| 140000051 |
Kindred Nursing and Rehabilitation - Ygnacio Valley |
020009069 |
B |
02-Mar-12 |
FGDY11 |
7868 |
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- (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services. The facility violated the aforementioned regulation by failing to readmit Resident 1 after hospitalization when she was ready to return to the facility. Record review on 3/11/11 showed that Resident 1 was readmitted to the facility on 12/31/10. Diagnoses included paraplegia (permanent paralysis caused by injury or disease affecting the spinal cord and resulting in the loss of sensation and movement in the legs and in part or all of trunk), chronic pain, severe protein-calorie malnutrition, and multiple pressure sores. Resident 1 had a nephrostomy (tube into the kidney to drain urine) tube that emptied into an external urine bag and a colostomy (opening into the colon allowing for feces to exit externally) that emptied the contents of the colon into an external bag. Resident 1 was responsible for health decisions. Nursing notes at 4:15 p.m. on 1/17/11 showed that Resident 1 complained of severe abdominal pain that was not relieved by prescribed narcotic medication. Resident 1 also complained about nausea that was not relieved by medication. A small amount of emesis with black grounds was also noted. When notified, the physician ordered staff to transfer Resident 1 for hospitalization. The "Notice of Bed Hold Policy" was completed for Resident 1 on 1/18/11.In Section II of the bed hold notice the following was written: "The Resident has left the Center for a hospitalization... and elects to: Hold [a] bed from 1/17/11 to 1/23/11 and agrees to pay the Center the above referenced daily bed hold charge for the period of time the bed is held in excess of any State required bed hold period, pursuant to the Resident's request." A second option allowed the resident to refuse the bed hold. During an interview at approximately 1:15 p.m. on 3/11/11, the Director of Medical Records stated that Resident 1 did not want the bed hold. She stated that Resident 1 did not want to privately pay for extended bed hold days. The facility policy entitled, "Bed-Hold & Readmission" contained the following statement: "Compliance Guidelines. 4. Should a resident elect not to pay for the bed-hold beyond the allowed duration, then the resident will be readmitted to the first available bed allowed by the pay source."Resident 1 was interviewed at approximately 12:30 p.m. on 3/11/11. Resident 1 wanted to be readmitted to the facility. Resident 1 cited the reasons for wanting to return to the facility, including access to a local support group and access to specific physicians and surgeons who were involved in long term treatment of the resident. During the interview, Resident 1 telephoned family members. One family member repeated these same reasons for returning Resident 1 to the facility. The hospital Director of Case Management and the Case Manager (CM) were interviewed at 11:15 a.m. on 3/11/11. They provided copies of the case management notes as follows: - On 1/25/11 the Case Manager wrote, "Patient was originally scheduled to go back to [the facility] on 1/24. Per [the Admission Coordinator] the facility did not want to accept back [resident] on IV Dilaudid, IV antibiotic and a wound VAC. In meantime, the [discharge] was postponed for medical reasons. Patient is not ready for transfer today."- On 1/26/11 the Case Manager wrote, "Spoke with [the Admission Coordinator] today regarding [discharge]. She states they have decided to accept [patient] back but they do not have a bed available today... Waiting for facility to have a bed available."- On 1/27/11 the Case Manager wrote, "No beds today." - On 1/29/11 the Case Manager wrote, "Again requested a bed at [the facility]. [Administrator] states had a room planned for the patient for tomorrow but it cannot now be utilized because of the condition of the other patient [i.e. open ports]. States [facility] is willing to accept patient but [patient] needs to have negative urine cultures." - On 2/4/11 the Case Manager wrote, "Patient has utilized all of [the] acute days, including Lifetime days as of the 26th of January. [Patient] therefore is MediCal solely... Also spoke with the [Admissions Coordinator at the facility] and they are still willing to try and accept if possible."- On 2/23/11 the Case Manager wrote, "Spoke with [the physician] and would like to [discharge] back to [facility] as soon as possible... [Facility] did not have an isolation bed for patient, nor did they have an appropriate co-habitate room. Will await [their] determination."- On 2/25/11 the Case Manager wrote, "Received message from [the facility Admission Coordinator] stating that the facility is unable to accept [patient] due to the insufficient funding/cost prohibitive due to extensive care needs."- On 3/1/11 at 10:19 a.m. the Case Manager wrote, "Per notes [the facility] declining admission because cost of care prohibitive/insufficient funding. Spoke with [facility's] business office today: patient was at [the facility] from 12/31/ to 1/7, and back 1/9 to 1/17. At that time [the patient] had exhausted all of [the] Medicare and was at that time only on MediCal. [Facility] accepted [patient] back on 12/31 on MediCal and the care needs are almost the same... Over recent weeks have worked with [the facility] and tried to assist with care planning and their concerns. [Facility] asked that patient be taken off of the Dilaudid because of a shortage... This was followed through... Patient has been accepted a couple of times, not because of cost but awaiting a bed, then at last moment told cost is an issue... Patient would like to return to [the facility] if at all possible."- On 3/1/11 at 11:42 a.m. the Lead Case Manager wrote, "Call placed to [Administrator] at facility. She states they are unable to accept patient back into their facility due to the cost of the patient's care." The facility administrator was interviewed at 1:50 p.m. on 3/11/11 regarding the reasons for refusing readmission to Resident 1. The Administrator stated that Resident 1 never indicated an interest in returning to the facility and that the resident was never refused readmission due to VRE. She said that the facility did not have a bed for Resident 1 because of the VRE issue. She stated that because Resident 1, who needed long term care, was known to have VRE, she could not place the resident in a room with a resident with a port (example - dialysis, tube feeding) and therefore, she did not have a suitable bed in the long term care unit. She stated that it was not their practice to readmit a resident that needed long term care to the short stay (Complex Care) unit. The Administrator stated that the resident was prescribed a narcotic (Dilaudid) that was in short supply in the community and was using nearly all of the medication allotted to the facility. The Administrator stated that Resident 1 was only eligible for MediCal benefits. She stated that she did not want to readmit Resident 1 because to the cost of care was prohibitive. Review of facility bed availability on the days the hospital contacted the facility to return the resident showed that the facility had available beds on 1/26, 1/27, 1/29 2/4, 2/23, 2/25 and 3/1/11. Therefore the facility failed to readmit Resident 1 after hospitalization when she was ready for discharge to the facility.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the patient. |
| 140000083 |
Kindred Transitional Care and Rehabilitation-Walnut Creek |
020010043 |
A |
29-Jul-13 |
S5DM11 |
13355 |
483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: The facility violated the aforementioned regulation by failing to ensure that Resident 1 was monitored appropriately when Respiratory Therapist (RT 1) placed a Passy Muir Valve (PMV) on her tracheostomy tube and left her room Resident 1 was found 55 minutes later without vital signs and died. Resident 1 had a history of not tolerating the PMVDefinitions: Passy Muir Valve (PMV)=A Passy-Muir valve is a one-way valve that attaches to the outside opening of the tracheostomy tube (tube inserted into airway of resident to allow breathing) and allows air to pass into the tracheostomy but not out. The valve opens when patient breathes in and closes when patient exhales, allowing the exhaled air to flow around the trachesotomy tube and up through the vocal cords and out the mouth and nose. The patient breathes out through the mouth and nose instead of the tracheostomy. Transverse myelitis is a neurological disorder caused by inflammation across both sides of one level, or segment, of the spinal cord which can cause nervous system scars that interrupt communications between the nerves in the spinal cord and the rest of the body. Subdural hematoma is bleeding under the lining of the brain. Status epilepticus is a life-threatening single prolonged seizure or a series of seizures without intervening full recovery of consciousness. Tracheostomy is an opening through the neck into the trachea (windpipe), so patient can breath and have secretions removed.Pulse oxymeter is a device that measures the oxygen saturation of arterial blood in a subject by utilizing a sensor attached typically to a finger, toe, or ear to determine the percentage of oxyhemoglobin in the blood pulsating through a network of capillaries.Resident 1 was an 81 year old female who was admitted to the facility on 11/3/12 with a diagnosis of respiratory failure and was readmitted to the facility after being hospitalized on 1/9/13. Medical Doctor (MD 1) wrote in a progress note on 2/8/12 that Resident 1 had Transverse myelitis, subdural hematoma, a frontal meningioma (brain tumor) and a seizure disorder. Resident 1 had a history of status epilepticus which resulted in a tracheostomy so she could breathe and have secretions removed.On 12/20/12, the tracheostomy tube was removed but the next day Resident 1 had acute respiratory distress and was sent to the hospital and again a tracheostomy tube was inserted. According to her initial minimum data set (MDS) assessment dated 11/15/12, she required tracheostomy care, suctioning and oxygen therapy. She had no speech but was sometimes understood, and had the ability to sometimes understand others as demonstrated by her responses to simple direct communication. She had short term memory problems and was moderately impaired for daily decision making. She was totally dependent on staff to care for her activities of daily living. She could not swallow and was fed by a gastrostomy tube (a tube inserted into the stomach to administer a liquid diet and give medications and water.)The quarterly MDS assessment dated 2/4/13 revealed the resident was unchanged. She was receiving respiratory therapy seven days a week, and had received 85 hours of speech and language therapy. The physician's orders, written on 1/9/13, included Shiley #6 tracheostomy trach care per protocol every day, assess and suction secretions every 2 hours, monitor oxygen saturation by pulse oxymeter, keep oxygen level at greater than 90%, and Passy-Muir valve (PMV) trials as tolerated.According to the Speech Pathology Evaluation, dysphagia (difficulty in swallowing) and communication record dated 1/10/13, the use of PMV trials with speech therapist and respiratory therapist as tolerated was planned to improve the resident's communication effectiveness and swallowing function with the goal to increase her quality of life. Review of the speech therapist progress note dated 1/3/12, showed that Resident 1 poorly tolerated the PMV trials and experienced stridorous breathing (an abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or voice box. It is usually heard when taking in a breath.)In an interview on 5/1/13 at 12:10 p.m. the Speech Therapist stated that Resident 1 had a history of dementia but could comprehend yes/no questions. She fluctuated between 60 to 80 percent with one step directions, and needed moderate to maximum cues. She stated that the resident stopped speech therapy on 2/14/13 and the use of the PMV was discontinued because she was not tolerating the valve due to the stridorous breathing sounds. She communicated that to the respiratory therapist on 1/31/13. MD 1 wrote in a progress notes dated 2/8, 11, 13, 15 and 18/2013 that the resident was not tolerating the PMV, and on 2/11/13 gave an order to schedule an ear, nose throat consult to rule out any obstructive mass or pathology of her airway. During an interview on 5/1/13 at 1:50 p.m. Medical Doctor (MD 2), who was the partner of MD 1 and familiar with Resident 1's care, said he thought the PMV trials should have been discontinued after learning the resident was not tolerating them. He stated that MD 1's notes indicated that Resident 1 was not tolerating the PMV trials.A review of the "Respiratory Daily Notes," showed Resident 1 had not been trialed with the PMV after the 2/14/13 until 2/20/12. According to the "Respiratory Daily Notes" on 2/20/12 at 10 a.m., Respiratory Therapist (RT) 1 wrote: "Placed PMV...".He recorded her heart rate at 125 beats per minute. This was a change from her heart rate of 95 beats per minute at 5:15 a.m. on the same day. At 10:20 a.m. RT 1 wrote "Does not tolerate...O (no) PMV at this time." On 2/20/13 at 11:05 a.m., RT 1 documented on a "Respiratory Therapy Summary Form" that Resident 1 was biting off the cuff balloon (inflated cuff balloon keeps the trach tube in place) on her Shiley #6 trach tube. The note revealed that he removed the trach tube due to a "cuff balloon breach. Later on 2/20/13 at 9:20 p.m., the "Respiratory Daily Notes" revealed that the resident was stable on room air, aerated by trach collar (oxygen given though a mask covering the tracheostomy opening), resting comfortably with no distress noted, and her heart rate was 106 beats per minute. The next day, 2/21/13, RT 1 documented on the Respiratory Daily Notes at 9:25 a.m. that the resident was stable on room air ...Placed on PMV."Her heart rate was 100 beats per minute. At 9:50 a.m. RT 1 documented, "Peeked in room - remains stable."At 10:45 a.m. RT 1 documented, "Code blue". Cardiopulmonary resuscitation (CPR) with a bag and mask was performed for 30 minutes, and Resident expired. A review of the "Code Event Minutes" dated 2/21/13, revealed that Resident 1 was found at 10:45 a.m. by two certified nursing assistants (CNA 1 and CNA 2) to be non-responsive, not breathing and with no pulse. Staff called 911 and a Code Blue. The PMV was removed. At 10:46 a.m. CPR was started, RT was "bagging" (aerating with ambu-bag) and AED (automated external defibrillator which is a portable device that checks the heart rhythm and If needed, it can send an electric shock to the heart to try to restore a normal rhythm.) was in place. At 10:58 a.m. the note revealed there was no "shock."The paramedic arrived at 11:02. At 11:03 a.m. the Paramedic called (off) the code and pronounced (the resident dead).During an interview on 5/1/13 at 11:50 a.m., the sub-acute unit nursing supervisor RN 1 stated that she was present in Resident 1's room and wrote the "Code Event Minutes" dated 2/21/13. She stated that RT 1 should have stayed with the resident during the trial of PMV, especially in light of the resident not tolerating the PMV the day before. RN 1 stated that she did not know what RT 1 meant in his note, "Peeked in room," and that was not an acceptable way to assess a resident's condition. On a physician's progress note dated 2/22/13 at 12:25 p.m. titled, "physician CPR note," MD 2 documented that he was called to evaluate the resident when the code blue was called on 2/21/12. He noted that in addition to CPR, an automatic defibrillator was connected to the resident's chest, and the resident did not "require defibrillation."In an interview on 5/23/13 at 1:30 p.m. MD 2 stated that the AED machine is simple and that anyone can use it. The machine is turned on and you follow the instructions. The pads are attached but will give a "shock" if the resident is in ventricle fibrillation (lower chamber of the heart beating very fast and irregular) or atrial-ventricle fibrillation (both upper and lower chambers of the heart beating fast and irregular). He stated that the AED machine did not give Resident 1 a "shock" because her heart was not beating. In an interview on 5/1/13 at 11:50 a.m. Respiratory Therapist 2 (RT 2) stated that she was working on both 2/20/13 and 2/21/13, along with RT 1. She stated that Resident 1 had a Shiley #6 trach with a cuff and outside pilot balloon. The outside pilot balloon will be inflated if the inside cuff is inflated. The trach cuff could be inflated using a 10 cc (cubic centimeters) syringe of air. To deflate the cuff she would draw out the air until the pilot balloon collapses. She stated that on 2/20/13, Resident 1 bit off her pilot balloon and her trach tube needed to be changed so she assisted RT 1 in changing the tube. On 2/21/13, she heard a code blue and went with RT 1 to Resident 1's room. She grabbed the ambu-bag and passed it to RT 1 and he gave her a syringe and she inflated the cuff. She was able to put in 6 or 7 ccs of air only. RT 1 ventilated the resident and RT 2 started chest compressions. They continued until the emergency medical technicians (EMT) arrived and took over. CPR was not successful and Resident 1 was pronounced dead at the bedside.In a follow-up telephone interview on 5/7/13 at 11 a.m. RT 2 stated that she remembered that Resident 1 had a pulse oxymeter attached to her toe. That was where they placed it on residents who have behaviors that cause the oxymeter to fall off the finger which was where it would commonly be placed. She did not know why it took so long to discover that the resident was not breathing and she wasn't sure if the pulse oxymeter was working or why the alarm did not sound. In an interview on 5/8/13 at 11:05 a.m., the charge nurse (LVN 1) stated that she had given medications to Resident 1 that morning on 2/21/13, and the resident was "doing o.k."She was writing her notes at the nurses' station when CNA 2 came to her and said that Resident 1 was not breathing. She went to the room with CNA 2 and CNA 1 was there with RN supervisor, and RT 1. LVN 1 stated that nurses can place PMVs on residents who are stable, but not on residents who are not tolerating or being trialed with the PMV, stating that only RTs can put on the PMVs in those cases and the RTs need to stay with the Resident. When asked if RT 1 had informed her that morning that he had placed the PMV on Resident 1 and was leaving the room, so that she could monitor, she stated "no, he didn't tell me anything." In a telephone interview on 5/16/13 at 7:40 a.m. RT 2 said he remembered placing the PMV on Resident 1 the day she died. He sat with her for about 20 to 25 minutes, she had a pulse oxymeter on either her finger or toe, but he couldn't remember for sure. He said she was tolerating it and her heart rate was steady, her breathing was steady. She was not really a talker so when he asked if she was o.k. she "nodded."He left her to check on other residents on the unit. He looked into Resident 1's room from the hallway and her monitor (pulse oxymeter monitor) was on, she "looked good."He stated that he couldn't actually see the pulse oxymeter monitor because it was next to her bed on the bed side stand next to the wall and behind the privacy curtain, but he didn't hear the alarm. He stated that he was following the doctor's orders when placing the PMV and the reasons she was being "trialed" (increasing resident's tolerance of PMV) was not documented, but heard that the family was pushing for her to have the PMV. He stated that he usually will trial a PMV for three days and if not tolerated, after that would consult with the doctor, and it had not been three days yet. He said he had worked at the facility for one and a half years and was the lead therapist.According to RT 1's personnel file reviewed on 5/1/13, he resigned from his position of lead respiratory therapist on 2/24/13, and no longer works for the facility. Violation of the regulations was evidenced by the facility's failure to closely supervise Resident 1 after placing her on a PMV on 2/21/13 at 9:25 a.m. and leaving the room. Resident 1 had a history of not tolerating the PMV and expired at approximately at 10:45 a.m.These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient. |
| 140000083 |
Kindred Transitional Care and Rehabilitation-Walnut Creek |
020011043 |
B |
02-Oct-14 |
943N11 |
3698 |
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 meet the aforementioned regulation by failing to provide adequate supervision and a safe environment for Resident 1 to prevent a fall and injury. On 6/11/14, during incontinent care, Resident 1 was left alone with the bed in the high position. This failure resulted in Resident 1 falling to the floor and sustaining hip and knee fractures. The hip fracture required surgery and a hospital stay. Record review on 7/1/14, showed Resident 1's illness prevented her from making reasonable, safe and rational decisions about daily life. She was receiving rehabilitation therapy for strengthening. Resident 1 used a wheelchair to get around. Assessments done on admission included a Bed Safety/Rails Assessment, dated 5/26/14. It showed Resident 1 was confused, required a quarter bed rail to enable movement, the bed should be in a low position, a tab alarm (sensor pad alerts staff if patient attempts to get up) should be used and fall precautions established. The previous Functional Assessment, dated 5/27/14, showed Resident 1 had a fall within the previous three months and she used a walker. The physical therapy treatment record, dated 6/8/14, showed Resident 1 required minimum to moderate assist with bed mobility, had full range of motion and had poor judgment with safety.In an interview, 7/3/14 at 11:25 a.m., Certified Nurse Assistant (CNA) 1 stated while doing incontinent care for Resident 1, on 6/11/14, he raised the bed to the high position so he could more easily do the care. The bed linens needed to be changed and there were no fresh linens in the room. CNA 1 left Resident 1 lying on her back, with the bed in high position, to go to the hallway linen cart and found it did not have the linens required. He proceeded down the hall, around the corner and down the next hall to the laundry room. When he returned, Resident 1 was sideways on the floor between the room's two beds. He stated side rails were not in use. CNA 1 stated Resident 1, "Wasn't agitated and was very calm," prior to leaving the room, or "I wouldn't have left her in that position." "I should have just put the bed down totally flat to the floor, in the lowest position. She would have been closer to the floor."Resident 1 sustained a fracture of the hip that required surgery under anesthesia, and a fracture of the knee and a hospital stay.In an interview, 7/1/14 at 11:10 a.m., a family member of Resident 1 stated sometimes he had to remind staff to return the bed to the low position after care. Review of the Managing Fall Risk policy and procedure, dated 2/28/14, showed the environment was to be maintained to promote patient safety. A component of this was to be accomplished by keeping, "The bed in its lowest position," initiation of a fall risk program with weekly interdisciplinary team meetings, falling star magnet placed on door frame, a care plan addressing falls, and individual interventions that would be revised as needed. Resident 1 had a care plan, dated 5/27/14, showing she was at risk for falls related to confusion and incontinence. Two interventions on the care plan were to "Anticipate and meet Resident 1's needs" and "Assure the bed is in the lowest position when unattended." Therefore the facility failed to provide adequate supervision and a safe environment for Resident 1 to prevent falls and injury. These violations had a direct relationship to the health, safety or security of patients. |
| 020000042 |
Kaiser Permanente Post-Acute Care Center |
020011148 |
B |
03-Dec-14 |
K6K811 |
5887 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation by failing to provide proper supervision when administering an enema to Resident 1 and by failing to ensure that a tab alarm (alarms sounds to alert staff when resident attempts to get up) was on Resident 1, resulting in Resident 1 getting out of bed and falling on the floor, sustaining a traumatic cerebral hemorrhage (bleeding inside of the brain from damage to the blood vessels as a result of hitting her head during the fall) which required an 18 day avoidable hospitalization.Record review on 8/25/14 showed Resident 1 was admitted to the facility on 8/10/14 from the acute care hospital, where she was diagnosed with Non-traumatic Cerebellar Hemorrhage (bleeding in the brain from a non-traumatic cause such as a stroke). The initial physician's orders, dated 8/10/14, for the skilled nursing facility included physical, occupational and speech therapy evaluation and treatment. The physician's orders dated 8/10/14 also included a routine bowel regimen of milk of magnesia 30 milliliters by mouth each day as needed for constipation, dulcolax suppository 10 mg (milligrams) per rectum daily as needed for constipation that is not relieved by the milk of magnesia, and Fleet enema 1 per rectum as needed for constipation if not relieved by oral laxative or suppository. According to the facility's "Fall Risk Evaluation" dated 8/10/14, Resident 1 had a score of 12 which represented a "High Risk" for falls. Resident 1 was chair bound and needed assistance with elimination (also known as urinating and defecating). Resident 1 had intermittent confusion, and was unable to stand on both feet without holding onto anything, or walk straight forward. A care plan dated 8/10/14, revealed that Resident 1 had the problem of being at high risk for falls due to, weakness, poor safety awareness, deconditioning, recent surgery, side effects of medication, and high blood pressure, in addition to the stroke. The resident was to be provided with a safe environment to decrease the risk of falls and that the resident would be free from injury daily for the next 90 days. The approaches for this care planned problem were, to assist with activities of daily living as needed, keep call light within easy reach at all times, tab alarm (a device that is attached to the resident's clothing that will sound an alarm if they attempt to get out of their bed or chair) in bed and wheelchair. According to the physical therapy notes dated 8/15/14, the resident needed moderate assistance to move from lying down to sitting up and minimum to moderate assistance to move from sitting to standing. She was able to walk six feet, twice while holding onto hand rails with moderate assistance. The note revealed that the resident "continues to c/o (complain of) nausea & dizziness." Review of nurses note dated 8/12/14 at 11:35 a.m., revealed that Resident 1 vomited undigested food of a moderate amount, her abdomen was soft and she had a bowel movement the previous day after receiving an enema. The note further revealed that the resident felt dizzy after therapy.Nurses note dated 8/13/14 at 12:30 p.m., revealed that Resident 1 vomited once and was given Zofran (an anti-emetic medication) 4 mg. for vomiting with relief. Review of nurse note, dated 8/16/14 at 3:30 p.m., showed Resident 1 vomited a moderate amount of undigested food and medications twice. She was given Zofran at 12 p.m. She was "checked for (fecal) impaction - negative. An enema given at 1:50 p.m.)." The next nurse's note dated 8/16/14 at 3 p.m., revealed Resident 1 was found on the floor lying on her right side. She complained of pain on the right side of her head. Another nurse's note timed at 5 p.m. revealed Resident 1 had a bump on the back of her head with slight bleeding noted. The advice nurse was notified and the orders were received from the on-call medical doctor was to transfer the resident to the acute hospital. She was transferred at 5:55 p.m. by ambulance to the hospital.In a telephone interview on 9/10/14 at 12:35 p.m., LVN 1 (licensed vocational nurse) stated she was told by her team leader (registered nurse (RN 1) on 8/16/14 that she had to give Resident 1 an enema because she hadn't had a bowel movement. LVN 1 stated she and RN 1 went together to the resident's room to give the enema. She asked the resident's family members to go out of the room for a while. LVN 1 stated that she turned the resident on her left side, closed the curtain and then RN 1 administered the enema. It was almost 3 p.m. at the end of her shift. LVN 1 left the resident on her side with the bed rails up. She stated, "I know she's confused, can only say yes or no...don't think she knew how to do (the) call light." LVN 1 then put her diaper on and left the room.In a telephone interview on 10/6/14 at 8:07 a.m., RN 1 stated she remembered giving the enema to Resident 1 and a few minutes later after she left the room, a visitor flagged her down and told her Resident 1 was on the floor. A review of the "Supervisory Post Fall Check List" dated 8/16/14 revealed that the resident did not have an alarm on. The discharge summary from the acute care hospital, dated 9/3/14 at 3:16 p.m. revealed Resident 1 was admitted to the hospital on 8/16/14 after "sustaining trauma to the back of her head due to a fall" at the facility. "CT (scan) of the head showed bleeding in the anterior falx (under the thick membrane surrounding the top half of the brain)." Resident 1 returned to the facility on 9/3/14.The above violation has a direct or immediate relationship to patient health, safety or security of residents |
| 140000023 |
Kindred Nursing and Healthcare - Bayberry |
020011891 |
B |
21-Dec-15 |
P8XS11 |
4271 |
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 residents dignity and respect in full recognition of his or her individuality.The facility violated the above regulation by failing to ensure Resident 1 was treated with dignity and respect when Certified Nurse Assistants (CNAs1 and 2) held his arm down and proceeded to change his brief over his objections resulting in Resident 1 becoming agitated and withdrawn. The Department received a report and started an investigation of the incident of 7/8/15 at 5:00 a.m. Review of the record showed Resident 1 was admitted on 1/14/14 with diagnoses including non-traumatic intracranial hemorrhage (bleeding into brain tissue), cerebrovascular disease (limited blood flow to the brain), left hemiparesis (weakness or loss of ability to move one side of the body). Review of the Minimal Data Set (MDS-assessment tool used to direct resident care), dated 1/18/14, indicated Resident 1 was cognitively intact. Resident 1 was capable of making himself understood and his speech was clear.In an interview on 7/16/15 at 12:20 p.m., the Executive Director (ED) stated, that on 7/8/15, CNA 1 and CNA 2 provided care to Resident 1 even though he was resistant to care. CNA 2 held down Resident 1's right hand (left hand was not mobile) while CNA 1 provided care. CNA 1 and CNA 2 did not report to Registered Nurse (RN) 1 that Resident 1 refused care. According to the ED, CNA 1 and CNA 2 should have taken a step back from Resident 1 when he refused care, saying, "No", as he had a right to refuse care. Resident 1 was upset about the incident.In an observation and concurrent interview on 7/16/15 at 1:00 p.m., Resident 1 stated he was awakened around 5:00 a.m. on 7/8/15 by CNA 1 to change his clothes. Resident 1 stated he told CNA 1 and CNA 2, "No," and to get out of his room. Resident 1 demonstrated how CNA 2 held his right wrist against the side rail of the bed by placing his right hand against the side rail. Resident 1 stated he told CNA 1 and CNA 2 to stop what they were doing, but CNA 1 and CNA 2 continued to provide care. Resident 1 stated CNA 1 twisted his left wrist and he was very upset. Resident 1 stated he could not put into words how he felt about the incident, and that what they did was not right. In an interview and concurrent record review on 7/16/15 at 2:20 p.m., the Director of Staff Development (DSD) stated CNA 1 and CNA 2 should have reported to their charge nurse if Resident 1 refused care.In a telephone interview on 7/20/15 at 1:25 p.m., CNA 1 stated he would continue to provide care if a resident continued to be angry or agitated.In a telephone interview on 7/20/15 at 1:45 p.m., CNA 2 confirmed Resident 1 got agitated during the care provided on 7/8/15. In a telephone interview on 8/11/15 at 9:30 a.m., Registered Nurse (RN) 1 stated Resident 1 reported CNA 1 yanked off Resident 1's blanket before providing care and that Resident 1 felt humiliated by that action. RN 1 stated Resident 1 reported CNA 2 held Resident 1's right hand while the CNAs provided care. RN 1 stated Resident 1 was highly upset and got agitated from the care he received.Record review of Resident 1's Progress note, dated 7/11/15, showed, "Appears to be withdrawn and displays occasional agitation." Review of the facility's policy and procedure titled, "Resident Rights," revised 4/28/09, showed, "Residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care." Review of the facility's undated policy, "Interventions for Distressing Behavior," indicated if resident refused care staff are to, "Choose schedules consistent with the resident's interests and preferences. Re-approach at a later time." Therefore the facility violated the above regulations by failing to failing to ensure Resident 1 was treated with dignity and respect when Certified Nurse Assistants (CNAs1 and 2) held his arm down and proceeded to change his brief over his objections resulting in Resident 1 becoming agitated and withdrawn. These violations had a direct or immediate relationship to the health, safety, security or emotional well-being of the patient. |
| 140000023 |
Kindred Nursing and Healthcare - Bayberry |
020011892 |
B |
21-Dec-15 |
FW6U11 |
5805 |
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 violated the above regulation when it failed to protect Resident 3 from abuse when Certified Nurse Assistants (CNAs) 2 and 4 forced her to get her brief changed while holding her hands down, causing painful skin tears. The Department received a report of abuse by two CNAs on 2/4/15. During an observation and concurrent interview on 2/12/15 at 9:40 a.m., Resident 3 stated CNA 2 entered her room without introducing themselves around 4:00 a.m. on 2/4/15 and wanted to change her adult briefs. Resident 3 told CNA 2 that she did not need to be changed and refused care. Resident 3 stated both CNA 2 and CNA 4 then entered her room a second time, turned her light on and proceeded to change her adult brief. Resident 3 stated that CNA 2 said to her that she was going to be changed whether she liked it or not. Resident 3 stated that CNA 4 held both of her hands down while CNA 2 changed her adult brief. This made (Resident 3) mad and that she had to fight them off as they changed her. Resident 3 stated that CNA 2 and CNA 4 did not listen to her as she refused care. Resident 3 stated she did not need to be changed if she did not want to be changed. Resident 3 stated she was angry that the facility could have someone like CNA 2 and CNA 4 working at the facility and what they did was not right. Resident 3 showed where she had been injured on her left lower arm. There was red and black discoloration spread throughout the back of Resident 3's left hand and red and black discoloration on the back of her left forearm. Both had gauze dressings on top of the injuries. Resident 3 stated that her skin came off where CNA 4 held both of her hands down. Resident 3 stated that the skin tears hurt a lot and that they bled at both sites.Record review of Resident 3's Minimum Data Set Assessment (MDS-an assessment tool used to direct care), dated 1/21/15, showed a Brief Interview for Mental Status score that indicated Resident 3's thinking and reasoning ability was intact. Resident 3's MDS showed she had clear speech and could make herself understood. Resident 3's MDS showed that Resident 3 required only one person's physical assistance for moving in bed and for toilet use.In an interview on 2/12/15 at 1:15 p.m., the Social Service Designee (SSD) stated Resident 3 did not like to be woken up before 6 a.m. by anyone. The SSD stated that Resident 3 was angry and upset after the incident and preferred that CNA 2 and CNA 4 not care for her any longer. The SSD confirmed that Resident 3 was alert and orientated, and was able to make her needs known. In a telephone interview on 2/12/15 at 1:40 p.m., Registered Nurse (RN) 1 stated she had found Resident 3 to be upset and did not want to be wakened early in the morning to receive care. RN 1 stated that Resident 3 said, "Get out, get out," to CNA 2 and CNA 4. RN 1 stated that Resident 3 had fragile skin upon admission to the facility. When asked if Resident 3 used her call light to ask for care, RN 1 stated that she did not think Resident 3 used her call light for any needs at the time of that incident. In a telephone interview on 2/12/15 at 1:55 p.m., CNA 2 stated that she went into Resident 3's room to check on her. CNA 2 stated that Resident 3 did not want her to touch or change her when she awakened her. CNA 2 stated she asked CNA 4 to assist her with Resident 3's care. CNA 2 stated Resident 3 was really upset and tried to fight off CNA 4 when they changed her. CNA 2 stated she tried to do her job with what she had and that, "When you have 95 patients with four to five CNAs, it is very difficult and a lot of things going on." CNA 2 stated she had spoken to RN 1 prior to Resident 3's being injured and that RN 1 did not say much of anything. CNA 2 stated that she did not know if RN 1 heard her or not.In an interview on 2/13/15 at 9:25 a.m., Resident 3 stated her sleep had not been good since the incident and that she was afraid the two CNAs were going to come back. Resident 3 looked at her left hand and wrist injuries and stated that it, "Kind of makes me mad thinking of it (referring to the incident)." In a telephone interview on 2/13/15 at 9:55 a.m., CNA 4 stated that Resident 3 complained on 2/4/15 when he helped CNA 2 pull the resident up in bed. In an interview on 2/13/15 at 1:15 p.m., the Executive Director (ED) confirmed that Resident 3 refused care when CNA 2 wanted to change her on 2/4/15. When asked what he expected CNA 2 to do when Resident 3 refused care, the ED stated that CNA 2 needed to go to her nurse, so that the nurse could talk to the resident.Review of the facility's policy and procedures titled, "Abuse," last revised on 8/31/12, showed, "Patients have the right to be free of verbal, sexual physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, neglect and misappropriation of patient property." Review of the facility's policy and procedures titled, "Resident Rights," last revised on 4/28/09, showed, "Resident Rights include the resident's right to: have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care." Therefore, the facility failed to protect Resident 3 from abuse when Certified Nurse Assistants (CNAs) 2 and 4 forced her to get her brief changed while holding her hands down, causing painful skin tears. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000079 |
Kindred Nursing and Rehabilitation - Medical Hill |
020013171 |
B |
2-May-17 |
066V11 |
4882 |
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. (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 provide an assistive device to prevent accidents when Certified Nursing Assistant (CNA) 1 served Resident 1 hot tea in a lightweight foam cup, Resident 1 spilled the hot tea on herself and sustained a second degree burn (involves the first two layers of skin and may appear as deep, reddening, and blistering of the skin) on the inside of her elbow.
