort care, hold Resident 1's Warfarin and discontinuing the levofloxacin.
Physician B stated there was no formal or written method by which physicians communicate changes in residents' condition or treatment, relying on verbal communication. Physician B stated he could not recall any notification by Physician A that Physician A prescribed levofloxacin for Resident 1 on 6/6/15. Physician B stated he believed he first became aware of the levofloxacin order on 6/10/15 when nursing staff contacted him about Resident 1's bruising and increased fatigue.
Physician B stated he identified "multiorgan failure" as Resident 1's cause of death given her multiple disease processes and poor health, and "acute blood loss" was based on her laboratory values.
Therefore, The facility violated the regulation by failing to ensure that Resident 1 was monitored for the potential for increased bleeding and a physician immediately notified of Resident 1's bruising, an indicator of excessive bleeding, after administration of medications with potential interactions (Warfarin and levofloxacin) that can cause excessive bleeding. Resident 1 died of multiorgan failure and acute blood loss.
The violation of the regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 630012729 |
Jackie Lee and Jim Houston House |
250013676 |
B |
21-Dec-17 |
09JH11 |
5335 |
Class "B" Citation
(W 149) Client Protections
(W 153) Staff Treatment of Clients
An unannounced visit was made to the facility on March 27, 2017, to investigate a report of a client's fractured right shoulder. It was determined the facility failed to ensure Client 3 was free from injury when transferred incorrectly. Staff failed to report the incident for four days to ensure timely medical care to stabilize the shoulder.
On March 28, 2017, Client 3's record was reviewed. Client 3 was admitted to the facility on May 16, 2011, with diagnoses including osteoporosis (brittle bones).
A bone scan (to determine bone strength), dated April 18, 2016, indicated, "Considered osteopenia," (fragile bones).
The face sheet summary indicated, "(Client 3) is non weight bearing and all transfers from wheelchair to wheelchair are done with a Hoyer lift."
The Physical Therapy assessment, dated October 6, 2016, indicated, "...4...Use a hydraulic lift when he is unable to participate in transfers..."
On March 27, 2017, at 8:45 a.m., in an interview with the House Manager (HM), she indicated that on March 10, 2017, Client 3 was transferred inappropriately at 4 p.m., and again at 5:15 p.m., when Direct Care Staff (DCS) 1 lifted Client 3 in a "cradle style," using his arms. He did not use the Hoyer (mechanical lift).
In an interview with the House Manager (HM) and Qualified Intellectual Disability Professional (QIDP), on March 27, 2017, at 9:10 a.m., they stated LVN 1 and DCS 1 did not notify the facility administrator or Registered Nurse (RN) regarding the incident or their concerns, and the incident was not documented in Client 3's record. The HM and QIDP indicated DCS 1 noticed Client 3's right arm and shoulder area appeared "sunk in" lower than the surrounding area, approximately one inch, and requested the Licensed Vocational Nurse (LVN) 1 to evaluate the client's shoulder.
On March 28, 2017, at 9:10 a.m., in an interview with DCS 1, he stated that on March 10, 2017, "I lifted (Client 3) up with a cradle hold. I noticed the right shoulder was drooping, with a little indent. It didn't look right to me. I called the LVN to look at it...I didn't tell the next shift, I didn't document it because the LVN cleared it. To me it was cleared because the LVN looked at it...The Hoyer lift takes a long time to use, and with just two people each shift, I try to get things done in a timely manner."
In an interview with LVN 1 on March 27, 2017, at 2:55 p.m., she indicated that on March 10, 2017, DCS 1 asked her to evaluate Client 3's shoulder.
LVN 1 stated, "(DCS 1) asked me, is it fractured?"
LVN 1 stated she did not ask what happened to Client 3's shoulder.
LVN 1 stated, "The shoulder looked normal to me...I worked the next day, March 11, 2017, I forgot all about what (DCS 1) asked me."
LVN 1 stated she did not inform any staff of the injury.
During an interview with DCS 2 on March 27, 2017, at 4:40 p.m., she indicated that on March 12, 2017, she transferred Client 3 from his bed to the shower bed.
DCS 2 stated, "I sat him up on his bed. I put my arms around his waist. I lifted him up and put his bottom on the shower bed...We do use a Hoyer (lift) here, but I pivot him...I know how to deal with the clients."
In an interview with the HM on March 27, 2017, at 4:45 p.m., she stated, "Staff are not to do that, for any client over 40 pounds, they are supposed to use a Hoyer lift transfer..."
In an interview with the Registered Nurse (RN) and HM on March 27, 2017, at 5 p.m., the RN and HM indicated Client 3's shoulder was dislocated when transferred by DCS 1 on March 10, 2017, then continued to be injured over the weekend.
On March 28, 2017, at 7:35 a.m., in an interview with DCS 3, she indicated that on March 14, 2017, she observed a dark blue bruise with swelling on the client's right arm from the elbow to the collarbone.
DCS 3 stated, "(Client 3) was tense, sweating, and was breathing hard."
Client 3 was transported to the Emergency Room on March 14, 2017, and admitted for a shoulder injury.
The hospital Consultation Report, dated, March 14, 2017, indicated, "Right proximal humerus (shoulder) fracture with dislocation...best treated with surgical fixation (repair)..."
The HM stated she conducted an interview with DCS 1 on March 16, 2017. DCS 1 did not mention the client was improperly transferred, and with a sunken shoulder area, on March 10, 2017.
The HM stated when she asked DCS 1 later why he did not inform her of the March 10, 2017, incident, DCS 1 told her, "I didn't think it was important."
The HM stated when she interviewed LVN 1 on March 18, 2017, LVN 1 stated she was requested by staff to observe Client 3's shoulder on March 10, 2017.
In an interview with the facility RN on March 27, 2017, at 3:25 p.m., she verified the incident was not documented, nor was the RN notified. The RN stated, "(LVN 1) should have notified me (of the change of condition)."
The facility failed to ensure one client was free from injury when transported incorrectly. Client 3 was at high risk for fracture related to improper transfer technique due to osteoporosis/osteopenia.
The violation of this regulation has a direct relationship to the health, safety, or security of the client. |