Review of the "Face Sheet," (a document that gives a resident's information at a quick glance) dated 3/1/17, indicated Resident 1 was a XXXXXXX year old admitted to the facility with multiple diagnoses that included dementia with behavioral disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and psychosis, (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality).
Review of the "Minimum Data Set" (MDS - an assessment tool which guides care), dated 12/29/16, indicated that Resident 1 had severe mental cognition (did not have the ability to reason or remember clearly).
Review of the "Care Plan," dated 1/1/17, indicated Resident 1 was "...at risk for injury (related to) getting hot water in the kitchen or sink for her tea. Resident is non-compliant with it. Resident only wants only xyloform (a type of Styrofoam) cups...staff to assist resident in getting warm water instead of hot water...."
During an interview with CNA 1, on 3/3/17 at 1:20 p.m., CNA 1 stated Resident 1 "liked her water really hot and will throw the cup of water at us if it is not hot enough." CNA 1 stated she brought Resident 1 tea on 3/1/17, but the resident said the water was too cool.
During a telephone interview with CNA 2, on 3/6/17, at 2 p.m., CNA 2 stated Resident "...does not like it (tea) warm, she wants it very hot or she will throw it at me. I use a big Styrofoam cup and put it on her tray with breakfast...she (Resident 1) throws something every day...."
During an interview with the Director of Nursing (DON) on 3/3/17, at 12:50 p.m., the DON stated Resident 1 had a long history of aggressive behavior and throwing her meal trays. The DON stated Resident 1 would only use a large foam cup and requested the water to be very hot for her tea. The DON stated Resident 1 would throw the cup with water at the CNAs if the water was not hot enough.
During an interview with the DON, on 3/3/17, at 12:50 p.m., the DON stated that Resident 1 had a two centimeter (cm) by two cm burn blister on her arm.
Review of the "Health Status Note," dated 3/1/17, at 9:45 a.m. indicated Resident 1 "...spill hot water on herself and burn her right forearm..."
Review of the "Weekly Skin Alteration Report," dated 3/1/17, at 11:43 a.m. indicated "...D. Assessment/Careplan Summary 1a. Summary of Care and Treatment of Wound "Resident will always ask for hot water for her tea and gets agitated when the water is not hot enough. She was given hot water this morning by CNA and assisted to make the tea with lemon before CNA left the room. After a few minutes staff heard yelling in her room and rushed into room. Charge nurse notice the cup on the floor and resident was complaining of discomfort in her right antecubital (inner arm in front of elbow). First degree burn noted...."
Review of the "Treatment Administration Record," dated March 2017, indicated Resident 1 had physician's order for a daily wound treatment for a burn to her right antecubital elbow.
Therefore, the facility violated the aforementioned regulation by failing to provide an assistive device to prevent accidents when Certified Nursing Assistant (CNA) 1 served Resident 1 hot tea in a lightweight foam cup, Resident 1 spilled the hot tea on herself and sustained a second degree burn (involves the first two layers of skin and may appear as deep, reddening, and blistering of the skin) on the inside of her elbow.
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000112 |
Kyakameena Care Center |
020013333 |
B |
3-Oct-17 |
NLPT11 |
6627 |
THIS CITATION IS AMENDED TO CORRECT THE DATE OF ISSUANCE
FROM 7/12/2017 TO 7/13/2017. ALL OTHER ITEMS OF THE CITATION
REMAIN UNCHANGED AND EFFECTIVE.
483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to follow the aforementioned regulation by failing to implement physician's orders to assess and provide appropriate pain relief based on comprehensive assessment and care plan for one resident (Resident 1) who was on hospice care (Hospice program - supportive care for the end of life with focus on comfort and quality of life) and suffered from chronic and acute pain.
Review of Resident 1's Minimum Data Set (MDS- comprehensive assessment tool) dated 4/06/16 showed Resident 1 was admitted to the facility on XXXXXXX16 with multiple diagnoses that included prostate cancer and painful muscle spasm, and involuntary and repetitive muscle contractions that cause twisting of body parts. "Brief Interview of Mental Status" score of 15 (Resident 1 had an accurate recall of short and long-term memory). Assessment of activities of daily living assistance showed Resident 1 was totally dependent on staff with one person physical assist for moving in bed, dressing, eating, personal hygiene, and bathing. The pain assessment showed Resident 1 was "Almost constantly having pain" with pain intensity of 8 from pain scale of 0 - 10.
Review of Resident 1's care plan dated 3/25/16 for pain due to prostate cancer and painful muscle spasm indicated "Assess intensity of pain on 1- 10 scale if resident is able. Also assess for quality of pain, e.g., burning, throbbing, aching, dull, or sharp. Pain scale for alert/oriented residents: 1 - 3 = mild pain, 4 - 7 = moderate pain, 8 - 10 severe pain ....Medication per order. "A Hospice care plan dated 3/25/16 showed that "Observe resident for s/s of pain &or discomfort & medicate prn [as needed]" (s/s - signs and symptoms; prn - as needed).
Review of Resident 1's Hospice order dated 3/24/16 showed the following: morphine sulfate 20 milligram/millimeter (mg/ml) to be given 0.25 ml under the tongue every one hour as needed for pain (Morphine Sulfate - narcotic pain medications used to treat moderate to severe pain). Monitor episodes of pain every shift. Monitor episodes of difficulty breathing. Another physician order by Resident 1's admitting doctor dated 3/25/16, for Morphine Sulfate 20 mg/ml, 0.25 ml every hour as needed for shortness of breath or pain.
Review of Resident 1's Medication Administration Record (MAR) for the month of March 2016, showed Resident 1 was not assessed for pain on 3/25/16. On 3/26/16 Resident 1 complained of pain twice with a level of 9 and 8. On 3/27/16, Resident 1 was not assessed for pain. On 3/28/16, Resident 1 had pain twice at a level of 8 on both occasions. On 3/29/16, Resident 9 was not assessed for pain. On 3/30/16, Resident 1 had pain at a level of 5. On 3/31/16, Resident 1had pain once with level of 8. Resident 1's MAR for the months of March and April did not reflect a pain assessment every shift as ordered.
During an interview on 4/27/16, at 9:35 a.m., Resident 1 stated during the first few days he was in the facility he waited a long time for the nurse to get his pain medications. Resident 1 added that while he was waiting he would try to reposition himself just to get some relief.
During an observation and interview on 4/28/16, at 1:30 p.m., Resident 1 stated he had pain all the time in his feet and pointed to his right wrist.
During an interview and concurrent record review on 4/29/16, at 10:40 a.m., Physician 1 stated it was a problem that Resident 1's pain was not being assessed on regular basis and his pain was not controlled. Physician 1 further stated that it was a concern the morphine sulfate and pain assessment every shift that was ordered, was not transcribed on the electronic MAR.
During an interview and concurrent record review on 4/28/16, at 3:45 p.m., Hospice Nurse stated Resident 1 had no orders for around the clock pain control medication. Hospice nurse stated the Morphine Sulfate was not the first pain medication the nurse should use. On the MAR for 3/26/16 at 02:07 a.m., Resident 1 had a pain level of 9, Hospice nurse stated Resident 1 received Tylenol with codeine #4 tablet (Tylenol combined with narcotic pain medication) and if the nurse reassess him about three hours later and pain was still present then, the nurse could use the Morphine Sulfate. Hospice Nurse added the nurse should monitor Resident 1's pain level at least every shift. Hospice Nurse stated Resident 1 reported he wished the nurses could get to him faster.
Review of hospice nurse's note dated 3/29/16 at 10:30 a.m., showed "Pt states wants to make sure he gets meds on time."
During a follow up interview on 4/29/16, at 11:20 a.m., Hospice Nurse stated at a level of 9/10 on the pain scale, it was more appropriate to treat the pain with Morphine Sulfate, since Morphine Sulfate would give Resident 1 a quicker relief from pain.
During an interview and record review on 4/29/16 at 7:40 a.m., Director of Nursing (DON) confirmed the Morphine sulfate 20 mg/ml, to be given under the tongue ever hour as needed for pain was not on the MAR, and there was no pain assessment every shift.
During an interview and concurrent record review on 4/29/16 at 1:15 p.m., DON reviewed Resident 1's MAR and confirmed the pain scale approved by the facility to use by nursing staff for assessing resident's pain was not listed on the MAR.
Review of the facility's policy and procedure titled "Pain Management" dated 09/01/2008 showed, "To assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication .... The licensed nurse shall assess the resident's pain utilizing the pain scale approved by the facility. "The facility's pain scale showed 0/10 - no pain; 4 - 7/10 - moderate pain; 8 - 9/10 - severe pain; 10/10 -excruciating pain.
Therefore the facility failed to implement physician orders to assess and provide appropriate pain relief based on comprehensive assessment and care plan. Resident 1 experienced unrelieved pain and unnecessary suffering due to lack of assessment and appropriate pain management.
The above violation has a direct relationship to the health, safety or security of patients. |
| 140000083 |
Kindred Transitional Care and Rehabilitation-Walnut Creek |
020013410 |
AA |
7-Aug-17 |
RVFM11 |
10846 |
483.25(k) - TREATMENT/CARE FOR SPECIAL NEEDS
The facility must ensure that residents receive proper treatment and care for the following special services:
(4) Tracheostomy care
The facility failed to provide proper treatment for tracheostomy care by failing to ensure staff hyperextended Resident 1's neck prior to changing a tracheostomy tube, as indicated in the facility's policy and procedure; and by failing to use an oral bag mask (BVM) to ventilate when Resident 1 experienced respiratory difficulty after the new tracheostomy tube was inserted, resulting in Resident 1's subsequent death.
Review of the clinical record showed Resident 1 was admitted on XXXXXXX 15 with diagnoses including acute and chronic respiratory failure. Resident 1 had a tracheostomy (a surgical opening through the neck into the trachea (windpipe) to allow for mechanical breathing in patients with respiratory failure and dependency on a ventilator (a breathing machine).
On 10/28/15, the Director of Respiratory Therapy (DRT), Respiratory Therapist (RT) 1, RT 2, and Medical Doctor (MD) 1 performed a scheduled tracheostomy tube change ordered for Resident 1. The DRT documented vital signs for Resident 1's prior to the tracheostomy change as follows: oxygen saturation level 99% (a measurement of oxygen concentration in the blood normal: 95-100%), heart rate was 73 beats/minute (normal: 60-100), respiratory rate was 14 breaths/minute (normal: 10-20). RT 2 stated Resident 1 did not have any respiratory issues prior to the tracheostomy tube change.
Review of the facility's policy and procedures, "Tracheostomy tube change," revised on 10/31/08, indicated to, "Hyperextend: (to extend beyond the normal range of motion) the resident's neck by placing a folded towel under the neck. Inflate the tracheostomy cuff (a balloon that seals off the space between the wall of the trachea and the trach tube), if physician ordered: a. Fill syringe with 10 ml of air, and attach to cuff inflation port. b. Place stethoscope over trachea. c. Slowly inflate the cuff until no airflow is heard during inspiration. d. Slightly deflate the cuff until a minimal amount of airflow is heard."
In an interview on 11/9/15 at 8:48 a.m., the DRT confirmed Resident 1 was placed in a semi-fowler's position (a position with the head of the bed elevated approximately 30 to 45 degrees) with Resident 1's neck extended. DRT stated Resident 1's stoma (an artificial opening in the neck area to allow for the tracheostomy) was patent and opened as he withdrew the old tracheostomy tube. The DRT stated he met resistance when he inserted Resident 1's new tracheostomy tube. DRT stated 15 seconds after he connected Resident 1's tracheostomy to the ventilator, Resident 1's condition changed and Resident 1's oxygen saturations decreased, Resident 1's heart rate was above 100 (60 to 100 beats per minute is normal), subcutaneous tissue emphysema was noted on the left side of Resident 1's neck, and Resident 1's lungs felt "tight". The DRT stated he deflated Resident 1's tracheostomy cuff and attempted to realign Resident 1's tracheostomy tube by backing it out, but he did not take the tracheostomy completely out. DRT stated Resident 1's oxygen saturation levels went up and down. The DRT stated he ventilated Resident 1 via Resident 1's tracheostomy tube with a bag-valve mask (BVM, a hand-held, manual, self-inflating bag used to provide ventilation) until the paramedics arrived.
In an interview on 11/9/15 at 9:40 a.m., RT 1 confirmed Resident 1's facial skin color turned to "ashy color" and her oxygen saturation levels dropped and fluctuated between 58 to 80% after the tracheostomy change.
In an interview on 11/18/15 at 10:45 a.m., RT 2 stated moments after Resident 1's tracheostomy tube was attached to the ventilator, Resident 1 developed subcutaneous tissue emphysema (air trapped under the skin) on the left side of her neck and her skin changed to "greyish-blue, dusky". RT 2 confirmed Resident 1 had diminished breath sounds in the left lung after the tracheostomy tube change. RT 2 confirmed Resident 1's skin color remained "dusky" when Resident 1 was taken to the hospital by paramedics and stated Resident 1's tracheostomy tube could have been misplaced during the tracheostomy tube change.
In a telephone interview on 11/18/15 at 11:45 a.m., RT 1 confirmed she had met resistance when she attempted to suction Resident 1 via the tracheostomy tube. RT 1 stated there were scant, blood-tinged secretions when she tried to suction the tracheostomy tube. RT 1 stated Resident 1's oxygen saturation levels were in the 80s and her heart rate was in the 120s after the DRT manipulated and repositioned Resident 1's tracheostomy.
In a telephone interview on 12/31/15 at 9:00 a.m., RT 2 stated a misalignment of a tracheostomy tube would cause subcutaneous tissue emphysema in the neck and confirmed Resident 1 was ventilated with a BVM through the tracheostomy tube and not through the mouth when subcutaneous tissue emphysema was noted on the left side of Resident 1's neck.
In a telephone interview on 12/31/15 at 9:20 a.m., RT 1 confirmed Resident 1 was ventilated with a BVM through the tracheostomy tube and not through the mouth. RT 1 confirmed Resident 1 was placed in a semi-fowler's position with no support under the neck. RT 1 stated Resident 1 started to develop subcutaneous tissue emphysema in the left neck area after her new tracheostomy tube was inserted.
In a telephone interview on 12/31/15 at 11:00 a.m., an Ears, Nose and Throat Doctor (ENT) from the General Acute Care Hospital that treated Resident 1 in the Emergency Room) stated the best position to do a tracheostomy tube change was to have a patient in a supine (flat on the back facing up) position with the neck extended and a towel placed under the neck, which would allow the neck to be more exposed visibly. The ENT stated, to indicate if a tracheostomy tube was placed correctly staff could pass a suction catheter through the tracheostomy tube without resistance, and listen to both lungs for good air exchange. The ENT stated manipulating the tracheostomy tube while still in the trachea would not help and may create a false passage. The ENT stated the tracheostomy tube must be taken out and re-inserted with a smaller sized tracheostomy tube if there were any problems in ventilation. The ENT stated covering the stoma and using a BVM via mouth was a way to properly ventilate someone in an emergency if ventilating via the tracheostomy was not an option.
In a telephone interview on 12/31/15 at 11:40 a.m., the DRT stated there were no emergency protocols or policy and procedures in an event like this, only to call 911. The DRT stated he did not feel comfortable to change the tracheostomy tube to a smaller size and confirmed he ventilated Resident 1 via the tracheostomy tube and not by the mouth with a BVM.
Record review of "Progress notes", dated 10/28/15 by the DRT showed, "Upon insertion DRT met resistance approximately two inches into stoma. Clear (breath sounds) on the right (lung), diminished on the left (lung). Shortly after Resident 1's oxygen saturation levels began to drop. Resident 1 placed on 100% oxygen via BVM. Resident 1 had a change in color, absent breath sounds on the left. Heart rate in the 120s. MD 1 noticed crepitus (a clinical sign characterized by a crackling or popping sound of air in the soft tissue) around neck. Resident 1 suctioned several times, blood tinged secretions".
Record review of MD 1's "Progress Note," dated 10/28/15, showed, "Resident 1's tracheostomy change got complicated with acute respiratory failure. RT 1 realigned the tracheostomy and did multiple suctions which were blood tinge for decrease oxygenation. Although her oxygen improved to the 90's initially and later fluctuated between 53-98%, also Resident 1 developed chest crepitus (crackling sound under the skin), 911 was called, started bagging (artificial respiration with a hand held air bag) and patient was transferred to acute care for tachycardia (rapid, ineffective heart beat) with decrease oxygen saturation (amount of oxygen in the blood)."
Record review of the Emergency Medical Technician-Paramedic "Patient care report", dated 10/28/15, showed, "Per RT upon insertion of new (tracheostomy) tube resistance was met and blood was noted around stoma. Staff member states poor BVM compliance noted. RT states subcutaneous (tissue) emphysema noted to left chest and believes tracheostomy may be displaced. Skin temperature cool, Skin color cyanotic, left lung sounds absent, right lung sounds decreased, capillary refill (a quick test to indicate blood flow in the tissue) absent, level of consciousness unresponsive, heart rate 134, and oxygen saturations 70% with supplemental oxygen".
Record review of "Emergency Department (ED) nursing notes", dated 10/28/15 showed, "Blood coming from tracheostomy tube. Crepitus around trachea. Resident 1 is mottled (spots or patches with different colors).
Record review of the "ED Physician progress notes", dated 10/28/15 at 1:40 p.m. showed, "...(Resident 1) with emergent airway issue and prolonged anoxia (absence of oxygen) with apparent severe brain injury...Unable to ventilate through trach in place with subterranean air(crepitus) felt in surrounding tissue...Time of death 1:20 (pm)."
Record review of the "Coroner's Report", dated 3/31/16 showed, "Autopsy (an examination used to determine the cause of death) findings: Perforation (a hole made by piercing) of posterior wall of esophagus (throat) and trachea due to improper placement of tracheostomy tube, with tip of tracheostomy tube impacting fifth cervical vertebrum (the upper spine that form the neck). These findings are consistent with placement of the tube in the esophagus with perforation. There is also evidence of the tracheostomy tube causing perforation of the trachea and entry of the tip of the tube into the lower esophagus. Cause of Death: Acute respiratory failure, with bilateral collapsed lungs, due to improper placement of tracheostomy tube, with tracheal and esophageal perforation".
The facility failed to provide proper treatment for tracheostomy care by failing to ensure staff hyperextended Resident 1's neck prior to changing a tracheostomy tube, as indicated in the facility's policy and procedure; and by failing to use an oral bag mask (BVM) to ventilate when Resident 1 experienced respiratory difficulty after the new tracheostomy tube was inserted, resulting in Resident 1's subsequent death.
These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient. |
| 140000083 |
Kindred Transitional Care and Rehabilitation-Walnut Creek |
020013446 |
B |
23-Aug-17 |
L4B011 |
5011 |
F323
483.25(d)(1)(2) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility violated the aforementioned regulation by failing to provide Resident 1 supervision and assistance with drinking hot tea which resulted in Resident 1 spilling hot tea on her abdomen and sustaining a second degree burn (involves first two layers of skin, may appear as a deep reddening and blistering of the skin).
On 5/16/17 Resident 1's caregivers reported to the Administrator (Admin) that there was a wound on Resident 1's abdomen. The wound was a burn from hot tea spilled on herself, as she was given a foam cup with, "The wrong lid."
Review of the record on 5/18/17 indicated Resident 1 was admitted on XXXXXXX17 with diagnoses including multiple sclerosis (a disease damaging the protective coverings of nerves. Symptoms can include vision loss, numbness, dizziness, lack of coordination and weakness).
Record review of the Minimum Data Set Assessment, dated 5/6/17, on 5/23/17 indicated, Resident 1 had a Brief Interview for Mental Status score of 15 (no deficits in mental ability). The assessment indicated Resident 1 needed, "Supervision" and "setup help," for eating and drinking (food and utensils set up so the resident could feed herself and drink safely).
During an interview and observation with Resident 1 on 5/18/17 at 3:20 p.m., Resident 1 lifted her gown and showed a bright red open wound on her abdomen about two inches long with no dressing on it. Resident 1 stated it (the wound) was supposed to have a (brand name non-stick) dressing on the wound. Resident 1 stated it was painful. Resident 1 said she had been served hot tea in a foam cup. Resident 1 stated the cup usually came with a "slitted" top for sipping. Resident 1 took a foam cup cover that was lying on her table and put it over a foam cup to show the way she was given the hot tea when she got burned. The lid was larger than the cup opening and did not fit. Resident 1 said she spilled the hot tea on herself. Resident 1 stated, her "Left hand wasn't working so well" and the tea had been placed on the over bed table to her left side. Resident 1 stated someone brought her a cold towel and an ice pack for the burn. Resident 1 stated the burned area blistered, and then the skin came off.
During an interview with Certified Nurse Assistant (CNA) 1 on 5/17/17 at 3:15 p.m. CNA 1 stated Resident 1 liked to use the foam cup with a lid, rather than a regular coffee cup for tea, because the coffee taste stayed in the cups. CNA 1 did not know when Resident 1 spilled the hot tea.
During an interview with the Admin on 5/18/17 at 3:10 p.m. she stated the temperature of the hot water from the kitchen was 175 to 180 degrees Fahrenheit (F). The Admin stated no one reported the accident with the hot tea and it was not known when it actually happened.
Review of the medical record Progress Notes, written by Registered Nurse (RN) 1, dated 5/16/17 12:55 a.m., indicated, "Situation: skin excoriation to left lower abdomen. Measurement 4.2 cm (centimeters) by 3.1 cm. CNA called writer and reported about the skin issue noted on patient's left lower abdomen...Assessed skin, noted redness, irregular size, skin is excoriated (damaged to the skin, causing redness), no drainage. Surrounding skin is normal. Cleansed affected site and kept dry, patient denies pain or discomfort, no itchiness."
A physician's order was obtained, four days later, on 5/20/17 for, "Left lower quadrant cleanse with NS (normal saline-salt water), pat dry apply Xeroform dressing (petroleum dressing that doesn't stick to wounds) and cover with foam dressing every day shift every other day."
A review of the facility's policy, Guidelines for Hot Beverages, dated 10/31/08, indicated the temperature for coffee was 185 to 200 degrees F, the recommended temperature for brewing black teas..."This temperature can result in a burn if the beverage comes in contact with the skin."
Precautions can be implemented to limit the risk of burns from hot beverages.
General Guidelines:
5. When serving hot liquids to residents, consider the following:
a. Don't overfill drinking cups
b. Place beverage away from the edge of the table and near resident's dominant hand.
6. Identify residents who may be at greater risk of spilling hot beverages on themselves, which may include but are not limited to:
a. residents with tremors (shaking)
b. Resident with poor hand control from CVA (stroke), arthritis (inflammation and pain of joints), weakness, etc."
Therefore the facility failed to provide Resident 1 supervision and assistance with drinking hot tea which resulted in Resident 1 spilling hot tea on her abdomen and sustaining a second degree burn. |
| 030001605 |
Kindred Transitional Care & Rehabilitation - Siena |
030009085 |
B |
07-Mar-12 |
LKKF11 |
11446 |
F328 Treatment/care For Special Needs - 483.25 (k) The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses. An unannounced visit was made to the facility on 11/2/09 to investigate complaint #CA00205459. The Department determined the facility failed to: Ensure the facility met the special respiratory needs of the resident. This failure resulted in Resident A becoming hypoxic (a condition in which the body is deprived of adequate oxygen supply). Resident A required transfer to the General Acute Care Hospital (GACH) where she was hospitalized for 8 days.Resident A, a 44 year old female, was originally admitted to the facility on 10/10/09, from the general acute care hospital. Her admitting diagnoses included bilateral pulmonary infiltrate (density area on x-ray), right lower lobe pulmonary embolism (occlusion of a major blood vessel to lung tissue resulting in decreased respiratory function), septic shock (generalized blood stream infection with evidence of shock), cellulitis (inflammation) of both hips, anemia and anxiety.Review of Resident A?s GACH Discharge Summary dated 10/10/09, documented her discharge diagnosis included: ?1) Ventilator-dependent respiratory failure secondary to adult respiratory distress syndrome and presumptive H1N1 infection. 2) Pneumonia with respiratory failure. 3) Hypercoagulable (increased blood clot formation) state due to acute infection with pulmonary embolism. 4) Critical-illness anemia. 5) Steroid-induced hyperglycemia?. The GACH Discharge Summary documented under the section ?Hospital Course? that Resident A had ?persistent hypoxemia after extubation (removal of ventilator tube) requiring up to 100% (oxygen via) non-rebreather mask, intermittently with 50% oxygen. The Discharge Summary further documented that Resident A was to be discharged ?on oxygen with the anticipation that the oxygen can be weaned off as she continues to improve.? Review of Resident A?s ?Transfer/Summary Orders to SNF,? dated 10/10/09, contained an order for oxygen to keep Resident A?s oxygen (O2) saturation (Sat) 90%. Resident A?s ?Nursing Assessment/Full,? dated 10/10/09 at 2:45 p.m., documented she was alert and oriented and obeyed commands. The assessment documented that Resident A needed limited assistance with transfers, ambulation/mobility, toilet use and dressing and was independent with eating. A non-rebreather mask (NRB) is a device that allows for the delivery of higher concentrations of oxygen, unlike the nasal cannula. The non-rebreather mask is utilized for patients with physical trauma, chronic airway limitation/chronic obstructive pulmonary diseases, smoke inhalation, and carbon monoxide poisoning, or any other patients who require high-flow oxygen, but do not require breathing assistance. (Wikipedia) A ?Resident Progress Note? dated 10/10/09, documented Resident A was assessed and her heart rate was ?115 bpm (beats per minute) irregular, pounding and galloping.? Resident A was described as being ?very anxious and flushed? and as being on high flow O2. The Licensed Nurse (LN) documented Physician 1 was informed and several orders were received which included Ativan (anti-anxiety), Lasix (diuretic-removes excess water from the body) and to start BIPAP (Bi-level Positive Airway Pressure- a breathing apparatus that helps get more air into lungs). A ?Respiratory Assessment? dated 10/10/09 at 9:40 p.m. was reviewed. The Respiratory Therapist (RT) documented Resident A as awake and alert on 15 Liters of oxygen via NRB. Resident A was described as having ?slight respiratory distress? and described Resident A?s breath sounds as ?coarse and wet sounding.? The RT also documented that Resident A was set up on BIPAP acute cycle with nasal mask and 15 Liters of O2. The RT further documented that Resident A?s O2 saturation was 96%. Review of an ?Initial Respiratory Assessment? (a late entry), dated 10/11/09, documented that at 2:45 p.m. (on 10/10/09) the RT went to Resident A?s room. The RT documented Resident A was status post intubation while in hospital and described Resident A as alert and orientated. The RT documented Resident A was on 15 Liters of oxygen via NRB, O2 saturation 93%, Pulse-109 and RR (respiration rate)-22-24 and described Resident A as being ?slightly labored? and appearing ?anxious.? At 2:50 p.m. on 10/11/09, the RT documented she gave Resident A a breathing treatment of Albuterol via HHN (hand held nebulizer) while on 15 L NRB. At 4:00 p.m. the RT documented Resident A was complaining of SOB (shortness of breath). The RT documented Resident A?s lungs were clear bilaterally and her O2 Sat was 94% on 15 LPM on NRB. Resident A?s RR was 21-22 and slightly labored. Resident A requested another breathing treatment and it was administered as ordered.The RT documented at 5:20 p.m. on 10/11/09 that Resident A was complaining of SOB. The RT documented Resident A?s lungs were clear bilaterally and her O2 Sat was 96-97% on 15 LPM on NRB. The RT documented Resident A was complaining of being ?hot? and feeling ?claustrophobic.? Resident A was moved to a private room. The RT documented during the transfer Resident A was disconnected from O2 to be placed on another source of O2 and Resident A?s O2 Sat declined from 95% to 84% in less than 10 seconds. At 7:00 p.m. the RT documented Resident A?s HR (heart rate) was 115 and her lung sounds were coarse and wet.The RT documented this was a ?change in condition? and further documented upon auscultation Resident A?s heart was ?irregular and pounding.? The RT described Resident A as having ?increased anxiety? and as being ?flushed.? The RT documented the LN informed Physician 1 of Resident A?s condition and an order was received for Lasix, Decadron (Corticosteroid- used to treat inflammation of the skin, joints, lungs, and other organs) and BIPAP. At 11:40 p.m. the RT documented BIPAP was started. A ?Resident Progress Note,? dated 10/11/09 at 4:20 a.m., documented Resident A?s pulse was 103 and her respirations were 24. The Progress Note documented that Resident A had refused to wear the BIPAP around 1:00 a.m. Resident A ?couldn?t breathe? and ?felt it wasn?t helping.? According to the Progress Note, Resident A was switched over to the NRB per Resident A?s request. The Progress Note documented Resident A?s O2 saturation was 95% on 15 L and that there was ?no further complaints of SOB (shortness of breath).? The Progress Note further documented there was no signs or symptoms of cardiac or respiratory distress. On 10/11/09, with no time documented, an order was received to decrease Resident A?s O2 to 3 L/min via a mask. A Resident Progress Note, dated 10/11/09 at 10:30 a.m., documented Resident A?s vital signs were the following: BP-110/74, P-90, T-97.4, R-24 and O2 saturation was 98% on 15 L via NRB mask. Physician 1 ?suggested? lowering O2 to 3L/min. The Progress Note documented Resident A was only on 3L/min for ?< 2 minutes? when Resident A was unable to tolerate it. The Progress Note documented Resident A?s O2 sat was checked immediately and was 40% and Resident A?s heart rate increased to 140 BPM per the O2 saturation monitor. The Progress Note documented Physician 1 immediately came back to the room and Resident A was put back on 15 L via NRB. Resident A?s O2 saturation was documented as increasing to the low 80?s but Resident A was described as ?flushed and very SOB.? The Progress Note documented, per Physician 1, Resident A was ?hypoxic? and was to be sent to the ?ER Stat.?During a telephone interview with Registered Nurse (RN) 1, on 11/20/09 at 1:00 p.m., she confirmed she recalled getting a report from the previous shift (night shift) regarding Resident A?s condition/status. RN 1 stated Physician 1 came into the facility and she talked to him at the Nurse?s Station stating it would be difficult for Resident A to participate in therapy if on 15 L NRB. RN 1 stated Physician 1 responded to the fact that her O2 level was way too much and wrote an order to decrease Resident A?s O2 to 3 liters via nasal cannula (N/C). RN 1 also stated she was in Resident A?s room when he told the resident that he reviewed her chart.When RN 1 was asked if she thought it was drastic to reduce Resident A?s O2 from 15 L to 2 liters she stated, ?not really? and further stated Resident A?s O2 saturation was 98% and the mask ?looked like it was too much.? RN 1 was further asked if the RT?s late entry had been in Resident A?s clinical record would she have questioned whether the order was appropriate. RN 1 was also asked what she would do if she didn?t agree with a physician?s order. She stated she would question the order and not implement the order.During a telephone interview with Respiratory Therapist (RT) 1 on 11/20/09 at 1:40 p.m., she confirmed there was no RT in the facility on 10/11/09, when Physician 1 ordered Resident A?s O2 level to be reduced to 3 liters. RT 1 was asked if it was standard practice to reduce a patient?s O2 from 15 L NRB to 3 L via N/C in which she responded, ?No.? RT 1 was then asked if she would have recommended this she stated, ?No.? RT 1 was asked, if she was in the facility at the time of the incident, what she would have recommended.She stated she would have reduced Resident A?s O2 to around ?10 L.? RT 1 also confirmed going from 15 L NRB to 3 L via N/C was a drastic measure.During an interview with Administrative Staff (AS) 1 on 11/2/09 at 9:05 a.m., she stated she would expect the LN to question the physician?s order if the LN had concerns regarding the order. AS 1 further stated if the LN did not like or agree with the physician?s explanation, the LN could refer to the RT or Pulmonologist. AS 1 also stated being a nurse herself she would have questioned the order.The Discharge Summary documented under the section ?History of Present Illness? that Resident A was ?discharged on 10/10/09 to Siena for pulmonary rehab and unfortunately after her arrival there her oxygen was drastically reduced from 50% mask to 3 liters. The patient (Resident A) developed hypoxia? Review of Resident A?s GACH ?Discharge Summary? dated 10/19/09, documented her diagnosis included: 1) Episode of ventilator-dependent respiratory failure secondary to pneumonia and acute respiratory distress syndrome readmitted this hospitalization after a failed skilled nursing facility placement for pulmonary rehab. 2) Persistent hypoxia requiring oxygen on discharge. 3) Sinus tachycardia secondary to hypoxemia and deconditioning. 4) Transient hyperkalemia (increased blood level of potassium) secondary to excess oral potassium.The Department determined the facility failed to: Ensure the facility met the special respiratory needs of the resident when the physician ordered Resident A?s supplemental oxygen to be drastically reduced from 50% via mask to 3 liters via a nasal cannula, effectively delivering 25-30% possibly.This failure resulted in Resident A becoming hypoxic (a condition in which the body is deprived of adequate oxygen supply). Resident A required transfer to the General Acute Care Hospital (GACH) where she was hospitalized for 8 days.This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000074 |
Kit Carson Nursing & Rehabilitation Center |
030009390 |
B |
12-Jul-12 |
K3C811 |
4363 |
F226 Develop/Implement Abuse/Neglect, Etc Policies 483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The following citation was written as a result of an unannounced visit on 3/17/10 to investigate complaint number CA000167694, a facility reported incident. The Department determined the facility failed to ensure an incident of alleged patient abuse was promptly reported to administrative staff for investigation as directed in their Policy titled Reporting Abuse to Facility Management, dated October 2004. This failure resulted in a patient's safety being compromised when a witnessed incident of rough patient handling by a Certified Nurse Assistant (CNA) was not reported to administrative staff as per policy. Patient A was a 99 year old admitted to the facility on 7/11/02. Her diagnoses included Alzheimer's disease and congestive heart failure. A Minimum Data Set (an assessment tool), dated 10/11/08, indicated Patient A had long and short term memory impairments. She had moderately impaired cognition. Patient A was dependent on staff for transfers. A Nurse Notes, dated 10/23/08 at 6:40 p.m., indicated Patient A sustained a skin tear on her right elbow measuring 3 centimeters by 0.5 centimeters (2.5 centimeters = 1 inch. The Note indicated Patient A was asked, "What happened" and Patient A responded, "I don't know how I got [the skin tear]." The Note indicated the skin tear was cleaned and bandaged and Patient A's physician was notified. A Report of Unusual Occurrence written by the Administrator, dated 10/27/08, was reviewed. The report indicated on 10/27/08, the facility's Director of Staff Development (DSD) informed the Administrator that CNA 1 had reported an incident of alleged improper patient handling to her during an in-service training on 10/24/08. According to the report the DSD instructed CNA 1 to report the incident to the Director of Nursing (DON). The report indicated that CNA 1 did not report the incident to the DON. Documentation in the report indicated the DON was not informed of the alleged improper handling until the DSD reported to her on 10/27/08.Documentation in the report detailed the alleged improper handling. On 10/23/08, CNA 1 was working with CNA 2. Both CNAs went to Patient A's room to transfer the patient from her wheelchair to her bed. The report indicated both CNAs were aware Patient A required a two person transfer; however, CNA 2 initiated the transfer by himself. The report indicated CNA 1 alleged CNA 2 "took hold of [Patient A] by inserting both of his forearms under her upper arms, with her forearms hanging down, putting pressure on her shoulder sockets." CNA 1 reported CNA 2 lifted Patient A roughly and "threw her into the bed" despite CNA 1's objections. The report documented Patient A sustained a skin tear which was reported to the Charge Nurse as an "accident."The facility's Reporting Abuse to Facility Management Policy and Procedure, dated October 2004, was reviewed. The Policy directed, "Any individual detecting an incident of Resident abuse or suspecting Resident abuse must promptly report such incident to a member of the nursing staff or to management." An interview was conducted with the DON on 3/17/10 at 11:30 a.m. The DON acknowledged when CNA 1 alleged she had witnessed rough handling toward Patient A by CNA 2 on 10/23/08, she did not promptly report what she had witnessed to the Charge Nurse or management staff. The DON acknowledged when CNA 1 reported the alleged rough handling by CNA 2 to the DSD on 10/24/08, the DSD did not report the allegation, nor did she initiate an investigation into the allegation. The DON acknowledged four days passed before any administrative staff was notified of the alleged incident and an investigation was initiated. The DON stated CNA 2 was terminated due to rough treatment of a patient. The Department determined the facility failed to ensure an incident of alleged patient abuse was promptly reported to administrative staff for investigation as directed in their Policy titled Reporting Abuse to Facility Management, dated October 2004. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000074 |
Kit Carson Nursing & Rehabilitation Center |
030010156 |
B |
26-Sep-13 |
Z69W11 |
8128 |
72315 Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). The following citation was written as a result of an unannounced visit on 8/26/10 for the investigation of complaint number CA00239622. The Department determined the facility failed to: 1. Provide skin assessments as ordered. 2. Provide treatment as ordered when a pressure sore developed. These failures resulted in the development of a pressure sore on Patient A's left heel which was not identified until it was assessed as a Stage III (full thickness tissue loss to subcutaneous tissue, ref. NPUAP 2007). Treatment orders for the pressure sore were not properly implemented to promote healing. "Pressure ulcers are areas of necrosis (dead tissue) and ulceration where tissues are compressed between bony prominences and hard surfaces; they result from pressure alone or pressure in combination with friction, shearing forces, or both. Risk factors include old age, impaired circulation, immobilization, undernutrition, and incontinence. Severity ranges from nonblanchable skin erythema (redness) to full-thickness skin loss with extensive soft-tissue necrosis. Diagnosis is clinical. Prognosis is excellent for early-stage ulcers; neglected and late-stage ulcers pose risk of serious infection and nutritional stress and are difficult to heal. Treatment includes pressure reduction, avoidance of friction and shearing forces, local care, and sometimes skin grafts." Ref. Merck Manual, November 2012.Patient A was a 78 year old admitted to the facility on 7/16/10 for rehabilitation services following a motor vehicle accident. Patient A's diagnoses included surgical repair of a fractured left ankle and diabetes. An Admission Nursing Assessment, dated 7/16/10, did not identify any skin problems with Patient A's left heel. The Assessment did indicate Patient A had a left foot splint, was non-weight bearing on the left lower extremity, and had an incision to the left ankle. A Care Plan entry, dated 7/16/10, indicated Patient A was at increased risk for skin breakdown and/or pressure sores due to decreased activity and poor nutrition. The Approach Plan included monitoring Patient A for skin breakdown and/or pressure sores daily. Physician Progress Notes, dated 7/23/10 and written by Patient A's Orthopedic Surgeon, indicated Patient A was to wear a short leg walking boot on his left leg. Patient A was to remain non-weight bearing on his left leg. The Physician ordered the boot removed daily to check Patient A's skin on his left leg and foot. Documentation in the progress note indicated Patient A's left ankle surgical sites were "well healed." Patient A had a stasis (non-pressure) ulcer on his left outer ankle. The ulcer was covered with eschar (hard, black, thick skin). Patient A was to be re-evaluated by the Orthopedic Surgeon in two weeks. A Care Plan entry, dated 7/23/10, indicated Patient A was to have a short leg walking boot applied upon rising daily. He was to remain non-weight bearing on the left leg. A soft splint with an ace wrap was to be applied at bedtime. Patient A's skin was to be checked daily. Nurse Notes, dated 8/1/10 at 12 p.m. (16 days after admission), indicted a Stage III pressure ulcer had been found on Patient A's left heel. This was the first time the pressure ulcer was identified. Patient A's physician was notified and a treatment order was received to apply antibiotic ointment daily. A Pressure Wound Sheet, dated 8/2/10, revealed Patient A had a Stage III pressure sore on his left heel. The sore measured 2 centimeters (cm) x 2 cm with .25 cm depth. The color was pink/purple with minimal drainage and 10% necrosis (dead tissue). Physician Progress Notes, dated 8/2/10, indicated Patient A was evaluated by his Orthopedic Surgeon. The physician documented the patient had a "new posterior wound [with signs and symptoms] of drainage." The physician ordered to continue the short leg boot during the day and the application of absorbent foam for the posterior left heel wound. Patient A had a Physician's Order, dated 8/2/10, for absorbent foam to be applied to the posterior (heel) wound. Also ordered was a PRAFO (Pressure Relief Ankle Orthosis) brace at night. The brace alleviated pressure on the heel, allowing it to heal.Review of Patient A's August 2010 Treatment Record revealed staff continued to apply antibiotic ointment to Patient A's left heel pressure sore from 8/1/10 through 8/10/10. Documentation on the Treatment Record indicated "absorbent foam to posterior wound." The treatment was to be documented every shift. Documentation indicated the absorbent foam to cushion Patient A's left heel pressure sore was in place on 16 of 27 opportunities, approximately 60% of the time. A Care Plan entry, dated 8/1/10, indicated Patient A had a Stage III pressure sore on his left heel. The Approach Plan did not include applying absorbent foam to the pressure sore. An interview was conducted with Licensed Nurse (LN) 1 on 2/17/11 at 11:40 a.m. LN 1 acknowledged Patient A was to have his left foot and leg checked for any skin problems daily. She stated she did not know why the pressure sore on Patient A's left heel had not been identified as it was developing at an earlier stage. She stated she documented on the Pressure Wound Sheet that the pressure sore on the Patient's left heel was a Stage III. LN 1 stated she was not aware of foam being applied to the area although she performed the daily treatment of applying antibiotic ointment to the pressure sore. Documentation on the Pressure Wound Sheet, dated 8/9/10, indicated the sore on Patient A's left heel measured 1.9 cm x 1.9 cm with undetermined depth and the color was pink, yellow, and purple. The description included the skin surrounding the sore which was "fragile" and there was 80% necrotic tissue and 20% slough (dead tissue separating from living tissue). There was no documentation which indicated the physician was notified of the worsened appearance of Patient A's left heel pressure sore that had deteriorated between 8/1/10 and 8/9/10. Nurse Notes, dated 8/11/10 at 8 a.m., documented Patient A went to a scheduled appointment with his Orthopedic Surgeon. Nurse Notes, dated 8/11/10 at 5 p.m., documented the facility was notified that Patient A was being admitted to the General Acute Care Hospital (GACH) for "surgery to feet." Review of documentation completed by Patient A's Orthopedic Surgeon on 8/11/10 indicated the patient had a "posterior (heel) pressure ulcer with [signs and symptoms of] drainage [approximately] quarter size." The physician documented Patient A would be admitted to the GACH for wound care debridement and ongoing wound treatment.Documentation on the GACH's Pressure Ulcer Photographic Wound Documentation form, dated 8/11/10 (10 days after the pressure sore was originally found), indicated Patient A's left heel pressure sore was Stage III and measured 5 cm x 4 cm. "To help prevent infection and promote healing, dead tissue is debrided (removed) often, usually by your doctor or another health professional. If there is dead tissue in the pressure sore, it gives bacteria a good place to grow and can cause infection. Dead tissue in the wound can also slow the growth of healthy tissue." Ref. WedMD, 2/15/11 Patient A developed an avoidable pressure ulcer to his left heel that was not identified in the early stages of development and resulted in a hospitalization and surgery for treatment of the wound. The Department determined the facility failed to: 1. Provide skin assessments as ordered. 2. Provide treatment as ordered when a pressure sore developed. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000773 |
Kindred Transitional Care & Rehabilitation - Valley Gardens |
030010244 |
B |
13-Nov-13 |
J7AX11 |
8971 |
F157 Notification of Changes (injury/decline/room, Etc.) 483.10(b)(11)A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a). F323 Free of Accident Hazards/supervision/devices 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.On August 5, 2013 an Informal Conference was conducted as part of the Complainant Appeal process provided in the California Health & Safety Code Section 1420 (b) (c). The Department findings of Complaint #CA00275021 and Entity Reported Incident #CA00275065 were reviewed and documents re-evaluated. Complaint #CA00365708 was initiated. Based on Resident (Patient) and family statements and written declarations, clinical record review, interviews and document review, the Department determined that the facility failed to: 1. Ensure the Resident received adequate supervision and assistive devices to prevent an accident. 2. Ensure the Resident's physician was consulted immediately when the potential for medical intervention was indicated.Resident A was re-admitted to the facility on 6/23/2010. Her admitting diagnoses included: BKA (below the knee amputation) of the left lower leg 6/16/2011, insulin dependent diabetes and severe peripheral vascular disease. The admission MDS (Minimum Data Set - an assessment tool) dated 7/01/2011 documented the following characteristics. Resident A was Spanish speaking but usually able to communicate her needs and understand others.Her vision was highly impaired. The memory section of the assessment was left blank. There were no mood or behavior problems noted. Resident A required 2 person assistance for transfers out of bed and was non ambulatory. She required extensive assistance for all activities of daily living. She had frequent left leg pain and required narcotic medication for pain control.Resident A's clinical record review revealed Resident Progress Notes dated 6/30/11 at 2:45 pm which documented, "Resident's family member complaining patient not wanting shower and C.N.A. (Certified Nursing Assistant) gave anyway even though pt (patient) had shower yesterday and says C.N.A. bumped her Left BK Amputation making it bleed...Dressing for Left BK amputation changed by treatment nurse. BK amputation dry, clean, free from infection."A Condition Change Form dated 7/02/11 as a late entry (untimed), documented, "On 6/30/11, Resident's left BKA with small amount of bleeding on dressing. Left BK amputation dressing changed by treatment nurse and bleeding stopped with no signs or symptoms of infection. No fever. No pus.No Odor. Left BK amputation skin intact. MD notified." Medical orders dated 7/02/11 at 3 pm included continued monitoring of left stump surgical wound...follow up appointment 7/5/11. Facility Treatment Records documented the monitoring as ordered started 7/02/11. On 7/05/2011, Resident A and her family met with the surgeon. The son indicated that Resident A "fell on her stump and since then has had blistering and redness." The wound was described by the physician as follows. "There is extensive ecchymosis (bruising) over the proximal flap...the suture line appears somewhat hypervascular (containing an excessive number of blood vessels). There is some superficial skin sluff (dead tissue). The area of the incision line measuring approximately 3 1/2 cm. (centimeter - one inch equals 2.5 cm) is appearing somewhat non-viable (unlikely to live)." The assessment was "Status post left below the knee amputation for peripheral vascular disease and diabetes with gangrene of the foot."The plan for care was discussed. The physician note indicated, "A lot of the trauma is probably from her recent trauma. I am concerned however that the significant portion of the medial suture line appears to be borderline viable, if not non-viable. I am not too optimistic regarding the wound at this point." Resident A was started on antibiotics with a plan to be seen in a week and possibly be scheduled for a wound revision. On 7/07/2011, Resident A and her family again met with the surgeon because of persistent pain. The wound was described as follows. "Left BKA shows extensive necrosis (death of tissue) of the medial edge of the incision. There is minimal drainage. No gross purulence (pus). There is some moderate erythema (redness) along the medial aspect of the incision. The area of necrosis measures approximately 6 cm. by 4 cm." The assessment was, "Status post left below the knee amputation for gangrene of foot with now gangrene of portion of the BKA stump."Gangrene is the term used to describe the decay or death of an organ or tissue caused by a lack of blood supply. It is a complication resulting from infectious or inflammatory processes, injury, or degenerative changes associated with chronic diseases such as diabetes. After much discussion a decision was made to proceed with an above the knee amputation to give Resident A "a good chance of healing."Resident A was re-admitted to the acute care hospital for a left above the knee amputation on 7/11/11.An interview with Resident A's surgeon was conducted by phone on 7/27/11 at 7:40 am. He indicated that "if she had a fall or bumped her stump, it would interfere with the healing process. He could not say 100% that a fall was a contributing factor to the need for another surgery because she had a lot of risk factors. She's a sick woman."The facility investigation report dated 7/11/11 was reviewed and documentation indicated that on 6/30/11 an injury had occurred described as "left stump area-minimal bleeding noted...no redness and no swelling." Resident A was interviewed as part of the investigation. "She stated they dropped her. She stated that when they stood her up - she started to fall. She fell back on the bed and that's when she slid to the floor and hit her BKA. She stated there was a big puddle of blood and she was in a lot of pain..." The conclusions of the investigation indicated, "both CNAs are adamant that they did not drop the resident...the daughter and brother informed the DNS (Director of Nursing Services that there was a possibility he (the surgeon) was going to have to perform an above the knee operation. He also informed the son that if she did fall it probably did not help, but ultimately she was going to need to have this done."The investigation included a section titled "It is the opinion of this nurse". Part 1 indicated, "I couldn't determine if a fall had occurred." Part 2 documented, "Because the bandage came off during transfer - the transfer was done inappropriately. Both CNAs should have used a stand up lift versus lifting her to the chair. Maybe during the transfer the knee was either bumped or they did not pay attention to the bandage making sure it was in place. They did not report it immediately to the RN (Registered Nurse) charge nurse." Part 4, "The CNAs have been counseled and will be required to attend the transfer inservice and will be re-educated on the proper transfer technique." Part 5, "The RN who was initially informed regarding the alleged fall was counseled and will be required to go through the nurse re-training and when to report any change of conditions or concerns from the resident." The report was signed 7/11/11 by the DNS.The report did not address the delayed physician notification on 7/02/11 of the incident that occurred on 6/30/11. The facility submitted a report of the alleged fall incident to the Department on 7/02/11.Resident A was present during the Informal Conference on 8/05/13. During the conference she was asked if she had anything to add and she re-iterated, "There were two girls came to take me to the shower. I was put on the edge of the bed and I fell." The Department determined that the facility failed to: 1. Ensure Resident A received adequate supervision and assistive devices to prevent an accident. 2. Ensure Resident A's physician was consulted immediately when the potential for medical intervention was indicated after the incident on 6/30/11. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000074 |
Kit Carson Nursing & Rehabilitation Center |
030011200 |
B |
24-Dec-14 |
Y7S411 |
5545 |
California Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of complaint #CA00416395. An unannounced visit was made to the facility on 10/10/14 to investigate a complaint received on 10/10/14. The Department determined the facility failed to report an allegation of abuse. This failure had the potential of allowing other residents to be subjected to abuse. Findings: Resident A was admitted to the facility for aftercare following back surgery and chronic pain. His Nursing Admission Assessment described him as alert and oriented to person, place, time, and situation. His pain level was measured as a 7 out of 10 on a pain rating scale of 0 to 10 (0 being no pain and 10 being severe pain). His activity level was documented as being able to transfer with the assistance of one person and walk with the aid of a walker. He required assistance with the majority of his activities of daily living. An interview was conducted with Resident A on 10/10/14 at 12:05 p.m. He reported that on his first night in the facility, "in the middle of the night", he awakened to the silhouette of a man by his bedside "playing" with his penis. Resident A stated he asked the man what he was doing and was told by the man that he was checking for a catheter (a tube inserted into the bladder through the penis and attached to a collection bag to promote the flow of urine). Resident A stated the man then ran out of the room. He described the man as being African American, very dark, slender with a narrow face and a pointed goatee.An interview was conducted with the Director of Nurses (DON) on 10/14/14 at 10 a.m. She stated Resident A's family member had phoned the Social Services Designee (SSD) on 10/7/14 and 10/10/14. On 10/10/14, the family member requested the name of the male Certified Nursing Assistant (CNA) who she felt had assaulted Resident A. The DON stated the Administrator, Manager of the Day, and the Charge Nurse had interviewed residents and staff in the area of Resident A's room and were unable to confirm Resident A's complaint. The DON stated she had informed Resident A's family member that the facility had not been able to confirm Resident A's allegation. An interview was conducted with the SSD on 10/14/14 at 10:30 a.m. regarding her encounter with Resident A's family member on 10/7/14. She stated the family member was calm and smiling as she listed several concerns regarding Resident A's stay in the facility. One of the concerns involved Resident A being touched on his penis by a black man checking for a catheter. The SSD stated the family member made a comment about not wanting to get anyone in trouble, but felt the facility staff should know about these concerns. The SSD indicated she referred the concerns to the Administrator and was asked to interview residents in the area of Resident A's room regarding any concerns about the night shift's staff provision of care. She stated no concerns were expressed by the residents. The SSD said the family member phoned her back on 10/10/14, was very angry, and demanded the name of the male CNA who had been on duty on Resident A's unit the night of the alleged incident. The family member told the SSD she planned to press charges. An interview was conducted with the Administrator on 10/14/14 at 12 noon. She stated she had first heard about Resident A's allegations at the morning meeting in the facility on 10/7/14. The Administrator stated when Resident A had talked with her prior to leaving the facility, he had reported being awakened for care, but had never mentioned anything about a black man being in his room and touching his penis. She stated she and the management staff performed an investigation, interviewed residents and staff on the unit where Resident A had stayed, and determined the allegation was not true. She stated she had not felt the allegation needed to be reported to the State authorities.An interview was conducted with the Director of Staff Development on 10/14/14 at 1 p.m. She stated the facility had 3 African American male nursing assistants (NA's) who would soon test for CNA certification. She stated the facility had 1 African American CNA who worked day shift. Following review of the Staffing Assignment and Sign In Sheets, she stated 2 of the 3 NA's did not work during Resident A's stay at the facility. The third NA was working with a CNA during the night shift.An interview was conducted with the CNA on 10/14/14 at 2 p.m. She stated she and the NA worked together with the residents. She reported that she heard Resident A tell the NA that he didn't need any assistance because he could go to the bathroom by himself.Review of the facility document titled Investigative Report indicated, "In conclusion, after gathering pertinent information relevant to this issue through interview of staff and other residents, the facility is not able to substantiate that there was a black man who held the resident's (Resident A) penis to check for (sic) catheter." The Department determined the facility failed to report an allegation of abuse. This failure had the potential of allowing other residents to be subjected to abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 100000773 |
Kindred Transitional Care & Rehabilitation - Valley Gardens |
030012717 |
B |
10-Nov-16 |
80YP11 |
4036 |
California Health and Safety Code, Section 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of complaint #CA00483112. An unannounced visit was made to the facility on 04/14/16 to investigate a facility reported incident received on 04/06/16 regarding an incident of alleged verbal abuse by an employee to a resident on 04/02/16. The Department determined the facility failed to: Report to the Department an allegation of abuse of Resident 1 immediately, or within 24 hours as required. Resident 1 was admitted to the facility on 4/3/13. She had multiple diagnoses including dementia and chronic pain. The most recent annual Minimum Data Set (MDS, an assessment tool), dated 3/23/16, indicated Resident 1 had moderate difficulty in hearing and was usually able to make herself understood. A Progress Note, dated 4/5/16, indicated, in part, "On 4/2/2016 alleged encounter with [Certified Nursing Assistant (CNA)] another staff was walking by overheard conversation between CNA and resident allegedly calling the resident to "shut up and said bitch." During an interview with the Administrator on 4/14/16 at 1 p.m., she indicated her expectation was that all cases of employee to resident alleged abuse be reported to the Department within 24 hours and the accused employee suspended during the investigation. During an interview with CNA 2 on 4/14/16 at 3:35 p.m., he stated he over-heard CNA 1 on 4/2/16 around 9 p.m. tell Resident 1 to "shut up, bitch" while she was providing care to her. CNA 2 stated he notified Licensed Nurse (LN) 2 of the incident and expected her to investigate and report the abuse. CNA 2 said he came back to work on 4/5/16 at 3 p.m., and when he saw CNA 1 at work, he notified LN 1 of the abuse allegation. During an interview with LN 1 on 4/14/16 at 4:14 p.m., she acknowledged CNA 2 notified her of the alleged verbal abuse on 4/5/16. LN 1 stated CNA 2 told her he had over-heard CNA 1 tell Resident 1 to "shut up, bitch" while providing care to her on 4/2/16 during the evening shift. During an interview with LN 2 on 4/14/16 at 4:32 p.m., she acknowledged CNA 2 reported the alleged abuse to her on 4/2/16 about 9 p.m. LN 2 said she and LN 3 interviewed CNA 1 (alleged abuser) and Resident 1 on 4/2/16. LN 2 said she did not investigate and report the alleged abuse as per the facility's policy as she had expected LN 3 to take over the responsibility. The State Form SOC 341 titled Report of Suspected Dependent Adult/Elder Abuse, dated March 2015, indicated the alleged verbal abuse occurred on 4/2/16. The date the form was completed indicated 4/5/16. The alleged verbal abuse was not reported to the Department until 4/5/16 at 9:29 p.m., 3 days later. The alleged abuser, CNA 1, was not removed from the schedule until 4/5/16. The facility's Abuse Policy, dated 7/28/2014, indicated, "Verbal, sexual, physical, and mental abuse...are strictly prohibited...All alleged violations involving mistreatment, neglect, or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with State law...The center staff must report all alleged violations involving mistreatment, neglect, or abuse...immediately to a Senior Clinician, or Operational Leader at the facility...in accordance with state law through established procedures (including to the State survey and certification agency)...[and] For All Abuse Allegations...If allegation against staff, suspend pending allegation (sic) [investigation]." Therefore, the Department determined the facility failed to: Report to the Department an allegation of abuse of Resident 1 immediately, or within 24 hours as required. Failure to comply with the requirements of Health & Safety Code Section 1418.91 shall be a class "B" violation. |
| 630012080 |
Kindred Hospital Brea D/P SNF |
060009042 |
B |
28-Feb-12 |
2BI611 |
9511 |
72311 (a) (1) (B) (2) Nursing Service-General(a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Patient A was admitted to the facility on 12/6/11, and transferred to the emergency room on 12/15/11 at 0210 hours, following a fall, resulting in a right hip fracture and nondisplaced fractures involving the right superior and inferior pubic rami (pelvic bones). Patient A was admitted to the facility with the need of a 1:1 sitter due to her risk for falls. On 12/8/11, the facility discontinued Patient A's 1:1 sitter and implemented the use of floor mats, bed in the lowest position and moving her closer to the nurses' station. Patient A had increasing attempts to get out of bed unassisted and on 12/15/11, she fell out of bed and sustained a fractured hip. The facility failed to revise the care plan to address her need for continued use of a 1:1 sitter for close supervision and failed to implement the approach plan for a scheduled toileting program.Health record review for Patient A was initiated on 12/22/11. Patient A was admitted to the facility on 12/6/11, with diagnoses including osteoporosis (brittle bones) and a lumbar compression fracture (a fracture of the lower back spine). Review of Patient A's Minimum Data Set dated 12/12/11, showed the patient needs extensive assistance from one staff member for bed mobility and transfers. Review of Patient A's Care Area Assessment (CAA) for falls dated 12/13/11, showed Patient A is not steady during transition (change from one position to another) and requires extensive assistance with transfers and during transitions.Review of Patient A's Interdisciplinary Physical Restraint Evaluation dated 12/6/11, shows she has fluctuations in level of consciousness, alteration in safety awareness due to cognitive decline, difficulty with balance or poor trunk control and is on medications that would require increased safety precautions. The Interdisciplinary Team (IDT) recommended to continue a 1:1 sitter (someone to stay with the patient constantly for safety) and every 15 minute visual checks for Patient A, based on Patient A's frequent attempts to arise to use the bathroom. On 12/8/11, the 1:1 sitter was discontinued and Patient A was moved closer to the nurses' station, the use of floor mats, a bed alarm (alarm to alert the staff when the patient attempts to get out of bed) and having the bed in the lowest position were recommended. Review of Patient A's Patient Nursing Evaluation dated 12/6/11, showed a fall risk scale of 40 (a score between 25- 44 = medium risk) and to refer to the Falling Star Program. Review of Patient A's Safety Rounds and Resident Monitoring Tool forms for dates 12/6/11, 12/7/11 and 12/8/11, showed staff initials every 15 minutes to show Patient A had frequent visual checks. Review of Patient A's care plan showed a care plan problem dated 12/6/11, to address her risk for falls related to a fall risk factor of 40, and osteoporosis. The care plan problem to address her risk for falls was updated on 12/7/11, to address episodes of getting up unassisted. An approach plan was for 1:1 supervision, and every 15 minute visual checks. On 12/8/11, Patient A's approach plans for 1:1 supervision and every 15 minute visual checks were discontinued and new approach plans were added to include bilateral floor mats, bed in the lowest position, and moving her room closer to the nurses' station. On 12/13/11, Patient A's fall risk care plan problem was updated to include episodes of confusion and hallucinations. An approach plan included close monitoring for safety awareness. Review of Patient A's Resident Progress Notes dated 12/7/11 and 12/8/11, showed Patient A was having episodes of confusion and attempts of climbing out of bed unassisted. A 1:1 sitter stayed with Patient A at all times to ensure her safety against falls. On 12/8/11, the use of 1:1 sitters was discontinued and at 1608 hours, Patient A was transferred to a room closer to the nurses' station. Every 15 minute visual checks were to be continued. On 12/10/11 through 12/14/11, Patient A continued with episodes of attempting to climb out of bed and confusion, and she started having hallucinations on 12/14/11.A Resident Progress Note dated 12/15/11 at 0050 hours, showed documentation of a loud noise being heard coming from Patient A's room. A licensed nurse entered Patient A's room and found Patient A lying on the floor, lying on her right side, crying and rubbing her back and right hip. At 0210 hours, Patient A was transported to the emergency room for evaluation of her back and hip injury. Review of Patient A's Resident Progress Note dated 12/8/11 at 1340 hours, showed the social service staff member documented a note to transfer Patient A to a room closer to the nurses' station for observation. On 12/13/11 at 1500 hours, the social service director (SSD) documented Patient A's family member stated Patient A was having episodes of hallucinations and a psychiatric evaluation was obtained. The staff was to monitor Patient A's hallucinations. On 12/14/11 at 1600 hours, the SSD documented Patient A continued with hallucinations, having nightmares and was scared at night. Review of Patient A's Interdisciplinary Progress Notes dated 12/8/11, show Patient A is alert with episodes of confusion and has poor/fair balance problems. The IDT recommended to discontinue the 1:1 sitter, move Patient A to a room closer to the nurses' station, apply a bed alarm, floor mats and implement a toileting program, secondary to Patient A remaining at high risk for falls and injury. The staff was to continue to monitor Patient A closely.Review of Patient A's care plan problem dated 12/6/11, to address her activities of daily living show Patient A needs extensive assistance in her toileting needs. An approach plan dated 12/8/11, show Patient A was to have scheduled toileting. No documentation was available to show Patient A's specific toileting schedule to instruct the staff of her pattern. Review of Patient A's Care Plan Conference Summary dated 12/14/11, showed Patient A felt scared at night and had nightmares. Patient A's family member told the staff of Patient A having hallucinations. Review of Patient A's psychiatric consult dated 12/14/11, showed Patient A has paranoid delusional nightmares versus sundowning (a state of confusion at the end of the day and into the night) with visual hallucinations.Review of Patient A's Post Fall Evaluation dated 12/15/11, showed at 0050 hours, Patient A was trying to go to the bathroom, fell and was found on the floor on her right side. Review of Certified Nursing Assistant (CNA) 2's Interview Record dated 12/15/11, showed at 0030 hours, CNA 2 changed Patient A's brief. Patient A wanted to get up and go to the bathroom. Patient A was transferred to the acute care hospital on 12/15/11. Review of Patient A's right hip x-ray results dated 12/15/11, showed Patient A sustained an acute nondisplaced right intratrochanteric (hip) fracture and nondisplaced fractures involving the right superior and inferior pubic rami. During an interview on 12/22/11 at 0920 hours, LVN 1 stated Patient A was confused and unable to make her needs known. He stated Patient A had a 1:1 sitter because she had a history of falls and often tried to get out of bed unattended.During an interview on 12/22/11 at 1450 hours, the Director of Staff Development (DSD) stated, if a patient is on fall precautions, the patient is placed on frequent visual checks. She stated frequent visual checks means the staff checks the patient every 15 to every 30 minutes. During an interview on 12/22/11 at 1550 hours, Registered Nurse (RN) 1 stated Patient A had a 1:1 sitter on admission. She stated the 1:1 sitter was discontinued on 12/8/11 and Patient A was moved closer to the nurses' station. A personal alarm, bilateral floor mats and the bed in the lowest position were implemented. RN 1 stated Patient A's condition improved and she no longer needed to have a 1:1 sitter or every 15 minute visual checks. She stated Patient A did not have hallucinations between 12/8/11 and 12/13/11. RN 1 stated Patient A had a psychiatric consult on 12/14/11, and was diagnosed of possibly having "sundowner's syndrome" (increased confusion at nighttime). RN 1 stated the licensed nurse could have made a judgment call and placed Patient A back on a 1:1 sitter, if needed.During a telephone interview on 12/28/11 at 1115 hours, CNA 2 stated during her routine rounds on 12/15/11 at approximately 0030 hours, she checked Patient A's diaper and it was dry. She stated she changed Patient A's dry diaper and gave her perineal care to make her more comfortable. CNA 2 stated Patient A went to the bathroom around 2030 hours, and she did not offer to take her to the bathroom when she changed her dry diaper. She stated Patient A was awake when she left the room. The facility's failure to develop and implement the care plan had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients. |
| 070000058 |
KINDRED NURSING AND TRANSITIONAL CARE-SANTA CRUZ |
070008820 |
B |
18-Jan-12 |
RE4E11 |
6092 |
Title 22 72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement their abuse policy when on 11/18/11 a volunteer staff member kissed Patient 1 on the mouth, by failing to remove the volunteer from all patient contact and notify the Ombudsman and the California Department of Public Health, Licensing and Certification Program within twenty-four hours. They also failed to implement their volunteer policy when they allowed a volunteer to lead social activities in the evening. The policy indicated volunteers do not perform any activity "which provides an economic benefit to the facility." These omissions could potentially result in the failure to protect the patients. 1. Patient 1 was admitted to the facility with diagnoses including colon cancer. Record review on 11/23/11 of her Minimum Data Set (MDS, assessment tool) dated 3/10/11 and 9/7/11 indicated she was alert, oriented, and had no cognitive impairment. Record review on 11/23/11 of her physician's orders dated 3/3/11 indicated she was capable of making her own decisions.During an interview with Patient 1 on 11/23/11 at 10:10 a.m., she stated the activity volunteer (AV) kissed her on the lips on 11/18/11 about 7:45 p.m. She stated the AV was her boyfriend and had been her boyfriend for the past seven months. Patient 1 stated he took her to her medical appointments and told her he loved her. During an interview with certified nurse assistant A (CNA A) on 11/23/11 at 10:50 a.m., she stated she saw the AV kiss Patient 1 on the mouth on 11/18/11 about 7:45 p.m. CNA A stated she also talked to Patient 1 about the incident. Patient 1 told her the AV was her boyfriend and had been her boyfriend for seven months. CNA A reported the incident to licensed nurse B (LN B) who told her she would report it. CNA A does not know what LN B did after she advised her of the incident. CNA A stated she did not report the incident to the Ombudsman or the California Department of Public Health, Licensing and Certification Program. During a confidential interview on 11/23/11 at 1:30 p.m., they stated they received a telephone call from LN B on 11/19/11. LN B stated CNA A told her she saw AV kiss Patient 1 on the mouth on 11/18/11 about 7:45 p.m. The incident was investigated and included interviews with AV, Patient 1, and CNA A. The AV stated he had hugged Patient 1 but he had never kissed her. Patient 1 stated the AV kissed her and had been "courting" her for the past seven months. CNA A stated she saw the AV kiss Patient 1 on 11/18/11 about 7:45 p.m. No report was sent to the Ombudsman or the California Department of Public Health, Licensing and Certification, within twenty-four hours of the incident because the administrator of the facility did not think the incident involved abuse since Patient 1 was alert, oriented, her own responsible party, and consented to the kiss. During an interview with the Ombudsman on 11/28/11 at 2:30 p.m., she stated she first became aware of the incident when she received a telephone call from a volunteer at the facility on 11/21/11. She had no prior notification from the facility. She went out to investigate on 11/21/11 and saw the AV still volunteering and interacting with patients at the facility. She interviewed Patient 1 who explained the AV had been her boyfriend for several months and he had kissed her.Record review on 11/23/11 of Patient 1's medical record indicated the facility's social worker interviewed Patient 1 in response to the allegation that the AV kissed her on the mouth. Patient 1 stated the AV kissed her and had been her boyfriend for months.A review of the facility's employee handbook dated 11/2010 indicated an example of serious misconduct included "engaging in inappropriate or unprofessional relationships with patients." The facility's 5/15/03 policy, "Protection of Resident During an Investigation" indicated a staff member implicated in an abuse allegation will be removed from any resident contact.The facility's 11/18/05 policy, "Responding to and Investigating an Abuse Allegation" indicated an internal investigation will be started for all abuse allegations. Also, report the alleged abuse to the appropriate State agencies, according to State law. 2. During an interview with the administrator on 12/12/11 at 4:10 p.m., he stated it had been the facility practice in the past to allow the AV to lead the activity program in the evening. The administrator stated the patients would not attend or do activities if the AV was not conducting the program.A review of the facility's "Volunteers Policy", dated 6/23/10, indicated "The activities in which the volunteers are involved may include but are not limited to: a) sitting or providing companionship to patients, b) sitting with the patients to allow their family member to take a break, c) running errands for patients or their family member, d) assisting patients to engage in activities offered by the nursing center, e) providing spiritual or emotional support to patient or family member, and f) reading to a patient...volunteers do not perform any work for the nursing center or otherwise perform any activity, which provides an economic benefit to the facility or which supplements the nursing center's paid staff." A review of the facility's "Volunteer Program Policy", revised 6/23/10, indicated the facility should "plan to train and supervise volunteers." The facility failed to implement their abuse policy to notify the Ombudsman and the Department of Public Health within 24 hours of an allegation of abuse. The facility also failed to protect patients after the volunteer kissed the patient on the mouth when the volunteer continued to have contact with patients. The facility did not follow their volunteer policy when the volunteer lead the activity program in the evening unsupervised. The above violations had a direct relationship to the health, safety, or security of patients. |
| 070000035 |
KINDRED NURSING AND TRANSITIONAL CARE-PACIFIC COAST |
070009012 |
B |
15-Feb-12 |
3QHW11 |
3585 |
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 reporting all allegations of abuse immediately, not to exceed 24 hours, and in accordance with State law, when they did not notify the California Department of Public Health and the Ombudsman until 12 days after they were informed of an allegation of abuse for one sampled resident.Resident 1 was admitted to the facility with diagnoses including developmental delay. On 12/18/11, his family member (FM) reported to the director of nursing (DON) that Resident 1 reported two staff members spanked him and put a towel in his mouth.Resident 1 was observed in his room on 1/23/12 at 9:15 a.m. He was sitting in a wheelchair leaning forward with his head resting on his arm. Resident 1 was interviewed with the assistance of a certified nurse assistant (CNA) who spoke in the resident's native language and who regularly cared for him. When asked if he was ok today, he shook his head up and down to indicate "yes." When Resident 1 was asked how he was, his responses were minimally audible and speech was slurred. When the CNA asked him additional questions that required a verbal response, his responses were minimal and barely audible. The CNA stated this was his usual condition and he rarely spoke clearly and said very little.On 1/23/12 the facility investigative report was reviewed and indicated the investigation was initiated on 12/18/11. The facility did not report the abuse allegation to the California Department of Public Health or the Ombudsman until 12/30/11, which was 12 days after being notified by the FM.The facility investigation report, finished on 1/19/12, noted Resident 1 had significant memory/cognition problems. The facility's investigation report concluded no evidence could be found to substantiate the alleged abuse.During an interview on 1/23/12 with the administrator and DON on 1/23/12, they both stated they did not think they had to report allegations of abuse if they conducted an investigation and concluded the allegation was not valid.On 1/25/12 the facility provided their 10/16/11 Kindred Healthcare policy for Abuse. It indicated under "Compliance Guidelines, #2," the policy directs staff to report: "[A]ll alleged violations involving mistreatment, neglect or abuse ... are reported immediately to the administrator ... and to other officials in accordance with State law through established procedures, including to the State survey and certification agency."The facility provided undated staff abuse training documents titled, "Abuse Reporting," indicating to direct staff to complete an event report and form SOC 341 (California form used to report suspected dependent adult/elder abuse) and to notify the Ombudsman and DHS (California Department of Public Health). They were to report any alleged abuse immediately and not to exceed 24 hours to the "Department of Health" (California Department of Public Health). The policies and procedures indicate that all allegations of abuse should be reported immediately or within 24 hours. Therefore, the facility failed to follow their policies and procedures for reporting an allegation of abuse in a timely manner.The failure of delaying a report of an allegation of abuse after notification for 12 days had a direct or immediate relationship to the health safety or security of the resident. |
| 070000058 |
KINDRED NURSING AND TRANSITIONAL CARE-SANTA CRUZ |
070010287 |
B |
04-Dec-13 |
82LS11 |
6129 |
F333 - 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. The facility failed to ensure that Resident 1 was free from a significant medication error when two patches of fentanyl (Schedule II controlled medication, a potent long-acting narcotic pain medicine applied to the skin) were applied to the resident instead of one, as ordered. This error could potentially result in a fatal overdose due to respiratory depression. Resident 1's clinical record was reviewed on 11/20/13 at 10:30 a.m. She was admitted to the facility with diagnoses including arthritis and chronic back pain. On 9/18/12, her physician ordered the application of a 75 micrograms (mcg) per hour fentanyl patch every seventy-two hours for pain management. A review of the medication administration record (MAR) indicated a 75 mcg per hour patch was applied to Resident 1's left chest on 11/17/13 and the old patch dated 11/14/13 was removed.Resident 1's nurses notes dated 11/18/13 at 7:30 p.m. indicated she complained of shortness of breath and difficulty breathing. Her nursing assessment indicated her lung sounds were clear, she was using her accessory muscles to breathe, she was lethargic and she was slow to respond. Her vital signs (measures of various physiological statistics taken by health care professionals to assess the most basic bodily functions) were normal and her oxygen saturation level (the concentration of oxygen in the blood) was 94% (normal is 95-100%) on room air. Her physician was called and he ordered two liters of oxygen per minute and a transfer to the hospital for further evaluation. After administration of the oxygen, her oxygen saturation level was 96%. Resident 1 was transported to the hospital at 8 p.m. The emergency room physician's note dated 11/18/13 at 8:24 p.m. indicated she had on two fentanyl patches, both dated 11/17/13. The hospital staff removed one of the fentanyl patches. Resident 1 was diagnosed with a urinary tract infection and over medication syndrome (symptoms caused by the administration of too much medication). An antibiotic for the urinary tract infection was prescribed and Resident 1 was transported back to the facility at 11:30 p.m. During an interview on 11/20/13 at 11 a.m., the director of nursing (DON) said the nursing staff who applied a new fentanyl patch on a resident must remove the used patch and document the removal on the controlled drug record (CDR). Also, the DON said, the administering nurse must destroy the used patch with another nursing staff as a witness. Both nurses then must sign for the destruction on the CDR. On 11/20/13, a review of Resident 1's September to November 2013 CDRs and the medication administration records (MAR) reflected the following: a. 9/17/13 - a new patch applied, no documentation of used patch removal and no witness signature b. 10/2/13 - a new patch applied, no documentation of used patch removal c. 10/17/13 - a new patch applied, no documentation of used patch removal and no witness signature d. 11/11/13 - a new patch applied, no witness signature The instructions on the CDR indicated: "USED PATCH DESTRUCTION when patch is removed, it must be immediately destroyed and witnessed with two nurse signatures." On 11/20/13 at 2:30 p.m., the DON verified the nursing staff was not consistently documenting the used patch removal and the witnessed destruction. During an interview on 11/20/13 at 3:20 p.m. with licensed nurse A (LN A), she stated she placed the fentanyl patch dated 11/17/13 on Resident 1's left chest and removed the old patch dated 11/14/13 from her right chest. She then disposed of the old patch in the narcotic container. She did not see another patch on Resident 1. On 11/20/13, a review of Resident 1's record reflected a CDR page that accounted for five fentanyl patches from 10/17/13 to 11/2/13 was missing. The DON said that on two occasions, on 11/21/13 at 9 a.m. and 11:20 a.m., the facility could not find it. She agreed the facility could not account for all the fentanyl patches administered to Resident 1. During an interview on 11/21/13 at 3 p.m. with licensed nurse B (LN B), she stated she was providing care for Resident 1 during the evening hours on 11/18/13 and received the telphone call from a nurse at the hospital prior to Resident 1's return to the facility. The hospital nurse told LN B Resident 1 had on two fentanyl patches when she arrived in the emergency room. One patch was on her chest and the other patch was on her back.During an interview on 11/22/13 at 2:30 p.m. with certified nursing assistant C (CNA C), she stated she took care of Resident 1 on 11/16/13, 11/17/13 and 11/18/13 during the day shift. She gave Resident 1 a shower on 11/16/13 and sponge baths on 11/17/13 and 11/18/13. On 11/18/13, CNA C noticed two patches on Resident 1 on 11/18/13. One patch was on her chest and one patch was on her left shoulder.During an interview on 11/25/13 at 8:23 a.m. with Resident 1's family member, she stated she was present at the hospital when the two fentanyl patches were found. The family member said the patch the hospital staff removed was fentanyl 75 mcg per hour and was not dated.A review on 11/21/13 of the facility's 2010 policy "Medication Administration Transdermal Delivery System (Patches)" indicated the patches should be labeled with the date and the nurse's initials and the old patch should be removed and disposed of properly. A review on 11/21/13 of the facility's 2013 policy "Fentanyl Protocol for Initiating Fentanyl Therapy" indicated fentanyl contains a high concentration of a potent Schedule II opioid and has a risk of fatal overdose due to respiratory depression.The facility failed to ensure Resident 1 was free from a significant medication error when two fentanyl patches were applied instead of one, as ordered. The facility's failure to ensure the application of one patch at a time could potentially result in a fatal overdose due to respiratory depression. This violation had a direct relationship to the health, safety or security of the resident. |
| 070000035 |
KINDRED NURSING AND TRANSITIONAL CARE-PACIFIC COAST |
070010621 |
B |
30-Apr-14 |
6IDK11 |
4229 |
F323 - 483.25(h)(2) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure one patient was free from an avoidable accident. Patient 1 was pushed out of the back of the facility van, without the lift ramp in place, fell and sustained a head laceration that required medical treatment.Clinical record review for Patient 1 indicated she was admitted to the facility on 2/20/14, for rehabilitation services. Her minimum data set (MDS, an assessment tool) dated 3/8/14, showed she had no cognitive impairment.On 3/18/14, Patient 1 was transported to a hospital for a scheduled treatment via the facility van, driven by a facility employee, Driver 1. Patient 1 was in a wheelchair and when assisting Patient 1 out of the van, Driver 1 failed to properly activate placement of the lifting plate to allow the wheelchair to move onto the plate that would be lowered after Patient was on the plate.At arrival at the hospital, Driver 1 did not put the lifting plate level with the van and instead the lifting plate was kept on the ground. Driver 1 went into the van to push Patient 1 backwards in her wheelchair onto the lifting plate; then he heard the safety alarm go off and felt the patient start to fall. Driver 1 dropped Patient 1 while she was a few feet off the ground, but she hit her head on the plate and sustained cuts to the back of her head. The hospital emergency room staff assisted and treated her injuries.The emergency room History and Physical dated 3/18/14, showed Patient 1 was in a wheelchair and was pushed out of the back of the van without the ramp being up. Patient hit the back of her head on the metal ramp and sustained three cuts to the back of her head and complained of a headache. One cut measured three inches by one inch and required medical treatment to close the wound. Review of Driver 1's employee file showed a final written warning dated 3/27/14, due to his failure to ensure the safety of a patient on 3/18/14 at 4:14 p.m. Driver 1 left the lift in the down position when off-loading a patient, which resulted in the patient falling and suffering an injury.On 4/4/14 at 9:35 a.m., Driver 2 was interviewed in the facility parking lot near the van. He demonstrated how the van lift ramp went up and down. He stated if the ramp was level with the patient inside the van, the alarm would not sound. Driver 2 raised the lift so it was uneven with the van and stood on the plate inside of the van. An alarm sounded to indicate the ramp was not even with the back plate. When Driver 2 adjusted the lift ramp even with the back plate and stood on the plate, no alarm sounded. Driver 2 stated the lift could not be lowered by itself; the button on the control box, in the back of the van had to be pushed to allow the lift ramp to be raised or lowered to the ground.During a telephone interview on 4/4/14 at 10 a.m., Driver 1 was asked how Patient 1 fell out of the back of the van. He stated the patient's wheelchair was wide and he was unable to see behind the patient when he pushed her out the back of the van.During an interview on 4/4/14 at 10:15 a.m., the maintenance director was asked how Patient 1 could have fallen out of the back of the van. He stated, "Could be human error." During an interview on 4/4/14 at 10:30 a.m., Patient 1 stated on 3/18/14, she was being transported to the hospital in the facility's van. She was in a wheelchair, facing the front of the van when Driver 1 pushed her in her wheelchair, out of the back of the van. Patient 1 stated the next thing she remembered was lying on the ground. Patient 1 stated the emergency room glued the cut on the back of her head (treatment for her head lacerations).The administrator was interviewed on 4/4/14 at 10:45 a.m. When asked if Patient 1's fall out of the back of the van could have been prevented, he stated, "If the lift gate was up, this would not have happened. It was caused by human error." The facility's failure had a direct or immediate relationship to the health, safety or security of patients. |
| 070000058 |
KINDRED NURSING AND TRANSITIONAL CARE-SANTA CRUZ |
070010708 |
A |
12-May-14 |
L3C011 |
10680 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure the transfer from bed to the electric wheelchair for one of 24 sampled residents (2), with right-sided weakness, was implemented according to standard of practice. Prior to a transfer on 2/16/14, two staff members failed to properly place Resident 2's electric wheelchair on the unaffected left side, failed to ensure the wheelchair toggle switch was in the "Off" position prior to the transfer and failed to correctly perform a transfer. Her electric wheelchair spun around, causing Resident 2 to fall out of the wheelchair, land on the floor and sustain a right orbital (eye) fracture. The failure of the facility to adequately implement proper transfer techniques caused Resident 2's fracture.Clinical record review on 4/21/14 for Resident 2 documented she was admitted to the facility in 8/2011, with diagnoses including a cerebral vascular accident (stroke) with right hemiparesis (weakness). Review of Resident 2's minimum data set (MDS, an assessment tool) dated 12/24/13, indicated she was alert, oriented and was able to make her needs known. Resident 2 was totally dependent for transfers with two staff members and had functional limitations to one arm and leg. Clinical record review for Resident 2 also indicated she was on Plavix 75 milligrams once daily by mouth (a blood thinner medication to help prevent stroke). Review of the website of Plavix (www.drugs.com/Plavix) indicated patients on Plavix are advised to avoid activities that may increase their risk of bleeding or injury. Review of Resident 2's care plan with a revised date of 1/2014, to address her self-care deficits related to her right side weakness, showed she was totally dependent on the staff for transfers and required a mechanical lift- a device to transfer a person from one surface to another. Review of Resident 2's Progress Notes dated 2/16/14 at 11:30 a.m., noted two certified nursing assistants (CNAs) called a licensed nurse into her room. Resident 2 was found lying face down on the floor with her right arm next to her body, complaining of right arm pain. Her head was turned facing left with red blood coming from a right temporal (the right side of her forehead) and her right eye was swollen and bleeding. A pressure dressing was applied to Resident 2's forehead to stop the bleeding. During the transfer from the bed to the electric wheelchair, the resident's arm hit the control switch and while sitting in the wheelchair, the wheelchair began spinning, hitting one CNA while the resident fell to the floor. Per a follow-up note the same day at 9 p.m., Resident 2 stated when she was transferred to the electric wheelchair, her left hand hit the control button and the wheelchair began to spin around, causing the resident to fall out of the wheelchair and hit her head. The resident stated the wheelchair should have been turned off (prior to her transfer). On 2/16/14 at 11:45 a.m., Resident 2 was transferred to the emergency room for an evaluation. Review of Resident 2's Transfer Form dated 2/16/14, documented that when the resident was being transferred from the bed to the electric wheelchair, while she was being seated, her arm hit the switch and the resident fell face down onto the floor. Review of Resident 2's computerized tomography (CT, X-ray) scan dated 2/16/14, revealed Resident 2 sustained a fracture of the floor of the right orbit (eye socket) with a right orbital hematoma (bleeding), intraorbital (in the eye socket) fluid and air, and some evidence of a very small fracture of the medial (middle) wall of the right orbit. There was acute blood filling the majority of the right maxillary sinus (a groove on the bone in the nose). Review of The Merck Manual Diagnosis and Therapy website (www.merckmanuals.com) on traumatic brain injury revealed subdural hematomas often occur with head trauma from falls and motor vehicle crashes. These hematomas more often occur in elderly patients (especially in those taking anticoagulant drugs). Review of Resident 2's hospital emergency room Discharge Instructions dated 2/16/14, showed she had a facial fracture. Instructions included Bactrim DS (an antibiotic) one tablet, twice daily by mouth for 7 days, Bacitracin-polymixin B topical TID for 5 days , an antibiotic, and Norco 325/5 one tab q4h PRN for pain. On 4/21/14 at 3 p.m., an interview was conducted with CNA F. She stated Resident 2 was alert, oriented and able to make her needs known. CNA F stated Resident 2 could not move her right arm (independently) and was unsure if the resident was able to move her right leg. She stated on 2/16/14, Resident 2 was transferred from the bed to her electric wheelchair, with the assistance of CNA G. She said the electric wheelchair was positioned to Resident 2's right side, and when the resident went to reposition herself in the wheelchair, the resident's left hand hit the control joy stick and the wheelchair spun around two times. CNA F stated Resident 2 "flew" forward out of the wheelchair and had blood on her forehead. When CNA F was asked the procedure used to lift Resident 2 off the bed, she stated she lifted the resident from under the resident's arm and pivoted the resident to the right (weak side). She stated she was unaware Resident 2 required a mechanical lift transfer. When CNA F was asked the reason the wheelchair was not positioned to Resident 2's left side (strong side), she stated there was no room. She stated after Resident 2's fall on 2/16/14, a sticker was placed outside the resident's door to alert the staff a mechanical lift was needed for transfers.During an interview on 4/21/14 at 3:20 p.m., the director of nurses (DON) stated Resident 2 is alert and oriented, with periods of forgetfulness. She stated on 2/16/14, when CNAs F and G were transferring Resident 2 from the bed to the wheelchair, the resident accidentally hit the joy stick with her hand, the wheelchair spun around 360 degrees and the resident fell out of the wheelchair. The DON stated the wheelchair power button was turned on. On 4/22/14 at 7:40 a.m., an interview was conducted with Resident 2. She stated she was unable to move her right arm and leg on 2/16/14, and two CNAs were transferring her from the bed to the electric wheelchair. Resident 2 stated, "The wheelchair spinned around and I flew out of the wheelchair and hit my head against the bookcase." Resident 2 stated the CNAs should have been "smart enough to turn the wheelchair off when they transferred me. I bled like a pig." During an interview on 4/22/14 at 8:45 a.m., the physical therapist stated the proper procedure to transfer a resident with right sided weakness is to place the wheelchair on the left side (stronger side). He was unaware of the reason Resident 2 was transferred from the bed to her wheelchair with the wheelchair positioned on her right side (weaker). During an interview on 4/23/14 at 7 a.m., the director of staff development (DSD) said she was aware Resident 2's wheelchair was turned on during the transfer on 2/16/14. When the DSD was asked if Resident 2's fall from the wheelchair on 2/16/14 could have been prevented if the wheelchair was turned off, she stated, "Absolutely." During an observation on 4/23/14 at 11:12 a.m., accompanied by the director of clinical operations, Resident 2's wheelchair had a toggle switch located on the left arm rest under the joy stick. The wheelchair toggle switch had to be pushed down to turn on the power and when the toggle switch was placed in the "on" position, amber lights lit up in front of the joy stick.On 4/23/14 at 11:15 a.m., an interview was conducted with CNA G. She stated on 2/16/14, she assisted CNA F with transferring Resident 2 from the bed to the electric wheelchair. CNA G stated she stood on the right side of the resident (paralyzed side) and CNA F stood on the resident's left side. She stated they both (CNAs F and G) placed one hand under each of the resident's armpits and the other hand on the resident's pants to pivot her from the bed to the chair. CNA G stated no gait belt was used. She stated Resident 2's buttocks almost touched the chair, but before the resident was totally sitting in the chair, the wheelchair turned clockwise and the resident landed on the floor with her head hitting the bookcase. CNA G stated Resident 2 had a lot of bleeding by her right eye. When CNA G was asked if the wheelchair was in the proper position, she stated "think not." She stated the wheelchair was on Resident 2's paralyzed side and should have been positioned on her strong side. When CNA G was asked the reason she assisted with the transfer knowing the wheelchair was not in the correct position, she stated because the wheelchair was already in place.The "Quickie S-525: User Instruction Manual" was reviewed and Section VI General Warning stated: Heed all warnings in this section. If you fail to do so a fall, tip-over or loss of control may occur and cause severe injury to you or others. Under VI N indicates to avoid a fall, always turn off the power before you transfer to and from your wheelchair. If you fail to do so, you may touch the joystick and cause your chair to move when you do not expect it. The joystick controls the direction and speed of your chair and the chair will move faster the more you move the joystick away from the neutral position (center).Review of the National Institute for Occupational Safety and Health website (www.cdc.gov/niosh/docs) documented for safe resident handling from the bed to the chair when the resident has impaired upper extremity strength, use a full-body sling (lift) and two caregivers should be used. If the resident has partial weight-bearing capacity, transfer toward the stronger side.Review of the facility's policy "Accidents and Supervision to Prevent Accidents" revised 4/28/11, stated the facility should provide an environment that is free from accident hazards over which the facility has control. The facility is to communicate the interventions to relevant staff, assigning responsibility to appropriate trained individuals implementing and documenting interventions. The facility is to assess the resident to determine the resident's degree of mobility and physical impairment and the proper transfer method. Resident 2's head injury and right eye orbital fracture were a direct result of two staff members transferring the resident from the bed to the electric wheelchair. |
| 070000066 |
KATHERINE HEALTHCARE |
070010985 |
B |
10-Sep-14 |
KEB311 |
9403 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 1 had adequate interventions and supervision to prevent accidents and injuries. Resident 1 was admitted to the facility on 6/14 with diagnoses including a stroke and a history of falls. On 8/7/14, a psychologist documented Resident 1 experienced a functional decline and had increased confusion. On 8/21/14 at 6:30 p.m., Resident 1 was found on the floor next to her bed complaining of right shoulder pain and blood was observed on the floor near her head. She was transferred to the hospital emergency room for an evaluation and required sutures to her forehead for a laceration (cut). The facility failed to follow their policy and procedure related to implementing interventions for residents identified as a high risk for falls which resulted in Resident 1 falling out of bed and sustaining a head injury. Review of the facility's policy, "Fall Evaluation and Management," revised 1/14, showed if a resident's Fall Evaluation Form had a score of 13 or greater, the resident is considered as having a high potential for falls, and staff should implement appropriate care plan interventions for fall management. Review of the facility's High Potential Fall Quick Reference Guide indicated for residents who are confused, have a history of falls within the last three months and have a score of 13 or higher, interventions may be required which include non-skid mats next to the bed, high/low bed, and 1/2 siderails.Clinical record review for Resident 1 was initiated on 9/2/14. Resident 1 was admitted to the facility on 6/14, with diagnoses including a stroke and a history of falls. Review of Resident 1's minimum data sets (MDS, an assessment tool), dated 6/23/14 and 7/18/14, indicated she had moderately impaired cognition and had a history of falls.Review of Resident 1's Nursing Admission Evaluation dated 6/16/14, indicated she had a history of falls.Review of a facsimile (FAX) transmission sent to Resident 1's physician on 6/17/14, indicated the resident requested the use of siderails related to her fear of falling out of bed.Review of Resident 1's Fall evaluation dated 6/22/14, indicated a score of 15 (a score of 13 or above-fall intervention review is required).Review of Resident 1's Device Evaluation Form dated 6/27/14, indicated the resident had weakness, syncope (fainting or passing out) and collapse. No device implementation was recommended.Review of Resident 1's Care Directive Form (certified nursing assistant guide) dated 6/29/14, 7/6/14, 7/20/14 and 7/27/14 and initialed by certified nurse assistants (CNA) to show Resident 1's care needs, documented Resident 1 was confused and forgetful. The sections were blank for safety equipment (floor mat, positioning pillows) and devices (low bed, perimeter mattress). A Care Directive Form initialed 8/3/14 indicated Resident 1 was forgetful, had positioning pillows for safety, and a bed and chair alarm. No other interventions were documented.Review of Resident 1's Nurse's Notes indicated on 8/3/14, 8/4/14, and 8/5/14, Resident 1 had occasional episodes of confusion and forgetfulness. On 8/5/14, Resident 1's physician was contacted to obtain an order for the use of pad alarms (sensors on chair or bed to alert staff by beeping if residents attempt to stand or get out of bed). On 8/16-8/20/14, Resident 1 had continued episodes of confusion and increased anxiety.Review of Resident 1's Psychology Consult evaluation dated 8/7/14, indicated Resident 1 had an episode of confusion, dizziness and shortness of breath. He documented "the question is the cause of her decline in cognitive functioning from the time of admission."Review of Resident 1's care plan, revised 8/5/14, to address her fall risk of 15, indicated an approach plan was to use bed and wheelchair alarms (alarm used to alert the staff when a resident is attempting to get up unassisted). Review containing Resident 1's cognitive pattern care plan was updated and revised on 8/8/14, and indicated Resident 1's mental status changed and she now had short and long term memory impairments.Further review of Resident 1's clinical record showed a FAX dated 8/15/14 directed to a physician from the facility which indicated Resident 1 had increased confusion for three days. Review of Resident 1's Screening Referral to Rehabilitation Services dated 8/21/14, indicated the staff requested a screening secondary due to Resident 1's decline in health. The physical therapist documented "it became apparent that her (Resident 1) functional mobility declined significantly in the past three weeks."On 8/21/14 at 6:25 p.m., a licensed nurse documented Resident 1 was found face down on the floor. The resident's head was bleeding, an alarm was sounding and the bed was not in the lowest position. At 9:30 p.m., Resident 1 was transported to the hospital emergency room. Review of Resident 1's Communication Form dated 8/21/14, showed Resident 1 fell out of bed and had increased confusion.Review of CNA C's Investigator's Interview/Statement of Event dated 8/21/14, indicated CNA C found Resident 1 lying face down on the floor, and bleeding. She documented the bed "was so high" and Resident 1 kept repeating "help me; I am bleeding."Review of licensed vocational nurse (LVN) B's interview statement dated 8/21/14, indicated on 8/21/14 at 4:40 p.m., Resident 1 was restless and tried to get out of bed. LVN B documented she told the resident to relax and not to get out of bed.Review of registered nurse (RN) A's interview statement dated 8/21/14, indicated she observed Resident 1 face down the floor and her head was bleeding. The resident's bed was in a high position (raised above the floor).During an interview on 9/2/14 at 9:50 a.m., RN D stated Resident 1 was alert with periods of confusion. She stated Resident 1's mental status had declined since her admission on 6/14. RN D stated prior to Resident 1's fall on 8/21/14, she had witnessed Resident 1 trying to climb out of bed and a physician's order for a pad alarm was obtained (device used to alert the staff of the resident attempting to get out of bed unassisted). When RN D was asked the interventions that would be implemented for a resident with a high risk for falls, she stated a pad alarm, low bed and floor mats. She confirmed Resident 1 was a high risk for falls and thought Resident 1 had a low bed and floor mats in place. On 9/2/14 at 10:25 a.m., a telephone interview was conducted with LVN B. She stated Resident 1 was alert with periods of confusion. LVN B stated on 8/21/14, around dinner time, a CNA told her Resident 1 was face down on the floor and bleeding from her head. She stated upon entering Resident 1's room, she found Resident 1 lying on the floor on the left side of her bed. LVN B stated Resident 1 had "a lot of blood" on the right side of her face and "it looked really deep." The pad alarm was sounding and the resident's bed was in a high position. LVN B stated she did not think Resident 1 had floor mats in place.During a telephone interview on 9/2/14 at 10:45 a.m., RN A stated Resident 1 is alert with periods of confusion. She stated on 8/21/14, a CNA told her Resident 1 fell out of the bed. RN A stated upon entering Resident 1's room, she observed Resident 1 lying on the left side of the bed and had a moderate amount of bleeding from her right forehead. She stated the pad alarm was beeping and the resident did not have floor mats.During an interview on 9/2/14 at 10:50 a.m., the interim director of nurses (DON) stated Resident 1 was disoriented. She stated on 8/21/14, she observed Resident 1 lying on the left side of her bed and had a large amount of bleeding coming from the resident's right orbit (eye). She was unable to recall if Resident 1 had floor mats in place. The DON stated Resident 1's fall could have been prevented if more interventions were implemented.Review of Resident 1's emergency room discharge instructions dated 8/21/14, indicated she was treated for a facial laceration (cut) requiring sutures sustained from the fall. Review of Resident 1's computerized tomography scan (CT scan: X-ray images) dated 8/21/14 indicated Resident 1 had an altered level of consciousness (change in mental condition) after her fall. The results showed the resident sustained right forehead swelling.Review of Resident 1's emergency room history and physical dated 8/21/14, indicated Resident 1 fell out of bed and sustained a 1.5 centimeter laceration to the right side of her head, requiring sutures.On 8/22/14 at 5:30 a.m., a licensed nurse documented Resident 1 returned from the hospital at midnight following the resident's fall. Upon examination, Resident 1 had sutures to her right forehead, a small skin tear to her right forearm, bruises to her right hand and left shin, both knees had abrasions and were slightly swollen and bruised and the resident had bruising under her right eye. The licensed nurse documented Resident 1 would have a 1:1 sitter (a person to stay with the resident at all times for safety) until full siderails were installed. This failure had a direct relationship to the health, safety or security of the resident. |
| 070000066 |
KATHERINE HEALTHCARE |
070012257 |
B |
17-May-16 |
25EV11 |
2593 |
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. Resident 3's clinical record was reviewed. The resident's Minimum Data Set (MDS, an assessment tool) dated 3/2/16, indicated the resident was totally dependent for dressing and had a diagnosis of diaphasia (loss of ability to express speech caused by brain damage). Resident 3 spoke a language other than English. Review of Resident 3's SBAR (Situation-Background-Assessment-Request Communication, a type of nursing communication form) indicated the resident had an incident of "verbal abuse by CNA."Review of Resident 3's Interdisciplinary (IDT, facility staff members from different departments who coordinate care provided to the residents) Progress Notes dated 5/2/16, indicated a CNA used "foul" language against the resident. During an interview with the administrator (ADM) on 5/11/16 at 9:30 a.m., she stated when CNA A assisted in dressing Resident 3, CNA A used inappropriate words in a language other than English.During an interview on 5/11/16 at 10:15 a.m., Student Nurse B (SN B) stated she observed CNA A helping Resident 3 dress in the room. SN B stated CNA A called Resident 3 "dumbass" and "fat" in a language other than English. SN B stated she could understand the language. During an interview on 5/11/16 at 10:20 a.m., Student Nurse C (SN C) stated she was outside Resident 3's room and heard CNA A called Resident A "dumbass" in a language other than English. SN C stated she was able to understand the inappropriate words and she felt bad for the resident. During an interview on 5/11/16 at 10:25 a.m., Student Nurse D (SN D) stated she observed CNA A's care inside the resident's room and heard CNA A use inappropriate words to Resident A during resident care. Review of the facility's policy "Abuse, Neglect and Misappropriation of Resident Prohibition" dated 11/13, indicated each resident has the right to be free from abuse. Verbal abuse is the use of oral language including disparaging and derogatory terms to residents within their hearing distance regardless of their age, ability to comprehend, or disability.The facility failed to ensure the resident was free from verbal abuse.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000058 |
KINDRED NURSING AND TRANSITIONAL CARE-SANTA CRUZ |
070012788 |
B |
5-Dec-16 |
W80L11 |
5661 |
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 ensure two residents (Residents 1 and 2), who were identified as being at high risk for elopement and used WanderGuards (alert devices setting off an audible alarm when passing through an exit of the building), had adequate supervision when they eloped from the facility on 10/11/16. Resident 1's clinical record was reviewed and indicated he had diagnoses including dementia (a group of thinking and social symptoms interfering with daily functioning). His physician orders, dated 8/4/13, included an order for a WanderGuard. His care plans, dated 10/20/14, indicated he was at risk for wandering and attempting to elope. Resident 1 also had a prior incident of eloping on 2/2/16. His Minimum Data Set (MDS, an assessment tool), dated 8/24/16, indicated he was ambulatory. Resident 2's clinical record was reviewed and indicated she had diagnoses including Alzheimer's disease (a progressive disease destroying memory and other important mental functions). Her physician orders, dated 11/2/15, included an order for a WanderGuard. Her care plan, dated 10/31/14, indicated she was at risk for wandering. Her MDS, dated 10/10/16, indicated she was ambulatory. Residents 1 and 2's nurses notes, dated 10/12/16, indicated they were last seen in the facility at 7 p.m. They were found off the property and returned by a neighbor at 7:28 p.m. Their WanderGuards were checked and functioning. They were both assessed and no injuries were noted. During an interview on 10/28/16, at 1:15 p.m., Resident 1 had no memory of the incident. During an interview later the same day, at 1:30 p.m., Resident 2 had no memory of the incident. During an interview on 10/28/16, at 1:45 p.m., registered nurse A (RN A) stated she was the charge nurse the evening of Residents 1 and 2's elopement. RN A stated she recalled seeing the two residents walking in the hall together at 6 p.m. She stated she was not aware they were missing until a neighbor brought them back at 7:30 p.m. RN A stated she assessed both residents after their return and did not note any injuries. During a telephone interview on 11/3/16, at 1 p.m., licensed vocational nurse B (LVN B) stated she was present when Residents 1 and 2 were returned by a neighbor. She stated she checked all of the doors in the facility and determined the alarms were functioning. During a telephone interview later the same day, at 1:25 p.m., certified nurse assistant C (CNA C) stated she was working the evening Residents 1 and 2 eloped. She stated she was feeding another resident in the nursing station close to the front door when she heard the alarm sound. CNA C stated she went out the front door into the parking lot and walked to the street to see if any residents were present. She stated she did not see anyone. CNA C also stated she saw a nurse sitting in his car eating and she asked him if he had seen anyone. When he answered he had not seen anyone, she stated she returned to the facility and turned off the alarm. CNA C stated she did not advise anyone else in the facility the alarm had sounded. During a telephone interview later the same day, at 1:35 p.m., LVN D stated she saw Residents 1 and 2 walking around the facility earlier in the evening. She stated a neighbor brought them back to the facility and asked her if she knew them. LVN D stated she did not know they were missing until the neighbor returned them. After the two residents returned, she stated she called their nurse to assess them and she assisted the other staff members by checking all of the doors and determined all of the alarms were functioning. During a telephone interview on 11/28/16, at 2:25 p.m., LVN E stated he was in his car in the back of the facility when a CNA asked him if he had seen anyone leave the building. He stated he told her he had not seen anyone. LVN E stated he did not hear the alarm sound. He also stated he assumed the CNA would advise the staff the alarm had sounded and she could not find anyone who possibly triggered the alarm. LVN E stated he later heard two of the residents had eloped. Review of the facility's 5/28/16 and 6/1/16 policies, "Unsafe Wandering Risk Evaluation" and "Unsafe Wandering Patient Bracelet", indicated residents who leave a safe area may be at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Residents are to be assessed upon admission to identify risk for unsafe wandering and if the resident is at risk, a wandering device should be placed on the resident. The facility failed to ensure Residents 1 and 2 had adequate supervision when they eloped from the facility. This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000035 |
KINDRED NURSING AND TRANSITIONAL CARE-PACIFIC COAST |
070013346 |
B |
18-Jul-17 |
KQXF11 |
6271 |
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 ensure Resident 1 was adequately assessed for proper transfer method to prevent injury. Certified Nursing Assistant (CNA) E failed to transfer Resident 1 safely from the wheelchair to the bed. Resident 1 was identified by the facility to require a two person transfer; however on 6/14/16 at approximately 4 p.m., CNA E attempted to transfer the resident by himself. He placed the wheelchair with Resident 1's weaker side against the bed. During the transfer Resident 1 yelled out in pain. CNA E noticed the prosthetic (artificial) leg did not pivot (turn) during the transfer. An X-ray was obtained on 6/17/17 that showed Resident 1 sustained a hip fracture. The failure of the facility to ensure staff were knowledgeable in proper transfer techniques was the direct cause of Resident 1's right hip fracture.
Clinical record review for Resident 1 was initiated on 6/30/17. Resident 1 was admitted to the facility with diagnoses including right hemiparesis (weakness), and status post right below the knee amputation, requiring the use of a prosthetic leg.
Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 3/23/17, indicated he had moderate cognitive impairment (usually understands). In addition, Resident 1 was totally dependent for transfers with two staff members and had functional limitations to one arm and leg.
Review of Resident 1's care plan with a revised date of 3/29/17, to address his self-care deficits related to his right side weakness, indicated he was totally dependent on the staff for transfers.
Review of Resident 1's Weekly Progress Note dated 5/29/17 showed the resident was legally blind and required extensive assistance with his activities of daily living (ADL) care and total assistance with transfers.
Review of Resident 1's Physician's Order Note dated 6/15/17 at 3:17 p.m., showed the resident complained of increased pain to his right below the knee amputation and an X-ray was ordered of his right hip to knee.
Review of Resident 1's hospital History and Physical report dated 6/18/17 showed his right knee/hip X-ray results showed he had an acute fracture to his right lower hip bone and a large right knee swelling. A hard cast splint was applied to his right stump (knee).
Review of Resident's 1 Investigation Report dated 6/23/17, showed during a transfer from the wheelchair to the bed, Resident 1 felt that his leg hit on the bed frame, causing him pain. An interview with CNA E showed during the transfer, the resident's prosthetic leg "did not fully turn with the rest of his body."
On 6/30/17 at 10 a.m., an interview was conducted with RN A. He stated Resident 1 was alert, oriented and able to make his needs known. He stated Resident 1 required total assistance from two staff members for transfers since admission.
During an interview on 6/30/17 at 10:15 a.m., Resident 1 was interviewed with CNA B as an interpreter. Resident 1 was alert to name and place. He stated he hurt his right leg during a transfer from the wheelchair to the bed. Resident 1 stated CNA E placed the wheelchair on the right side of the bed with his head facing the wall (weaker side against the bed). He stated during the transfer, he was wearing his prosthetic leg and his right leg hit the bed frame. Resident 1 stated he was "screaming in pain" during the transfer. A concurrent observation of Resident 1's right stump showed a hard cast/splint in place with an ace wrap. He was not able to wear his right prosthetic leg.
During an interview on 6/30/17 at 11:15 a.m., Physical Therapists (PT) C and D stated the proper procedure to transfer a resident with right sided weakness is to place the wheelchair on the left side (stronger side). They stated Resident 1 required a two person maximum assistance for transfers. PT C and D stated they were unaware of the reason Resident 1 was transferred from the bed to his wheelchair with the wheelchair positioned on his right side (weaker).
During an interview on 6/30/17 at 11:30 a.m., the director of nurses (DON) stated if a resident has hemiplegia, two staff members should transfer the resident with the resident's dominant side closest to the bed/chair.
During an interview on 6/30/17 at 11:40 a.m., CNA E stated on 6/14/17 at approximately 4 p.m., he was transferring Resident 1 from the wheelchair to bed. He stated he turned the wheelchair around so the resident was facing the wall and the resident's right side was against the bed. CNA E stated during the transfer the resident's prosthetic leg did not turn with him and the resident yelled out in pain. He stated he did not notify the nurse about Resident 1's pain because the pain subsided when the resident laid down in the bed. When CNA E was asked the reason he positioned Resident 1's weaker side against the bed, he stated because there was no room on the opposite side of the bed. He was unable to answer the reason he was unable to answer.
Review of the National Institute for Occupational Safety and Health Website (www.cdc.gov/niosh/docs) documented for safe resident handling from the bed to the chair when the resident has impaired upper extremity strength, use a full-body sling (lift) and two caregivers should be used. If the resident has partial weight-bearing capacity, transfer toward the stronger side. |
| 120001472 |
KAWEAH MANOR CONVALESCENT HOSPITAL |
120010404 |
B |
05-Feb-14 |
MG1511 |
2297 |
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.(c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code.On March 8, 2012 at 10:20 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding the alleged financial abuse with one patient (A).Based on interview and record review, the facility failed to notify the California Department of Public Health (CDPH) within 24 hours of discovery of the alleged financial abuse.During an interview with the Administrator on 3/8/12, at 10:25 AM, he indicated the alleged financial abuse had been occurring for over a year, whereby the daughter of Patient A had failed to pay a share of cost for the patient's stay at the facility. The Administrator indicated he reported the alleged financial abuse to the Department of Justice on 10/19/11 when he thought it might be a case of financial abuse. The Administrator stated he did not report this alleged abuse to the California Department of Public Health (CDPH) until 3/2/12.During an interview with the Administrative Assistant (AA) on 3/8/12, at 10:30 AM, she indicated the share of cost was assessed for the amount in September of 2010. The daughter was contacted at this timeand she agreed to pay the amount. She had never paid any of the shares of cost since it was first assessed back in 2010.The facility policy and procedure titled, "Reporting Abuse to Facility Management" undated, read "When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator...will notify the following persons or agencies of such incident: a. The State licensing/certification (CDPH) agency will be called within 24 hours..." There was no record the facility reported the alleged financial abuse to the Department until 3/2/12 when the report was faxed to the Department.Therefore the facility failed to notify the Department of an allegation of abuse within 24. |
| 120000695 |
KERN VALLEY HEALTHCARE DISTRICT D/P SNF |
120010562 |
B |
26-Mar-14 |
OYJH11 |
2214 |
Health and Safety Code 1418.91(a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.Based on interview and record review, the facility failed to report an allegation of abuse to the Department of Public Health within 24 hours.Patient A was an 85 year old female with the diagnosis of Alzheimer's (a type of dementia that causes problems with memory, thinking and behavior that progresses slowly over time), Obstructive hydrocephalus (is a form of hydrocephalus which is caused by some visible blockage in the flow of cerebrospinal fluid), and depressive disorder. During an interview with Family Member 1 (FM 1) on 8/15/12, at 5 PM, she described Patient A's Responsible Party (RP 1) took advantage of Patient A when she used the money meant for Patient A's care. FM 1 stated in April of 2012 RP 1 was visiting and when questioned about Patient A's funds it was revealed to them there was misappropriation of Patient A's funds and property. The clinical record for Patient A was reviewed on 8/16/12, at 10:40 AM. A notarized, untitled document dated 4/10/12, stated "To whom it may concern: I (RP 1)... acknowledge I had complete control of all assets and properties of Patient A...as well as...bank account...I acknowledge there may have been mismanagement of the bank account and properties while in my control..." This document was signed by RP 1. During an interview with the Director of Nurses (DON) on 8/16/12, at 1PM, she stated Family Member 2 (FM 2) did take over Patient A's financial and medical authority, and we heard he was filing for Medicare/Medical fraud. Although the untitled document in Patient A's clinical record, dated 4/10/12 indicated there was mismanagement of Patient A's account and properties, this was not reported to the Department within 24 hours.Therefore, the facility failed to report an allegation of financial abuse to the Department within 24 hours. In accordance with health and Safety Code Section 1418.91, this violation is a class "B" violation. |
| 120001472 |
KAWEAH MANOR CONVALESCENT HOSPITAL |
120011622 |
A |
25-Aug-15 |
KNSN11 |
6232 |
F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion Based on observation, interview, and record review the facility failed to protect one of one sampled resident (1) from abuse when Certified Nursing Assistant (CNA) 1 hit Resident 1 with a closed fist and then CNA 1 came back into the room five minutes later, slapped Resident 1 in the face and swore at him which violated the resident's rights and resulted in Resident 1 looking like he was going to cry and then staying very quiet afterwards.An unannounced visit was made to the facility on 6/30/15 at 12:01 PM to investigate an allegation of resident abuse by staff.Resident 1 was a 71 year old male admitted to the facility on 2/18/15 with diagnoses including encephalopathy (disease affecting the brain), muscle weakness, dementia with behavioral disturbance (Dementia is a syndrome caused by a number of brain disorders which cause memory loss, decline in some other aspect of cognition, and difficulties with activities of daily living. Behavioral disturbance could include wandering, striking others, resistance to care, etc.), anxiety (a multisystem response to a perceived threat or danger), and psychosis (incorrect beliefs not based on reality).During an interview on 6/30/15 at 12:30 PM, CNA 2 stated she was in Resident 1's room with CNA 1, CNA 3, and CNA 4 and Resident 1 became combative on 6/24/15 at 2:40 PM. CNA 2 stated "He (Resident 1) cornered her (CNA 1) in the corner and he grabbed her arm. She (CNA 1) hit him in the back of the neck with a closed fist. He looked like he was going to cry. We finished with him and I left. It happened so fast, we were all in shock."A statement written on 6/30/15 at 12:35 PM by CNA 2 indicated: "I went into the room to help my co-worker (CNA 3) change (Resident 1). I put gloves on and so did she. (CNA 1) and (CNA 4) walked in the room and put on gloves to help us. As soon as we started pulling down his pants to change him, he became combative and his merry chair (a walker with a seat constructed of plastic pipe) cornered (CNA 1) against the wall. He then started to swing his arms and he managed to grab onto (CNA 1)'s arms with his hands and nails. She then made a fist and hit him on the back of the neck, upper back. She managed to get away after that and walked out of the room. The incident happened at 2:15 PM."During an interview on 7/1/15 at 8:30 AM, CNA 1 stated "He grabbed my arm and I pulled my arm away. I may have hit him because he was trying to bite me." CNA 1 stated she had not been trained on how to handle a combative resident.During an interview on 7/1/15 at 12:05 PM, CNA 3 stated "He (Resident 1) was in his merry walker. He was in the corner and (CNA 1) was against the wall. He got agitated and clawed her arm. She hit his neck with a closed fist and shoved him in the corner. She left the room and then came back and slapped him saying, 'I hope you die motherf---ker.' I was the only person in the room when she came back and slapped him."A statement written on 7/1/15 at 12:10 PM by CNA 3 indicated: "It was about 2:20 PM, when me and (CNA 2) were getting ready to change (Resident 1). During that time, (CNA 4) and (CNA 1) walked in and saw that we were getting ready to change (Resident 1) so they put on gloves to help us. When we started changing (Resident 1) he started getting combative and started to dig his fingernails on (CNA 1)'s arms, he was also trying to bite her arm. (CNA 1) got mad and hit (Resident 1) with a closed fist behind (his) neck. We pulled his pants up and (CNA 1) shoved him in his chair. About five minutes later, she came back into the room, closed the door, went up to him and slapped him on the cheek. She then told him 'I hope you die motherf---ker.' After the incident I noticed (Resident 1) was shocked because he just sat on his chair still and ....he stayed quiet afterwards."During an interview on 7/1/15 at 12:20 PM, CNA 4 stated "He (Resident 1) didn't want to stand and (CNA 1) yanked him up by the arm. He grabbed her left arm and dug his nails in. She pushed his head away with open hand. She pushed him back in the chair and pushed his head again."A statement written on 7/1/15 at 12:40 PM, by CNA 4 indicated: "Around 2:10 PM, I went to go in and check to see if the other aid, (CNA 1) needed help....but saw that she was changing (Resident 1) for CNA 3 and went over to help. (Resident 1) wasn't wanting to stand up so (CNA 1) pulled him up by his left arm quick and in a hard motion, which agitated [sic] the resident. (Resident 1) then tried to bite her while grabbing her left arm and digging his nails into her arm. When the resident was doing that (CNA 1) got mad and pushed his left temple enough to make his whole head move, which made the resident even more angry... Then, he grabbed his side table and tried pushing it into her side while she was changing him... By the time I got the table from him (CNA 1) was done changing him and had his pants back up. She pushed (his) left temple again after she got done changing him and pushed him back down into his chair and pushed him once more in his left temple and then left the room angrily[sic].During a concurrent interview and observation on 6/30/15 at 2 PM, Resident 1 was seated in the merry walker next to his bed. His eyes were closed and his hands were on his lap. CNA 5 was seated several feet away from him and stated "Yes, he's tried to hit me a couple of times. You just need to stay out of his reach."The facility policy titled "Reporting Abuse to Facility Management", undated, indicated: "Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friend, or other individuals."Therefore, the facility failed to prevent the abuse of Patient 1 which presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120001472 |
KAWEAH MANOR CONVALESCENT HOSPITAL |
120011778 |
A |
02-Nov-15 |
FW0U11 |
5166 |
F279 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe 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 ?483.25; and any services that would otherwise be required under ?483.25 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(b)(4). Based on interview and record review, the facility failed to develop and follow a comprehensive plan of care for two or more person assistance during transfer for one of one sampled resident (1) which resulted in Resident 1 sustaining a broken leg.An unannounced visit was made to the facility on 8/28/15 at 9:20 AM, to investigate a fall with fracture sustained by Resident 1. Resident 1 was a 78 year old female with a history of asthma (a chronic inflammatory disease of the airways), acute respiratory failure (a syndrome in which the respiratory system fails in one or both of its gas exchange functions), chronic kidney disease (Chronic kidney disease occurs when disease or disorder damages the kidneys so that they are no longer capable of adequately removing fluids and wastes from the body), congestive heart failure (a condition where the heart is unable to maintain an adequate circulation of blood in the bodily tissues or to pump out the venous blood returned to it by the veins), urinary incontinence, difficulty walking, and generalized muscle weakness.The clinical record for Resident 1 was reviewed and contained the following:The physician's orders dated 8/16/15, indicated Resident 1 was to be receiving oxygen at two liters a minute continuously.A Nursing Evaluation/Data Collection form dated 8/16/15, indicated Resident 1 had a weight of 232 pounds and was 64 inches tall with a body mass index (BMI) of 39.8 (a person with a BMI over 30 is considered obese). This form indicated when Resident 1 was transferred between surfaces and moved to a standing position; she was totally dependent on staff and required two or more person physical assistance.Resident 1's care plan for assistance in daily living dated 8/16/15, indicated she was dependent on staff with transfers and toileting and required maximum assistance. The area under approach indicating how many persons would be required to assist the resident was checked but the actual area for how many persons required was left blank.A Balance Assessment Tool dated 8/18/15 indicated Resident 1 was unable to rise from a chair without help, had unsteady balance and was unsafe to sit back down.Nurse's notes dated 8/18/15 at 10:30 PM, indicated "CNA (certified nursing assistant) went into room... to answer resident's bathroom call light. Resident was in the bathroom. At 1645 (4:45 PM), CNA stood resident up and resident's knee buckled up. CNA guided resident to floor. CNA notified CN (charge nurse) immediately.Nurse's notes dated 8/19/15 at 5:15 PM, indicated: "Resident had x-ray of knees done due to complaint of pain. X-ray results showed fracture to left femur (thigh bone),"Resident 1's x-ray report dated 8/19/15 at 3:15 PM indicated: "Acute oblique displaced fracture of the distal femoral diaphysis and metaphysis." (Recent slanted fracture of the thigh bone head and shaft where the bone is not aligned.)During an interview on 8/28/15 at 9:30 AM, the Administrator stated Resident 1 was in the restroom and felt weak. She started "going down" and CNA 1 called for help.During an interview on 8/31/15 at 4:48 PM, CNA 1 verified she was the only staff member assisting Resident 1. CNA 1 stated: "It was around 4:45 PM, I stood her up and she was holding on to the sink... Her left knee buckled and I guided her to the floor. She went down on both knees. I got someone to help me get her into the wheelchair. I told (Licensed Vocational Nurse [LVN]) 1 what happened."During an interview on 9/2/15 at 12:30 PM, LVN 1 stated: "When I was called, (CNA 1) said she eased her to the floor. She was leaning toward the sink... I ran and got (another CNA) and we lifted her onto the toilet chair seat and we put oxygen on her. She didn't have oxygen on at the time. We took her to bed.She said her left knee was hurting. I don't know who put her in the bathroom. She was a two-lift person. She's heavy and not strong and has to have oxygen on all the time."The facility policy and procedure titled "Duties and Responsibilities" undated, read "Developing a comprehensive care plan for each resident... Reviewing care plans to assure that: They reflect the resident's medical and nursing assessment, they are oriented toward preventing declines in functioning and/or functional levels. They attempt to manage risk factors... They reflect and interdisciplinary approach to maintain or improve functional abilities." |
| 120000695 |
KERN VALLEY HEALTHCARE DISTRICT D/P SNF |
120012164 |
B |
19-Apr-16 |
032T11 |
4321 |
Health and Safety Code 1418.91(a):(a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b)A failure to comply with the requirements of this section shall be a class "B" violation. On 3/15/16, at 8:30 AM, an unannounced visit was made to the facility to investigate a entity reported incident regarding alleged abuse between a staff member and a resident. Based on interview and record review, the facility failed to report an allegation of verbal abuse for one of one sampled Resident (1) within 24 hours to the California Department of Public Health (CDPH) when facility reported the allegation of verbal abuse on the 6th day after the report was received from Resident 1. This had the potential for abuse allegations to go unreported.During an interview with the Activity Assistant (AA), on 3/18/16, at 11:20 AM, the AA stated Resident 1 reported to him an allegation of verbal abuse. When asked what he did next, he stated, "I finished my day, I did not see my Supervisor [Activity Coordinator]. I did not report to anybody because I was waiting for my Supervisor, but she wasn't here." When asked when he report to his Supervisor, he stated, "I reported to her the next day and she told me to report to [Mental Health Coordinator-MHC] but I waited until Monday because it was Saturday." AA stated he got to report to the MHC on Wednesday. When asked when the abuse allegation should be reported, he stated, "I know now that it should be reported within 24 hours but I did not."During an interview with the Activities Coordinator (AC), on 3/18/16, at 11:56 AM, when asked if she received a report from the AA about Resident 1's allegation of verbal abuse, she stated, "Yes and I told him to report to [MHC]. I assumed he did that, I did not check again." AC stated she followed up again on Wednesday and the allegation was not reported yet. When asked who the mandated reporters are, she stated, "Everyone." When asked when an allegation of verbal abuse should be reported to the CDPH, she stated, "Within 24 hours. I walked [AA] to the [MCH] and Director of Nursing (DON) to report on 3/9/16." During an interview with the DON, on 3/18/16, at 11:45 AM, she stated, "The resident's [1] report was not reported within 24 hours. It was reported to the CDPH on 3/10/16 [on the 6th day after the allegation of verbal abuse from Resident 1 was received]." The facility Abuse in service, titled "Reporting Abuse of Skilled Nursing or Swing Bed Residents", undated, indicated, "Every hospital employee is a Mandated Reporter. If you, in your professional capacity, or within the scope of your employment have observed or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or you have been told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonably suspect abuse has occurred, you must: Make a telephone report to the Long Term Care Ombudsman or local Law Enforcement, immediately or as soon as possible. (Ombudsman posters displaying the phone number for the Long Term Care Ombudsman are posted throughout the facility.) Contact your DON immediately. This step is crucial to ensure safety and welfare of all residents and staffs are addressed. Obtain and complete form SOC 341 and mail it to the address you have given by the Ombudsman. (Forms are available in the Nursing Office, ER, Supervisor's office, and on the bulletin boards located in the Employee Dining Room and Nursing Center Day room.) This report must be completed and submitted within 2 working days. You may not delegate your supervisor or anyone else to make the report for you. You must make it yourself! (Facility Name) policy indicates you should always let your supervisor know when you report so that the facility can take immediate steps to protect the resident from further abuse, remove an abusive care giver, report abuse to the California Department of Health Services and begin the required investigation. The facility is required by law to take these steps, and cannot do so if you don't report the abuse to your supervisor." |
| 120001472 |
KAWEAH MANOR CONVALESCENT HOSPITAL |
120012372 |
B |
6-Jul-16 |
4QWX11 |
4708 |
Health and Safety Code 1418.91(a): (a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on observation, interview and record review, the facility failed to report an allegation of abuse of Resident 1 to the California Department of Public Health and other state agencies within 24 hours which had the potential for the abuse to continue and cause physical and psychological harm to the resident. An unannounced visit was made to the facility on 5/4/16, at 12:45 PM, to investigate an allegation of resident abuse by a visitor. The clinical record for Resident 1 was reviewed. Resident 1 was admitted to the facility with diagnoses which included: Other late effects of cerebrovascular disease (stroke) and quadriplegia (paralysis of all four limbs). A nurse's note dated 4/30/16 at 3:16 PM, and written by Licensed Vocation Nurse 1 (LVN 1) indicated, "I saw the visitor had his hand under the resident's sheet. I saw he was moving his hand back and forth in the resident's groin area... " The History and Physical examination dated 12/15/15, indicated Resident 1 "Does NOT have the capacity to understand and make medical decisions During an observation on 5/4/16 at 12:50 PM, Resident 1 was lying in bed with her body turned towards the door. Resident 1 was unable to verbalize her name and made facial grimaces when spoken to. During an interview on 5/4/16 1 PM, the Administrator stated on 4/30/16, Certified Nursing Assistant (CNA) 1 had observed a visitor in Resident 1's room with his hand under the sheet stroking Resident 1's groin and upper thigh area. The Administrator stated CNA 2 also observed the incident and LVN 1 was notified. LVN 1 entered the room and asked the visitor to step out of the room. The Administrator stated LVN 1 called her and Resident 1's responsible party (RP) to report the incident. The Administrator stated she and the RP came in to the facility and attempted to interview the resident. The Administrator stated Resident 1 acknowledged the visitor touched her groin area. The Administrator stated she interviewed the visitor who acknowledged he was massaging Resident 1's "upper leg ". The Administrator stated Resident 1 did not have capacity to understand and make medical decisions. The Administrator stated she did not report the allegation of abuse to the Department or other agencies within 24 hours. During an interview on 5/10/16 at 9:20 AM, the RP stated: "I agreed with the doctor that she can't make decisions. I want to deem it sexual abuse. During an interview on 5/10/16 at 10:10 AM, CNA 1 stated: "I was standing right outside the room talking to (LVN 1) ...the gentleman's hand (visitor) was holding her (Resident 1's) hand above sheet. He was by the wall. I think he thought I couldn't see. He put his hand under sheet and moved his hand dead middle of private area. He locked my eyes and looked like he saw a ghost." During an interview on 5/10/16 at 12:42 PM, LVN 1 stated: "I was doing med pass across hall from (Resident 1). They grabbed me and I went in and saw his hand under (the) sheet." During an interview on 5/10/16 at 2:55 PM, CNA 2 stated: "We were at the room across from her ... (CNA 1) said 'Look at A bed'. The visitor's hand was under the sheet at the groin area going back and forth." The Department received a letter from the facility on 5/4/16 at 10:32 AM from Admin 1 which indicated: "This letter is to report the unusual occurrence called in 5/2/2016 at approximately 1900". This call was made 54 hours after the incident. The facility's abuse reporting document was faxed to law enforcement and the Long Term Care Ombudsman on 5/4/16. The facility's policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" undated indicated: "Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator or his/her designee, will notify the following persons or agencies (verbally or in written of such incident within 24 hours or, if involving great bodily injury with 2 hours). a. The CEO and/or CCO b. The State licensing/certification agency responsible for survey/licensing the facility; a. The local State Ombudsman; b. Completion of SOC-341[sic] form; c. The resident's representative (sponsor) of record; d. Adult protective services; e. Law enforcement officials if indicated; f. The resident's attending physician...." |
| 120000695 |
KERN VALLEY HEALTHCARE DISTRICT D/P SNF |
120012485 |
B |
8-Aug-16 |
MTG011 |
5011 |
F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 2) from sexual abuse when Resident 1 touched Resident 2 under her skirt. This failure resulted in Resident 1 sexually assaulting Resident 2 two times. An unannounced visit was made to Facility A and Facility B where Resident 1 and Resident 2 had been transferred because of a fire around the facility on 6/28/16 at 12:57 PM (Facility A) and 2:15 PM (Facility 2) and an unannounced visit was made to the facility after Resident 1 and Resident 2 returned on 7/7/16 at 9:30 AM, to investigate an allegation of resident to resident abuse. Resident 1 was a 75 year old male with diagnoses of congestive heart failure, diabetes, chronic obstructive pulmonary disease, and labile mood. Resident 2 was an 88 year old female with diagnoses of dementia, anxiety disorder, generalized muscle weakness and abnormalities of gait and mobility. The clinical record for Resident 1 was reviewed. The patient progress note dated 7/18/15 at 2 PM, indicated Resident 1 was found in Resident 2's room and was touching her breast [first incident]. The plan of care for Resident 1 dated 7/18/15, indicated Resident 1 had inappropriate sexual behavior. The interventions for this behavior included "Resident (Resident 1) is to have line of sight from staff while out of bed." This care plan was updated 6/3/16 with no change to the above intervention. The "Patient Progress Notes", dated 6/15/16, at 3:04 PM, indicated at approximately 1:45 PM, Resident 1 was found in Resident 2's room by Certified Nursing Assistant 1 [CNA 1] with his hand up Resident 2's dress and Resident 2 screamed which alerted staff [second incident]. During a review of the clinical record for Resident 1, the "Cognitive Patterns", dated 6/2/16, indicated a Summary Score of 13 [score of 13-15 means cognitively intact]. Resident 1's attending physician's assessment documented on 6/26/16, after Resident 1 was transferred to Facility A, indicated Resident 1 had the capacity to understand and make his own medical decisions. During a review of the clinical record for Resident 2, the admission record indicated Resident 2 had a diagnosis of dementia. The "Cognitive Patterns", dated 5/17/16, indicated a Summary Score of 8 [score of 8-12 means moderate cognitive impairment]. During an observation on 7/7/16, at 9:49 AM, in the Activity Day Room, Resident 1 was sitting beside a private sitter. Resident 2 was approximately 2 meters away from Resident 1 with an Activity Staff sitting in between them. Resident 1 and 2 were playing kick ball with 6 other residents. During an interview with CNA 2, on 7/7/16, at 11:34 AM, she stated right before the incident, Resident 1 was wandering in hall 2 [where Resident 2 was] and CNA 2 removed Resident 1 and placed him in his room. CNA 2 stated, "After few minutes, [Resident 1] was found in [Resident 2's] room." During an interview with the Mental Health Coordinator (MHC), on 7/7/16, at 11:46 AM, she stated, "We are aware [Resident 1] is such a predator, he will target the confused residents. He can't be trusted." MHC stated Resident 1 was on every 15 minute checks before the incident. MHC stated, "[Resident 1] had history of previous attempts of touching other residents." During an interview with CNA 1, on 7/11/16, at 9:35 AM, she stated she heard Resident 2 screaming for help and was saying 'Get out of my room'." CNA 1 stated, "When I walked in [Resident's 2's] room, I saw [Resident 1] facing [Resident 2], both in their wheelchairs, with his [Resident 1's] hand inside [Resident 2's] skirt moving back and forth." CNA 1 stated she had seen Resident 1 try to look under other resident's clothing. CNA 1 stated the facility was aware Resident 1 wanders in the hall and goes into other resident's rooms. The facility policy and procedure titled "Abuse Prevention Program", dated 3/2016, indicated, "In the event of suspected maltreatment, the needs of the resident will be immediately assessed and the safety of the resident will be ensured. The safety and health of the resident(s) will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment, including medical intervention as needed. Sexual Assault: Sexual contact that results from threats, force, or the inability of the person to give consent, and involving a range of activities, including, but not limited to, assault, rape, or sexual harassment. Any sexual activity that occurs when an individual cannot or does not consent." This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000695 |
KERN VALLEY HEALTHCARE DISTRICT D/P SNF |
120012551 |
A |
22-Sep-16 |
CL1E11 |
7181 |
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 ensure one of two sampled residents (Resident 1), who was wandering in the facility, did not picked up a medication card containing Norco tablets (a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication and is a narcotic. Acetaminophen is a less potent pain reliever that increases the effects of hydrocodone. Norco is used to relieve moderate to moderately severe pain) from nurse's station. This resulted in Resident 1 experiencing a change of condition after ingesting a portion of the Norco and then being emergently transferred to an acute hospital. An unannounced visit was made to the facility on 8/16/16 at 10:06 AM, to investigate an incident of ingestion of narcotic medications by a resident. Resident 1 was an 84 year old male with a medical history of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), hypertension (high blood pressure), affective mood disorder (Any of a group of psychiatric disorders, including depression, characterized by a pervasive disturbance of mood), pain, and wandering (wandering refers to a resident with cognitive impairments moving aimlessly about inside a facility). During a review of the clinical record for Resident 1, the Minimum Data Set (MDS- a comprehensive assessment tool) dated 6/9/16, indicated Resident 1 had a short term memory problem and was able to walk independently. The "Wandering Risk Scale" dated 6/15/16, indicated a score of 11 (meaning Resident 1 was high risk to wander). The careplan for Resident 1 titled "Dementia with behavioral disturbance" dated 1/8/16, indicated Resident 1 wandered in the facility and became agitated when redirected by staff. The facility document titled "Possible Diversion" undated, indicated "Medication was delivered by retail pharmacy on 8/1/16 at approximately 1800 (6 PM) and signed in by (Licensed Vocational Nurse 1-LVN 1). Norco 10/325 mg (milligrams) was amongst the medication that was delivered. (LVN 1) reported that he left the medications on the table in front of him at the nurse's station while he continued charting. (LVN 1) reported that he left the medication on the table unattended to speak with the CNA (Certified Nursing Assistant) Instructor in the medication room (MR). A short time later resident (Resident 1) came into the nurse's station and picked up a medication card (a large paper card that has plastic bubbles containing individual medication tablets commonly known as a bubble pack). CNA # 1 found a bubble pack of Norco 10/325 mg tabs dated 8/1/16 at 2303 (11:03 PM) that evening, on the dresser, in the resident's room. It was noticed that 14 of the 30 tablets were missing...On 8/2/16...Resident drug screen was negative. On 8/3/16 resident was evaluated in the Emergency Room (ER/Acute Hospital [AH 1]) for hypertension (a condition in which the force of the blood against the artery walls is too high), fever and an altered mental status (is a disruption in how your brain works that causes a change in behavior). The resident's room was searched again and two half tablets consistent with Norco 10/325 identification markings were found under the resident's bed. It was determined with the ER work-up that he was now opiate (a drug with morphine like effects) positive on UDS (Urine Drug Screen). Resident was treated and returned to the unit a few hours later...On 8/4/16 at 8:00 PM RN (Registered Nurse) # 1 reported... and noted that the residents gait became unsteady and was hypotensive (abnormally low blood pressure) with lethargy (lack of energy). Resident was sent to and evaluated in the Emergency Room (AH 1). Resident was stabilized and transferred to another acute hospital (AH 2)...RN # 1 searched residents room and found 1 white tablet that is oblong inside a goldfish box. When an open package of zoo animal crackers was poured out there were 8 white medication tabs mixed with the animal crackers." During an interview with the Director of Nursing (DON), on 8/16/16, at 10:10 AM, she stated Resident 1 was confused, able to ambulate independently around the facility and had a history of wandering. DON stated the facility found a total of 10 out of the 14 tablets of missing Norco. During a concurrent observation and interview with Resident 1 at the nurse's station on 8/16/16, at 10:36 AM, Resident 1 walked into the nurse's station. Resident 1 was ambulating by himself. Upon interview, he stated he was "Okay" but continued his walking. Resident 1 was noted ambulating back and forth in front of the nurse's station. Resident 1 went inside the nurse's station and was grabbing papers. During an interview with LVN 1, on 8/17/16, at 9:25 AM, he stated on 8/1/16, at approximately 6 PM, he received the pharmacy delivery. LVN 1 stated he received the medications delivery including the residents' medications which were assigned to the other two nurses working on the floor. After receiving the medications, he placed the medications on top of the table in the middle of the nurse's station. LVN 1 stated he went to the facility's parking lot and stayed in the parking lot for approximately ten (10) minutes. He then returned to the nurse's station and he noted the medications were still on top of the table. LVN 1 then went to the MR and talked to the CNA Instructor and stayed inside the MR for approximately 10 to 15 minutes. LVN 1 went back to the nurse's station and completed his nursing documentation. After his nursing documentation he grabbed the medications on the table and secured them away. LVN 1 stated he did not recheck the amount of medications before securing them. LVN 1 stated the facility staff informed him about the missing narcotic medications and that the staff found some tablets in Resident 1's room. The AH 2 clinical record for Resident 1 titled "History and Physical" dated 8/5/16, indicated Resident 1 was admitted to the hospital with a diagnosis of Norco overdose. The acute hospital clinical record for Resident 1 titled "D/C (discharge) Summery" dated 8/9/16, indicated Resident 1 required a four day hospital admission to recover from his Norco overdose (8/5/16-8/9/16). The facility policy and procedure titled "NARCOTIC COUNT" dated 7/1/15, indicated under "PROCEDURE: Controlled substances are not available to other than nurses, pharmacist, and medical personnel designated by the facility." Indicated under NOTE: THE NARCOTICS SUPPLY IS TO BE KEPT UNDER TWO LOCKS AT ALL TIMES. THE LOCK ON THE MEDICATION CART AND THE LOCK ON THE NARCOTICS DRAWER ARE TO BE LOCKED AT ALL TIMES. IF THE CART IS KEPT IN A MEDICATION ROOM, THE MEDICATION ROOM IS TO BE LOCKED AT ALL TIMES." These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000695 |
KERN VALLEY HEALTHCARE DISTRICT D/P SNF |
120012608 |
B |
11-Oct-16 |
TGE911 |
6207 |
F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) who had a history of committing sexual abuse of other residents, was on one to one monitoring (one staff assigned to stay close to the resident at all times) as indicated in his plan of care. This failure resulted in the harming of another sampled resident (Resident 7), when Resident 1 entered her room and inappropriately touched her while she was asleep. An unannounced visit was made to the facility on 9/6/16, at 9:25 AM, to investigate an allegation of resident abuse by another resident. Resident 1 was a 75 year old male with a history of diabetes type II (a disease that causes blood sugar levels to rise higher than normal), chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), congestive heart disease (CHF- a condition in which the heart has lost the ability to pump enough blood to the body's tissues), labile mood (marked fluctuation of mood), and hypertension (high blood pressure). Resident 7 was a 69 year old female with a history of diabetes type II. The clinical record for Resident 1 was reviewed. The Brief Interview for Mental Status (BIMS- a screening tool used to assess cognitive function) score dated 6/2/16, indicated Resident 1 had a score of 13 which meant he was cognitively intact (A BIMS score of 13 to 15 indicates a person is cognitively intact). Resident 1's "Plan of Care", dated 6/15/16 and dated 7/2/16, both indicated he had inappropriately touched another resident and he had a history of sexually abusing "Others". The interventions for this behavior on both care plans included to keep him on a one to one monitoring by staff. During a review of Residents 1's "Nurse's Notes", dated from 9/1/16 through 9/5/16, it indicated when staff had asked him about inappropriately touching Resident 7, Resident 1 responded, "I don't know why I did it" and that he would "[Explicit word] do it again." During a review of Resident 7's "Nurse's Notes", dated from 9/1/16 through 9/5/16, it indicated on 8/31/16, at approximately 9:15 PM, Resident 7 reported to the night nurse that Resident 1 had entered her room and "Was touching her buttocks". The notes also indicated since the incident, Resident 7 verbalized being "A little fearful" to fall asleep and had asked the staff to ensure the "Stop" sign was fastened more securely to her door. She had also avoided going to her usual activities if Resident 1 was in or around the area. A review of Resident 7's recent Brief Interview for Mental Status score, dated 7/13/16, indicated it was 15 (score of 15 meant the resident was cognitively intact). During an interview with the Charge Registered Nurse, on 9/6/16, at 10:52 AM, she was unable to provide information that indicated the assigned one to one staff for Resident 1 on the night of the incident on 8/31/16. During an interview with the Mental Health Coordinator (MHC), on 9/6/16, at 11:36 AM, she stated on the night of the incident, Resident 7 informed her nurse that Resident 1 had been inside her room. MHC stated a certified nursing assistant (CNA 1) who was assigned to watch Resident 1 had left him in the care of an activity assistant (AA 1). AA 1 had left Resident 1 in front of the nurse's station after activities were over. During an interview with CNA 1, on 9/6/16, at 11:41 AM, he stated he was Resident 1's one to one sitter on 8/31/16, during the dayshift, 7 AM to 7:30 PM. CNA 1 stated he took Resident 1 to the dining area at dinner time. After dinner, around 7:20 PM, he left Resident 1 in the care of AA 1 and clocked out of the facility at 7:30 PM. CNA 1 also stated he notified the night shift nurse at the nurse's station where Resident 1 was located and that he had clocked out of his shift. During an interview with the Activities Coordinator (AC), on 9/6/16, at 2:15 PM, she stated she was aware Resident 1 needed one to one monitoring; however, she was not previously aware of a sign-out sheet (staff needed to note on the sheet when they are taking over monitoring of the resident). AC stated according to AA 1's accounts on the night of 8/31/16, AA 1 had taken Resident 1 to the nurse's station after activities ended, notified the nursing staff, and left him there. She was not aware of what happened afterwards. During an interview with Resident 7, on 9/6/16, at 3:10 PM, in the patient's room, she stated she was asleep and was lying on her right side with her back towards the door. She was dressed in a long robe. She stated she awoke when she felt Resident 1's right hand inside her robe and touched her "brief" (underwear). She stated "I was mad". Since the incident, she stated she had stopped going outside for fresh air because she did not want Resident 1 to be looking at her. During an interview with the Director of Nursing (DON), on 9/6/16, at 3:39 PM, she stated the staff were given in-service training regarding Resident 1 needing one to one monitoring as indicated in his plan of care dated 6/15/16 (after a prior incident with a different resident). The DON stated she confirmed with the Education Department that AA 1 had not received the in-service training regarding the plan of care for Resident 1 not to leave him unattended. The facility policy and procedure titled "Abuse Prevention Program" revised 3/16, indicated "Each resident will be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. Additionally all residents will be protected from abuse, neglect, and harm while they are residing in the facility. No abuse or harm of any type will be tolerated and all residents will be monitored for Protection. The facility will strive to educate all participants in techniques to protect all parties. These failures had a direct relationship to the health, safety, or security of residents. |
| 220000082 |
Kindred Transitional Care and Rehabilitation-Tunnell Center |
220011607 |
B |
08-Jul-15 |
N2LS11 |
4202 |
Health and Safety Code 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. This STATUTE is not met as evidenced by: The facility failed to report an allegation of abuse for one patient to the Department of Public Health immediately or within 24 hours (Patient 1). Patient 1 reported an allegation of abuse to the facility on 4/12/15, the facility did not report this incident to California Department of Public Health (CDPH) until 4/15/15, 72 hours after the incident was reported. The deficient practice which had the potential to result in decline in psychosocial status of the patient and put him at risk for further abuse under the care of one facility staff (Certified Nurse Assistant 1 [CNA 1]).Findings:Patient 1 was admitted to the facility on 4/10/15 with diagnoses including viral syndrome (a virus infection causing feelings of "being tired", loss of appetite, "aching all over", and fever) and hypertension (high blood pressure). Patient 1 was discharged to home with family on 4/22/15. Record review of the Minimum Data Set (MDS-a patient assessment tool) with a reference date of 4/18/15 indicated that Patient 1 was alert and orientated to person, place, and time. Patient 1's Brief Interview for Mental Status (BIMS) score was 14 (BIMS is a brief screener that aids in detecting cognitive impairment, a score of 13-15 indicated cognitively intact or no cognitive impairment). Record review of progress notes dated 4/10/15 thru 4/12/15, section labeled nurses notes dated 4/12/15 at 2:48 pm indicated Registered Nurse (RN) 1 notified by Patient 1 that during the night CNA 1 took away his phone, cell phone, placed call light out of reach, and made a "racist comment" as she left room. During an interview on 5/28/15 at 12 noon, RN 1 stated that Patient 1 voiced his complaints to her regarding CNA 1 early in her 7 am to 3 pm shift. RN 1 stated that Patient 1 told her that CNA 1 "took a long time to answer his call light, unplugged his phone so that he could not make calls, and called him a Baluga" (a derogatory term for a very dark person). RN 1 stated that she called the supervisor to report the incident.Record review of the Administrator's incident file indicated that the facility Administrator and the District Director of Clinical Operations were notified of an allegation of abuse on 4/13/15. The form SOC 341 was completed on 4/14/15 and copy faxed to Ombudsman on 4/14/15 at 5:23 pm. Summary of the allegation and investigation of abuse faxed to (CDPH) on 4/15/15 at 10:45 am. Record review of facility Abuse policy dated 7/28/14, indicated "... #2-The center staff must report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, immediately to a Senior Clinician, or Operational Leader at the facility, or District, or National Level and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).During an interview on 5/28/15 at 12 noon the Director of Nursing (DON) and RN 1 stated that they were unable to find documentation of CDPH being notified within 24 hours of the incident in the progress notes dated 4/12/15 thru 4/15/15.During interview 5/28/15 at 12:45 pm the DON and RN 1 stated that their understanding was that reporting to the Ombudsman was all that was required. The DON and RN 1 stated they thought the Ombudsman reported incidents to the State.Therefore the facility failed to report an allegation of abuse for one patient (Patient 1) to the Department of Public Health immediately or within 24 hours. For Patient 1 the facility failed to report an allegation of abuse to California Department of Public Health (CDPH) within 24 hours of incident which had the potential to result in decline in psychosocial status of the patient and put him at risk for further abuse under the care of one facility staff (Certified Nurse Assistant 1 [CNA 1]).The deficient practice had a direct relationship to the health, safety, or security of patients. |
| 220000020 |
Kindred Transitional Care and Rehabilitation-Lawton |
220012308 |
B |
08-Jun-16 |
JLNQ11 |
8412 |
F 201 483.12(a)(2) REASONS FOR TRANSFER/DISCHARGE OF RESIDENT The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or The facility ceases to operate. This Requirement is not met as evidenced by: Based on interview and record review, the facility failed to accurately inform 4 of 4 sample residents (Residents 1, 2, 3, and 4) regarding the facility's Medi-Cal status. Medi-Cal is a California Medicaid health insurance program serving low-income individuals. The facility discharged Medi-Cal eligible Residents 1 and 2 to a facility in Oakland when their Medicare ran out. Additionally, the facility was in the process of discharging Residents 3 and 4 when their insurance ran out. According to the www.medicare.gov website, Medicare "...is the Federal health insurance program for people who are 65 or older, ...(Medicare) covers inpatient hospital stays, care in a skilled nursing facility ... After a 3 day hospital stay, Medicare pays 100% of the cost (of skilled nursing), but only for the first 20 days of skilled nursing care ...". For days 21 through 100, the resident is responsible for a co-payment (as of this date of $161 per day). On day 101 and beyond, the resident is responsible for the entire cost at the skilled nursing facility. According to the California Department of Health Care Services' website, www.dhcs.ca.gov, "Medi-Cal is California's Medicaid health care program. This program pays for a variety of medical services for children and adults with limited income and resources". In a Medicare and Medi-Cal certified skilled nursing facility, Medicare residents without other insurance and with limited income are transitioned to Medi-Cal as they reached their 21st day of stay. Medi-Cal pays for the resident to stay at the facility. 1. Resident 1 was admitted to the facility on XXXXXXX. Her primary health insurance payer was Medicare. After she was dis-enrolled from Medicare, the facility discharged her to an Oakland facility accepting Medi-Cal. 2. Resident 2 was admitted to the facility on XXXXXXX. Her primary health insurance payer was Medicare. After she was dis-enrolled from Medicare, the facility discharged her to an Oakland facility accepting Medi-Cal. 3. Resident 3 was admitted to the facility on XXXXXXX. Her primary health insurance payer was Medicare. After she was dis-enrolled from Medicare, the facility gave the family the option of paying out of pocket a daily rate or discharge to an Oakland facility accepting Medi-Cal. 4. Resident 4 was admitted to the facility on XXXXXXX. Her primary health insurance payer was a private health insurer. When her private insurance ran out, the facility gave the family the option of paying out of pocket a daily rate or discharge to an Oakland facility accepting Medi-Cal. Failure to accurately inform Residents 1 and 2 and their family members regarding Medi-Cal insurance and availability of long-term care beds resulted in Residents 1 and 2 being discharged out of San Francisco to Oakland. Failure to accurately inform Residents 3 and 4 and their family members regarding Medi-Cal insurance and long-term care beds, had the potential for an unnecessary discharge and may negatively impact continuity of care. Findings: During an interview on 3/23/16 at 10:00 AM, the Administrator was asked to provide documented evidence the facility was dis-enrolled from Medi-Cal. The facility failed to provide documented evidence of a notification to the Department the last Medi-Cal resident had been discharged from the facility. This notification is the last step for dis-enrollment from Medi-Cal. On 3/25/16, the facility was asked not to discharge any Medi-Cal eligible resident until this matter was resolved. During an interview on 4/19/16 at 11:41 AM, the Administrator was informed the Department still considered the facility as a Medicare and a Medi-Cal certified facility. 1. Review of Resident 1's face sheet dated 4/22/16 indicated she was admitted to the facility on 2/18/16 after multiple falls. Her primary health insurance was listed as Medicare. During an interview on 4/8/16 at 9:27 AM, Resident 1's family member stated they were told the facility was a "short-term" stay facility and since Resident 1 was stable, she needed to be discharged to another facility. The family was told the facility was not a long-term care facility and there were no long-term care beds available in San Francisco. The family member stated they were given a choice of either paying out of pocket for each day Resident 1 stayed at the facility or be discharged to a facility in Oakland. Resident 1 was discharged to a facility in Oakland on XXXXXXX. Resident 1's family member stated it was a hardship for Resident 1's spouse to travel from San Francisco to Oakland to visit. Additionally, all of Resident 1's doctors were in San Francisco. Scheduling and transporting Resident 1 from Oakland to San Francisco for doctor appointments was no easy task. Resident 1's family stated if she had known the facility did not accept Medi-Cal residents and discharged residents after their Medicare ran out, she would not have agreed to admit Resident 1 to the facility. 2. Review of Resident 2's face sheet dated 4/22/16 indicated she was admitted to the facility on XXXXXXX after lack of red blood cells and infection. Her primary health insurance was listed as Medicare. During an interview on 4/5/16 at 4:06 PM, Resident 2's family member stated "...(the facility) said Medicare refused to pay. ...(the facility) did not tell me about Medi-Cal. ...(the facility said) we found a place for you in Oakland, we can't find a place in San Francisco. I did not (want Resident 2) to go to Oakland. ...(I was) not happy with (the) process. Now Social Security is going to discontinue (Resident 2's) payment because ... (Resident 2) is in Oakland." 3. Review of Resident 3's face sheet dated 3/24/16 indicated she was admitted to the facility on XXXXXXX with multiple diagnoses including leg fracture, heart problem, kidney failure, and cognition problems. Her primary health insurance was listed as Medicare. During an interview on 3/24/16 at 2:15 PM, Resident 3's family member stated "...(the hospital transferred my mom to the facility) ...3-4 days before ...(Resident 3 was dis-enrolled from Medicare, we were ) told to leave (the facility), (a facility staff) call(ed) me. She gave me a phone number to extend ... (Resident 3's) stay". During a voice mail message on 3/29/16 at 12:35 PM, Resident 3's family member stated she was told by the facility there were no long-term care beds available in San Francisco. The family member was given a choice of paying a daily rate or transfer to an available bed at an Oakland facility which accepts Medi-Cal. Resident 3's family member stated this was not what the family wanted as they wanted Resident 3 to remain in San Francisco. 4. Review of Resident 4's face sheet dated 4/22/16 indicated she was admitted to the facility on XXXXXXX after muscle injury, high blood pressure and kidney problem. Her primary payer was listed as a private health insurance company. During an interview on 3/23/16 at 4:49 PM, Resident 4's family member stated "...(the facility) want(ed) to discharge ...(Resident 4) to an Oakland facility". During an interview on 3/24/16 at 2:49 PM, Resident 4's family member stated "...(the facility) did not tell us during admission (about the different types of insurance and staying in San Francisco). We wanted to stay in San Francisco. ...If there's a chance ...(Resident 4) could not stay in San Francisco (we would not have agreed to the admission).?" |
| 220000077 |
Kindred Nursing and Rehabilitation-Golden Gate |
220012792 |
B |
6-Dec-16 |
GVHU11 |
4559 |
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. This Requirement is not met as evidenced by: Based on observation, interview and document review, the facility failed to ensure one of one sampled Patient, Patient 1's feet were off the floor while wheeling him on a wheel chair without using foot rests. This deficient practice has resulted in Patient1's right foot being caught on the floor, and consequently, fracture of the distal femur (broken leg bone) on the right side. Findings: Patient 1 was admitted on xxxxxxx with diagnosis included: rheumatoid arthritis (chronic inflammatory bone disorder), spondylosis in lumbosacral region (degenerative spinal bone disease in the lower back), and chronic obstructive pulmonary disease (progressive lung disease). Review of the Minimal Data Set (a Patient assessment tool), dated 11/15/15, indicated Patient 1: 1) had unimpaired cognitive function; 2) required extensive assistance to change position in bed and used wheelchair for ambulation. Document review of the "Progress Note" by Registered Nurse 1, dated 1/30/16, indicated: "At 3:15 pm (1/29/16) Resident (Patient 1) completed therapy session going out the gym prefers not to use her foot rest while wheeled by the therapist she caught her right foot on the floor while the wheelchair still moving. Resident (Patient 1) felt right knee was overextended and complains of severe pain... 7:30 PM Resident (Patient 1) transferred to [Hospital 1] emergency for treatment and evaluation. 2:20AM Came back from hospital with diagnosis of fracture of the distal femur on the right side. Modified splint on right knee..." Document review of the Hospital 1's "After Care Instructions", dated 1/29/16, indicated Patient1 had a diagnosis of "closed fracture of distal end of right femur." Document review of the "Progress Note" by Registered Nurse (RN) 2, dated 1/30/16, indicated: " (Patient 1) Came back from hospital, with modified splint (pillows and tape) on RLE (right lower extremity) fractured distal femur... With swelling on RLE, limited motion. Complained of 10/10 (10 out of 10 - worst possible) pain on RLE when moving/turning..." Document review of the "Progress Note" by RN 2, dated 1/31/16, indicated: "Given Norco (a pain medication) for 9/10 (9 out of 10) pain on RLE, ..." During an interview on 2/9/16 at 11:35 am, Patient1 stated: "On 1/29/16, at around 3 pm, the Physical Therapist [1] pushed me [with my wheel chair] out of the therapy room. She did not know my foot caught on the floor,... I screamed the house down... I was in agony... It still hurts like a hell, whenever I move [my right leg]..." During a concurrent observation on 2/9/16 at 11:35 am Patient1 was observed to have her right leg immobilized with pillows and tape. During an interview on 2/18/16 at 1:50 pm, Physical Therapist (PT) 1 stated that after a routine physical therapy session on 1/29/16 at around 3pm, she pushed Patient 1's wheel chair to get her back to her room as she was tired. "She was a large lady, I was not able to see her feet while pushing the wheel chair... I did not know that her right foot got caught on the floor until she screamed... On the hind sight, I should have used footrests to prevent this from happening." During an interview and concurrent observation on 11/28/16 at 12:05 pm, PT 1 stated the footrests were not used during the 1/29/16 incident because we were trying to build her leg muscles to tap on the floor to help to propel the wheel chair as she had weak arms due to rheumatoid arthritis. PT 1 showed the surveyor the white metal threshold under the safety door where Patient1's right foot got caught on 1/29/16. It has a rise of approximately 0.5 to 1 cm from the floor surface. Document review of facility policy titled "Wheelchair Transport", with a reviewed date of 10/31/08, indicated "The Patient who requires assistance with wheelchair transportation is treated in a manner that preserves the resident's dignity and provides for their safety." Before wheeling the resident, the transporter should "ensure that the footrests are lowered, and the resident's feet are firmly on the footrests..." The facility failed to ensure Patient 1's feet were off the floor while wheeling him on a wheel chair without using foot rests. The violation had a direct relationship to the health, safety, or security of patients. |
| 230000366 |
Kindred Transitional Care and Rehabilitation - Canyonwood |
230008912 |
B |
20-Jan-12 |
2DL611 |
3909 |
(b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. A 805 T22 DIV5 CH3 ART5-72521(b) Administrative Policies and Procedures Based on interview and record review, the facility failed to carry out its "Employee Code of Conduct," when Facility Staff (FS) A accepted a substantial sum of money from Patient 1. This action resulted in Patient 1 experiencing emotional distress, when he disclosed the event to the facility, and feared that he would get FS A in trouble. On 11/22/11, a review of the record showed that Patient 1 was admitted to the facility on 2/6/10 with diagnoses that included heart disease, leg ulcers caused by veinous insufficiency (poor blood return back to the heart) and joint disease. The Minimum Data Set (a patient assessment tool), dated 11/1/11, indicated that Patient 1 was cognitively intact and needed extensive assist with walking. Patient 1 was his own responsible party.A progress note, dated 11/17/11 at 5 pm, written by the social service director, read that Patient 1 was "angry" and believed that "employees are jealous because he shows favoritism to other employees." The note continued to read that Patient 1 began "to cry" and when he reported that he gave money to a staff member but "no one stole from him." Patient 1 stated that he was concerned that he was "getting employees in trouble."A progress note, dated 11/18/11 at 3 pm, read that Patient 1 had been "very upset over events of the last few days" and "has refused treatment for his lower extremity ulcers for two days."During an interview on 11/22/11 at 9:15 am, Patient 1 stated that he had given FS A $300, all at one time, as he did not want her evicted from where she was living. He also stated that he felt close to FS A, and he did not want to get her in trouble. Patient 1 stated, "I just want it all forgotten. I wish someone could put $ 300 in an envelope and it would be over." During an interview on 11/22/11 at 12:10 pm, FS A stated that she had talked with Patient 1 about her personal issues and about the need to move. She stated that one day in July or August 2011 that she had accepted $300 cash from Patient 1, but she did not tell anyone. She also stated that there were two other times that Patient 1 had given her $20 cash. She stated that she never brought it up to pay back Patient 1 as she had felt that she had "adopted him as a grandfather" and "considered (Patient 1) family." FS A acknowledged that she had received the facility's "Code of Conduct" and "Employee Handbook," and stated that she "knew it was wrong." On 11/29/11 a review of the facility's "Code of Conduct" further identifies that "... no employee of (the facility) may solicit or obtain any improper personal benefit by virtue of his or her work or employment with the Company." On 11/29/11, a review of the facility's "Employee Handbook," dated 11/10, read in part that "This Handbook contains a summary of the policies, procedures, practices and work rules that apply to all employees." It also identified examples of "serious misconduct" that included "accepting or providing money or gifts from/to patients, residents, visitors, or those doing business with (the facility) of more than a nominal value..." Therefore, the facility failed to carry out its "Employee Code of Conduct" when FS A accepted a substantial sum of money from Patient 1. This action resulted in Patient 1 experiencing emotional distress, when he disclosed the event to the facility, and fear that he would get FS A in trouble. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 240000365 |
Knolls West Post Acute LLC |
240012201 |
B |
20-Apr-16 |
YSQ511 |
7095 |
REGULATION VIOLATION: Title 22 72527(a)(10) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On October 30, 2015 at 11:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of physical abuse, when a certified nursing assistant (CNA 1) continued grasping Patient A's hand as she clung to the side-rail during personal care. Patient A repeatedly told CNA 1 to stop grasping her hand, because the grasp was tight and it was hurting her hand. CNA 1's failure to respond to Patient A's request to let go of her hand, and telling CNA 1, "You're going to break it," caused physical pain and potential emotional distress for Patient A. During a review of Patient A's clinical record, the face sheet (contains resident demographics) indicated Patient A was admitted to the facility on August 23, 2011, with diagnoses which included: CVA (stroke, damage to the brain when blood flow is disrupted). The face sheet indicated Patient A was primarily Spanish speaking and that she understood and could speak some English.During further review of Patient A's clinical record, the Resident Assessment Instrument (RAI, a resident assessment tool) dated August 26, 2015, indicated in Section C (section pertaining to cognition assessment) Patient A's Brief Interview for Mental Status (BIMS) score was 15 (The BIMS is tool used to determine cognitive function in patients who are able to verbalize or write their answers. Total possible score= 15. A score<7= severe cognitive impairment, a score 7 but < 12= some cognitive impairment, a score of 13-15 indicated a patient was cognitively intact).During an observation of Patient A on October 30, 2015 at 12:00 PM, the patient was observed sitting in a wheelchair awaiting lunch in the dining room. Patient A's right hand was observed to have no visible swelling, redness, or bruising. Patient A was able to move her right hand with full range of motion, and she stated that her hand was not hurting at the time. Review of the assignment list dated October 28, 2015, indicated CNA 1 was the CNA assigned to care for Patient A. Patient A had previously requested only female staff provide care for her but agreed to have male staff care for her if no female staff was available.During an interview with Patient A on October 30, 2015 at 12:05 PM, with Employee 1 providing interpretive services (Patient A was primarily Spanish speaking), Patient A stated CNA 1, who spoke Spanish, had not responded to her repeated requests to stop grasping her hand so tightly. Patient A stated she was in her room, in bed, holding on to the bed side-rail for support as CNA 1 was attempting to change her brief during the early morning hours of October 28, 2015 at approximately 4 AM. Patient A stated, "I yelled at him (CNA 1) to please, please, let my hand go or you are going to break it." When asked if CNA 1 stopped what he was doing, Patient A stated, "Not for a long time ...It hurt very bad when he was grabbing it (her right hand) ...my fingers were numb for a while ....he wanted to show me how strong he was ....I do not want to see him (CNA 1) anymore." Patient A appeared to be physically shaking as she stated this.During a review of the facility's, "Resident Abuse Investigation Report Form," dated October 29, 2015, the report indicated Patient A, speaking English, had asked CNA 2, a day shift CNA who was toileting Patient A on the morning of October 28, 2015, "Is my hand broken?" CNA 2, who did not speak Spanish, went to get the housekeeping supervisor (HS) who spoke Spanish to translate. Patient A told the HS, "The guy last night, when he was turning me, I put my hand on the rail and he told me to let go of the rail...this man grabbed my hands with his two hands and then he squeezed my hands very tight and it hurt." Further review of the report indicated Patient A had told the Spanish speaking Activities Supervisor (AS), that CNA 1 was rough when turning her on her side. Patient A told the AS that she likes to hold on to the side-rails for support because she feels as if she is going to fall. Patient A reported to the AS that she told this to CNA 1 when he was attempting to change her position in bed, and CNA 1 told her she was not going to fall. CNA 1 proceeded to grab her hand that was holding onto the side-rail, and with both hands, took her hand off the side-rail. Patient A told the AS she yelled out because it hurt her and CNA 1 told her she yells too much and she exaggerated too much when yelling.The report indicated a Licensed Vocational Nurse (LVN 1) had heard shouting coming from the area of Patient A's room, but the charge nurse was in the area, so he continued on with his assignment. An interview was conducted on October 30, 2015 at 12:15 PM, with Patient A's roommate (Patient B). When asked via a Spanish interpreter, the HS, about the incident, Patient B stated, "I don't remember anything."During a review of the employee file for CNA 1, with the Facility Administrator (FA), the file indicated CNA 1 received Elder Abuse training on April 14, 2015. There was no documentation in the file concerning previous patient complaints regarding CNA 1. CNA 1 was suspended during the investigation of the allegation on October 28, 2015.The Employee Separation Report, dated October 30, 2015, indicated CNA 1 was terminated that day. Suspected allegation of patient abuse was indicated as the reason for separation. During a concurrent record review of the Resident Abuse Investigation Report Form completed by the FA dated October 29, 2015, under Summary of Investigator's findings, "...if resident indicated she was being hurt this CNA (CNA 1) should have stopped immediately and sought assistance from another co-worker." The FA stated that had CNA 1 stopped what he was doing and sought assistance, that his termination could have potentially been avoided.Review of the facility policy and procedure entitled, "Resident Abuse/Rights/Reporting/Investigation," dated June 2007, indicated, "Policy-General ...(2)The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any resident, family member, staff member, visitor, volunteer, student, or other persons." The same policy under the section entitled, "Reporting...4. Abuse must be reported if a "Mandated Reporter" observes it or if the elderly person tells a mandated reporter that he/she suffered abuse, or if the mandated reporter had knowledge of an incident that reasonably appears to be abuse..."The facility's failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000365 |
Knolls West Post Acute LLC |
240012285 |
B |
26-May-16 |
None |
14053 |
REGULATION VIOLATION: Title 22 72311 Nursing Services - General (a)Nursing services shall include, but not be limited to, the following:(3)Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (F)Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. During an unannounced recertification survey, conducted on April 11, 2016 through April 15, 2016, the facility failed to: Promptly notify the physician of abnormal PT/INR laboratory result (prothrombin time - a test that measures how long it takes blood to clot, it diagnoses bleeding and clotting disorders)/INR (international normalized ratio -a test that measures a person's blood tendency to clot) and obtain an order for a significant medication, Coumadin (Warfarin - a prescription anticoagulant medicine used to prevent heart attacks, strokes, and blood clots in veins and arteries) for Patient A. This failure resulted in Patient A who had a history of cerebral infarction (a type of stroke resulting in blockage in the blood vessels supplying blood to the brain), and atrial fibrillation (an irregular and often rapid heart rate) experiencing a rapid drop in her PT/INR by not receiving the medication necessary to regulate the PT/INR which could cause an extension of the injury to her brain or cardiac arrest. During a review of the clinical record for Patient A, the face sheet indicated Patient A was readmitted to the facility on February 2, 2016, with an admitting diagnoses to include: cerebral infarction (a type of stroke resulting in blockage in the blood vessels supplying blood to the brain), hemiplegia (complete paralysis ) secondary to hemiparesis (weakness to either side of the body) following, dysarthria following (speech that is slow and difficult to understand), chronic atrial fibrillation (an irregular and often rapid heart rate), peripheral vascular disease (PVD - circulation disorders that affect blood vessels outside of the heart and brain) and a right below the knee amputation (BKA). A review of Patient A's admission orders dated February 2, 2016, included the medication: "Coumadin 5 mg (milligram - a unit of measurement) tablet daily at 5 PM for Atrial Fibrillation." A review of Patient A's physician's orders for Coumadin administration beginning March 28, 2016, indicated the licensed nursing staff were to hold Coumadin for two days, and recheck the PT (prothrombin time - a test that measures how long it takes blood to clot, it diagnoses bleeding and clotting disorders)/INR (international normalized ratio -a test that measures a person's blood tendency to clot) on March 31, 2016. A review of the Medication Administration Record (MAR) shows the medication Coumadin was held on March 29, 2016 and March 30, 2016.A review of Patient A's laboratory results for PT/INR drawn on March 31, 2016, indicated the results were abnormal, PT/INR of 18.2/1.60, (reference range 11.0 - 13.6 and therapeutic range 2.0 -3.0). An abnormally low PT/INR increases the risk for Patient A who had a history of a cerebral infarction (type of stroke) of forming a blood clot which could extend the area of injury to the brain. A review of Patient A's physician orders and the nurse's notes dated March 31, 2016; do not indicate the physician was notified of the abnormal laboratory results. A review of the MAR reflected Patient A did not receive Coumadin medication from March 31, 2016 through April 3, 2016 (a total of four days). During review of a physician's order dated April 4, 2016, indicated the physician ordered Coumadin 2 mg tablet x (times) three (3) days, PT/INR [to be drawn on] April 7, 2016. A review of the MAR indicated Patient A received Coumadin 2 mg tablet from April 4, 2016 through April 7, 2016. During a review of Patient A's laboratory results dated April 5, 2016, indicated a PT/INR was done. The results reflected a significant drop from 18.2/1.60 on March 31, 2016, to 10.0/0.90 (below therapeutic level), placing Patient A at risk for blood clots and extending her brain injury related to her cerebral infarction.A second PT/INR done on April 7, 2016 (after Patient A had received Coumadin for three days) indicated the level had increased to 11.2/1.0 (This level indicated the INR remained low, Patient A remained at risk for blood clots).A review of Patient A's physician order dated April 8, 2016, indicated staff were to, "D/C (discontinue) Coumadin 2 mg tab, start Coumadin 7.5 mg, (repeat the) PT/INR (on) April 11, 2016." On April 15, 2016 at 9:30 AM, during a concurrent interview and record review with the Director of Nursing (DON), the DON stated, "Yes, there was an order to hold it (Coumadin) for two days, there should have been an order on the 31st (March 31, 2016)." When asked who wrote on the lab results, "Coumadin 2 mg tab x 3 days, recheck on Thursday, c/o (call out) to physician," the DON stated the handwriting belonged to the Licensed Vocational Nurse (LVN 1) who worked the afternoon shift on March 31, 2016.The DON stated that there was no documentation of Coumadin administration on the MAR's from March 31, 2016 through April 4, 2016, that a telephone order had not been received from the doctor, that there weren't any nurse's notes documenting the attempts to contact the physician with the abnormal laboratory results on March 31, 2016. During an interview on April 15, 2016 at 11:00 AM, with the DON, when asked if she knew that Patient A had not received Coumadin for 4 days, the DON replied, "I did not know prior [to now]." During an telephone interview on April 15, 2016 at 11:15 AM, with the Supervisor Registered Nurse (RN 1), who worked March 31, 2016, afternoon shift, when asked if she remembered receiving the PT/INR laboratory results for Patient A and had been made aware LVN 1 did not receive new orders for Coumadin, RN 1 stated she did not remember and was not aware LVN 1 did not receive orders. RN 1 replied, "When the lab results come in, it is the Charge Nurse's responsibility (LVN 1 was the charge nurse)." During a telephone interview on April 15, 2016 at 4:00 PM, with LVN 1 regarding the laboratory results for Patient A received March 31, 2016. LVN 1 stated, the results were faxed to the Patient's physician around 6 PM or 7 PM on March 31, 2016. Since there had been no response from Patient A's attending physician, a call was made to the facility's Medical Director the following day, on April 1, 2016. On orders of the Medical Director, Patient A's alternate physician was called on April 2, 2016, and the new order for Coumadin was received. LVN 1 was unable to explain the delay from receiving the order on April 2, 2016, to faxing the order to the pharmacy on April 3, 2016.When LVN 1 was asked if she had informed another nurse, or documented her attempts to reach the physicians, or asked anyone to follow-up to get the physician's order for Coumadin administration, LVN 1 stated, "It was reported. I did not write anything to follow-up or tell it to another nurse. I know it was my mistake on that." When asked if the Nursing Supervisor and/or the DON were notified, she replied, "I told a Registered Nurse (RN) that the Coumadin order was late and he [a RN Supervisor] said to try to get a hold of the doctor. I did not document it." LVN 1 stated she did not know if the DON was notified. During an interview on April 15, 2016 at 3:00 PM, with the Pharmacist for the facility, regarding Coumadin administration for Patient A, the Pharmacist replied, that they did not receive the PT/INR laboratory results of March 31, 2016 until April 3, 2016, and on the bottom of the laboratory results was handwritten, "Coumadin 2 mg PO (by mouth) x 3 days, PT/INR on Thursday (the pharmacy would have assured there was no lapse in coverage with the corrected Coumadin dose based on the laboratory results)."When asked when the order for Coumadin 2 mg tablets was sent to the facility, the pharmacist replied, "We did not dispense anything until we got the new order (telephone order slip) on April 3rd, we dispensed (the Coumadin) on April 4, 2016." When asked if the pharmacy had been made aware that Patient A had not received Coumadin for four days, she replied, "When we got the new order [April 3, 2016], it might not have been immediately apparent that it [the Coumadin] was held prior [to the order being obtained]. We don't monitor Coumadin dosage for this facility. We will look at the labs to make sure dosages are ok." During an interview on April 15, 2016 at 4:20 PM, with the facility's Pharmacy Consultant, the pharmacist stated, "I was not aware that this Patient didn't receive Coumadin for four days, but they [facility staff] would only contact the physician, since I don't monitor [lab results]." When asked the Pharmacy Consultant's role in Coumadin administration, the pharmacist stated, "I double check periodically that PT/INR results are done." During an interview on April 15, 2016 at 5:00 PM, with the Medical Director (MD), when asked was he aware that Patient A did not receive Coumadin from March 31, 2016 through April 3, 2016, he replied, "Yes," and that they [the facility] had a QA (Quality Assurance) meeting on April 4, 2016. "We discussed a system to make sure that we follow-up with Coumadin, PT/INR results, and that the physician is notified of the results." When asked if other Patients [besides Patient A] were discussed, the MD replied, "I do not recall." The MD gave a list of names of who was present at the QA meeting, which included the facility administrator and the DON. The MD was asked if he was contacted by LVN 1 when she was unable to reach Patient A's physician on April 1, 2016, with the abnormal laboratory results, he responded, "I do not recall, so many things, I am not sure if she asked me." During an interview on April 15, 2016 at 6:00 PM, with the DON regarding the Quality Assurance meeting on April 4, 2016, when asked if the medication Coumadin was discussed, the DON replied, "Not specifically Coumadin." The DON stated that laboratory results were mentioned, but did not specify which laboratory results. The DON then stated that PT/INR lab results were discussed, but not Patient A. When the DON was asked about the MD's statement that the QA Committee discussed Patient A at the meeting on April 4, 2016, the DON stated, "I don't have anything else."During a review of the facility's Drug Regimen Review (DRR) done by the Pharmacy Consultant for outcomes entered between April 1, 2016 and April 12, 2016, the abnormal PT/INR results and the missed Coumadin doses for Patient A were not identified by the Pharmacist Consultant. A review of the facility's "Pharmacy Policies and Procedures," (undated) "Appendix R-Warfarin Administration" indicated, "The facility nursing staff will receive and report the serum monitoring for administration of Warfarin such as Protime (PT or International Normalized Ratio (INR). The report will be called or faxed to the prescriber immediately. Documentation of physician notification of the results and prescriber's response will be made in the Nurses Notes, including the date and time. Laboratory target range for Atrial Fibrillation 1.75-3.0." A review of the facility's policy titled "Lab and Diagnostic Test Results - Clinical Protocol" revised September 2012, indicated "1. A nurse will review all results. a. If the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure." A review of the facility's policy titled "Test Results" revised April 2007, indicated, "The Patient's Attending Physician will be notified of the results of diagnostic tests. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results." A review of the facility's job description titled "Charge Nurse" dated 2003, indicated, "Duties and Responsibilities . . . Report all discrepancies noted concerning physician's orders . . . to the Nurse Supervisor. Perform routine charting duties as required and in accordance with established procedures. Order prescribed medications . . . Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift. Consult with the Patient's physician in providing the Patient's care, treatment, rehabilitation, etc., as necessary." A review of the facility's job description titled "Nurse Supervisor" dated 2003, indicated, "Duties and Responsibilities . . . Meet with your shift on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to assist in the improvement of services. Review nurses' notes to ensure that they are information and descriptive of the nursing care being provided. Report problem areas to the Director. Assist in developing and implementing corrective action. Assist the Charge Nurse in monitoring seriously ill Patients. " A review of the facility's job description titled "Medical Director" dated 2003, indicated, "Duties and Responsibilities . . . Monitor adherence of medical staff to rules and policies governing the medical care of Patients. Assist in assessing and assuring quality, timeliness, and appropriateness of services rendered to Patients, as well as the appropriate documentation and maintenance of quality records. Provide medical coverage for emergency situations of all individual Patients." Therefore, the facility failed to administer a significant medication for four days, to promptly notify the physician to obtain an order for a significant medication for four days, and failed to document in the clinical record any attempts made.These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 910000324 |
KENNEDY POST ACUTE CARE CENTER |
910008788 |
A |
16-May-13 |
HE1F11 |
8758 |
483.25(h) F323 FREE OF ACCIDENTHAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The Department received a complaint on July 25, 2011, alleging a resident (Resident 1), who had dementia (a loss of brain function that affects memory, thinking, language, judgment, and behavior), fell while being transferred from a wheelchair to the bed. She sustained a left hip fracture, a right leg skin tear, and struck her head, requiring hospitalization. On August 9, 2011, an unannounced complaint investigation was conducted.Based on interview and record review, the facility's nursing staff failed to provide Resident 1 adequate supervision while being transferred from the wheelchair to the bed, in accordance with the resident?s assessment and the facility?s policy. These failures resulted in Resident 1 falling twice within five days, sustaining injuries. The first fall resulted in Resident 1?s leg being caught in the wheelchair and sustaining a right leg laceration. Five days later the second fall occurred resulting in the resident striking her head sustaining an occipital hematoma (a collection of blood compresses your brain tissue) and a left hip fracture, requiring a transfer to the general acute care hospital (GACH). Resident 1underwent a surgical repair of the left hip, received intravenous (into the vein) narcotic pain medications, and physical therapy treatment. A review of Resident 1?s clinical record indicated she was an 88 year-old female originally admitted to the facility on May 16, 2007, with diagnoses that included atrial fibrillation (heart irregularity), cerebral vascular accident ([CVA] is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain), hypertension (high blood pressure) and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain). A review of a care plan dated April 29, 2010, and re-evaluated in June 2011 titled, ?Fall,? indicated the resident was at risk for falls due to poor safety awareness, diagnosis of CVA, poor trunk control, being non-ambulatory, and other diagnoses. The staff?s approaches included many interventions; however it did not include using a two-person assist as stipulated in the facility?s policy and procedure and the resident?s assessment. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated June 13, 2011, indicated Resident 1 had short and long-term memory problems and was severely impaired in cognitive skills for daily decision-making. According to the MDS, the resident was not able to understand or be understood, was non-ambulatory and was totally dependent upon the staff for all activities of daily living (ADLs), including transfers. The MDS indicated Resident 1 required a two-person assist with transfers.A review of a Fall Risk Assessment, dated July 7, 2011, indicated the resident had a high risk for falls due to her disorientation (does not know person, place, or time), being bed bound, multiple diagnoses, and medications. A review of a Charge Nurse Evaluation Note, written by Staff 1, indicated on July 19, 2011, on the day-shift (without a time) Resident 1 was being transferred from the bed into a wheelchair by CNA 1. The resident's right leg got caught on the wheelchair resulting in a laceration on her right lower leg (no measurement of the wound was documented).A review of another Charge Nurse Evaluation Note, written by Staff 1, dated July 24, 2011 and timed at 2 p.m., indicated Resident 1 was being transferred back to bed after lunch by CNA 1 using a Hoyer lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, using hydraulic power) improperly. The resident fell on the floor head first. According to the note, CNA 1 did not ask for assistance during the transfer although the resident required a two-person assist. The CNA reported the fall to Staff 1 (a licensed charge nurse). Staff 1 notified the physician who ordered an x-ray of the resident?s hips because the resident was complaining of pain. The x-ray indicated the resident had a left femur (thigh bone) neck fracture.A review of the GACH?s Emergency Room record, dated July 24, 2011, and timed at 6:55 p.m., indicated Resident 1 arrived to the hospital via ambulance with a left hip fracture and head hematoma due to a fall. The resident received Dilaudid 1 mg. (a narcotic pain reliever used to treat moderate to severe pain) intravenously (into the vein) for pain. A review of an orthopedic (a physician who specializes in the musculoskeletal system) consultation, dated July 25, 2011, indicated the resident was transferred to the hospital after a ?mechanical fall? at the skilled nursing facility (SNF) with an immediate onset complaint of pain to the left hip. According to the consultation note, the x-rays of the left hip showed a femoral neck (the ball of the ball and socket hip joint is broken off) fracture with some impaction (one of the broken fragments of the bone wedges into another). The note also indicated the resident hit the back of her head and a CT-scan (computed tomography /uses X-rays to make detailed pictures of structures inside of the body) was ordered. The orthopedic surgeon documented, Resident 1 was experiencing a lot of pain without any motion and did not allow anyone to move her hip. A review of an Operative Report, indicated Resident 1?s pre-operative diagnosis was a left hip femoral neck fracture with slight displacement, impacted. The resident underwent a left hip closed reduction and percutaneous pinning using three cannulated screws (reducing the fracture and placing pins/screws to maintain alignment).According to a case manager?s note from the GACH, dated July 28, 2011, Resident 1?s family did not want her transferred back to the SNF where she had fallen. Resident 1 was transferred to another SNF on July 29, 2011. On August 9, 2011, at 4 p.m., the director of nurses (DON) stated she interviewed CNA 1. The DON stated the CNA informed her while transferring the resident alone, from the wheelchair back to bed on the Hoyer lift, the resident leaned back and to the right side causing the CNA to lose balance of the lift and the resident slid down. The CNA grabbed Resident 1's legs, but could not hold her and the resident slid backwards hitting her head first, followed by the rest of her body on the floor. The DON stated the facility's policy indicated two CNAs would work their assignments as partners, especially for transferring residents and that all transfers should be performed by two CNAs.A review of the facility?s assignment sheet for July 24, 2011, on the evening shift (3 p.m.-11 p.m.), revealed there were five teams with two CNAs on each team.CNA 1 was not available for an interview as she no longer worked at the facility. A review of the CNA?s employee file revealed a written counseling notice, dated July 24, 2011, indicating CNA 1 was written-up and counseled for not asking for assistance in transferring Resident 1, which resulted in a fall with an injury. There was also a ?Separation Notice? dated July 29, 2011, indicating CNA 1 was terminated from the facility due to her failure to follow proper policy and procedures while caring for Resident 1, which resulted in major injury to Resident 1. A review of the facility's policies titled, ?Lifting Machine, Using a Portable? dated, April 2007, and ?Locking Arms with the Resident? dated March 2004, indicated two CNAs were required to transfer residents when the resident was not able to assist.The facility's nursing staff failed to provide Resident 1 adequate supervision while being transferred from the wheelchair to the bed, in accordance with the resident?s assessment and the facility?s policy. These failures resulted in Resident 1 falling twice within five days, sustaining injuries. The first fall resulted in Resident 1?s leg being caught in the wheelchair and sustaining a right leg laceration. Five days later the second fall occurred resulting in the resident striking her head sustaining an occipital hematoma and a left hip fracture, requiring a transfer to the GACH. Resident 1 underwent a surgical repair of the left hip, received intravenous (into the vein) narcotic pain medications, and physical therapy treatment.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 and did occur to Resident 1. |
| 970000029 |
KINGSLEY MANOR CARE CENTER |
920013186 |
A |
10-May-17 |
None |
7445 |
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
(l) Dialysis
?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.
On June 7, 2012, at 12:55 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s sustaining a fracture to the right arm.
Based on observation, interview and record review, the facility failed to ensure its residents 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, and that each resident receives adequate assistance to prevent accidents and injuries, including:
1. Failure to ensure Resident 1, who was assessed as dependent on staff for dressing, received the assistance necessary without rushing and forcing a right paralyzed (unable to move or feel) arm into a sleeve when putting on a shirt.
2. Failure to develop an individualized plan of care addressing Resident 1?s safety needs due to having a right arm paralyzed and osteoporosis (thin and brittle bones) including use of loose-fitting clothing, additional physical support needed, and specific technique in dressing.
3. Failure to follow the facility?s Job Description for Certified Nursing Assistants (CNAs) dated October 2006, for the CNA to perform all duties in a safe manner and to utilize aide of a co-worker when assisting Resident 1.
As a result, on May 18, 2012, Resident 1 sustained a broken right upper arm, experienced unnecessary pain, and was unable to attend facility?s activities.
According to the admission record, Resident 1 was originally admitted to the facility on XXXXXXX 2011 and was readmitted on XXXXXXX 2012 with diagnoses that included cerebrovascular accident (CVA - stroke) with right side hemiplegia (paralysis on one side of the body), and osteoporosis.
The Minimum Data Set (MDS ? a standardized assessment and care-planning tool) dated February 28, 2012 indicated Resident 1 had no memory problem and was totally dependent on staff for dressing with one-person physical assistance.
A care plan developed due to Resident 1?s self-care deficit in activities of daily living (ADLs) related to CVA with left sided weakness, had a goal for the resident to be groomed, clean and properly positioned daily by staff. The interventions included total care, assistance with repositioning, and anticipating needs. The plan of care did not address techniques to safely handle the resident to prevent accidents and injury related to osteoporosis.
A review of the Joint Mobility Assessment dated April 30, 2012 indicated Resident 1 both shoulders had minimal loss of function (25% to 50%).
According to a Licensed Personnel Progress Notes dated May 18, 2012, timed at 8:30 a.m., for the 7 a.m. to 3 p.m. shift CNA 1 called the nurse to Resident 1?s room. The resident was alert and oriented and was complaining of right shoulder to elbow pain. There was also pain when the arm was moved and touched. CNA 1 explained that she tried to put resident?s shirt, but the shirt was tight and she forced resident?s right arm causing the injury. The resident was medicated with Tylenol 325 milligrams two tablets, the physician was notified and an order ?stat? (immediately) x-ray of right elbow and shoulder.
At 8:45 a.m., on the same day, the nursing note indicated that Resident 1 was still complaining of pain level 5/10 (five in a pain rating scale from zero to ten, where zero is no pain and 10 is the worst pain possible). At 9:45 a.m., Resident 1 was transferred to a general acute care hospital (GACH) via ambulance.
A review of Resident 1?s GACH emergency department (ED) notes dated May 18, 2012, at 11:32 a.m., indicated the resident complained of right arm pain after being changed and heard a pop when her arm was being moved by a CNA, trying to put her shirt on. The x-ray interpretation of the right shoulder was osteopenia (weak bone) with fracture (broken bone) of mid shaft humerus (the upper arm) with angulation (bent). The notes indicated outpatient follow up with splint and comfort. Resident 1 was sent back to the facility.
On June 7, 2012, at 1:15 p.m., during an interview, CNA 1 confirmed she provided care to Resident 1 on May 18, 2012. CNA 1 stated she was dressing the resident while the resident was lying in bed and the shirt was too tight.
On June 7, 2012, at 5 p.m., during an interview, Resident 1 stated CNA 1 was strong and rough with her, and pushed her arm in the shirt. Resident 1 stated that at the time of the incident her pain was 10/10 (severe pain).
On June 7, 2012, at 6 p.m., during an interview, Resident 1?s family member (FM 1) stated CNA 1 was in a hurry and was also a new staff member. FM 1 stated her mother had loose clothing that CNA 1 could have used. FM 1 stated that after the fracture, her mother was in a lot of pain and was unable to attend activities as she used to.
According to the facility?s job description for Certified Nursing Assistant dated October 2006, under the direction of the Charge Nurse, Director of Staff Development (DSD) and/or Director of Nurses (DON), CNA is responsible for performing routine care according to policies and procedures and within acceptable nursing standards. Essential duties and responsibilities included to perform all duties in a safe and efficient manner. Physical demand over 50 pounds, required to utilize mechanical assistance or aide of a co-worker.
The facility failed to ensure its residents 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, and that each resident receives adequate assistance to prevent accidents and injuries, including:
1. Failure to ensure Resident 1, who was assessed as dependent on staff for dressing, received the assistance necessary without rushing and forcing a right paralyzed (unable to move or feel) arm into a sleeve when putting on a shirt.
2. Failure to develop an individualized plan of care addressing Resident 1?s safety needs due to having a right arm paralyzed and osteoporosis (thin and brittle bones) including use of loose-fitting clothing, additional physical support needed, and specific technique in dressing.
3. Failure to follow the facility?s Job Description for Certified Nursing Assistants (CNAs) dated October 2006, for the CNA to perform all duties in a safe manner and to utilize aide of a co-worker when assisting Resident 1.
As a result, on May 18, 2012, Resident 1 sustained a broken right upper arm, experienced unnecessary pain, and was unable to attend facility?s activities. |
| 970000111 |
Kei-Ai Los Angeles Healthcare Center |
940012895 |
A |
20-Jan-17 |
FJ6Q11 |
11829 |
42 CFR 483.25(h) (2). Accidents and Supervision.
The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.
On 6/16/16 at 1:10 pm, an unannounced visit was made to the facility to investigate a complaint regarding a resident to resident altercation.
Based on observation, interview, and record review, the facility failed to provide adequate supervision to residents in the dining room to keep residents safe while staff members were taking other residents to their respective rooms after dinner. Consequently, Resident 38 hit Resident 37's forearms with a metal spoon after dinner on 1/25/16 resulting in seven skin tears to her left forearm and three skin tears with bruises on her right forearm, with moderate bleeding. Resident 37, who had left-sided paralysis, had to undergo skin treatment for two weeks and was given Tylenol (a medication used to treat mild to moderate pain) 650 milligrams (mg) for complaints of mild pain.
A review of the Incident Report, dated 1/25/16, indicated Resident 37 was assessed as having seven (7) skin tears to her left forearm, and three (3) skin tears with bruising on her right forearm, with moderate bleeding, as a result of the altercation with Resident 38.The initial nursing observation, assessment, and treatment on the incident report indicated that after dinner at 5:45 pm, Resident 37 was noticed being stabbed and hit with a (metal) spoon by another resident (Resident 38). Both residents were separated right away.
A review of Resident 38's admission record (Face Sheet) indicated the resident was readmitted to the facility on XXXXXXX15. The resident's admission diagnoses included impulsive disorder (an inability to resist the impulse to perform an action that is harmful to one's self or others), Alzheimer's disease (a group of brain disorders that cause the loss of rational and social skills), and cataract (a clouding of the lens in the eye leading to a decrease in vision).
A review of Resident 38's Minimum Data Set (MDS, an assessment and care screening tool), dated 2/10/16, indicated that the resident was severely impaired in cognition, and was able to make her needs known and understand others. The MDS indicated the resident required supervision during meals.
A review of Resident 38's care plan titled, "Cognitive Loss," dated 2/11/15, indicated the resident had cognitive loss related to dementia/Alzheimer. The interventions included providing the resident with "cueing, directions and oversight frequently when interacting with the resident, passing in hallways, or in dining or activity rooms."
A review of Resident 38's care plan titled, "Dementia/Alzheimer's Disease," dated 5/11/15, indicated the resident had potential for injury related to inappropriate judgement manifested by aggressive outburst (verbal). The interventions included providing the resident with monitoring for unfavorable behaviors.
A review of Resident 38's care plan titled, "Mood and Behavior," dated 5/14/15, indicated that the resident had mood and behavior problems related to impulse control disorder manifested by angry outburst and refusing treatment. The interventions included reporting to the charge nurse if resident does not respond to a re-direction and to monitor the resident's behavior every shift.
A review Resident 38's Nurses Progress Notes, dated 1/25/16 at 4:30 pm, indicated the resident was moved by a certified nursing assistant (CNA) to sit at the first table in the dining room near the television set, as requested by the resident "in order for the resident not to get angry." The progress notes indicated the resident was calm and quiet at this time, her medications were given as ordered, and she was very cooperative and was not exhibiting angry outbursts.
The Nurses Progress Notes, dated 1/25/16 at 5:45 pm, indicated a charge nurse's medication cart was parked in front of the table where Resident 38 was seated. After dinner, the charge nurse/ licensed vocational nurse (LVN 12) noticed that Resident 38 was stabbing a resident (Resident 37) beside her. The two residents were separated right away and Resident 38 propelled herself back in the hallway. The social worker spoke with Resident 38 to remind the resident that hitting another resident was inappropriate. Resident 38's legal representative was informed about the incident and a psychiatric evaluation was requested.
A review of Resident 38's Nurses Progress Notes, dated 1/25/16 at 11 pm, indicated that the resident was provided with close visual monitoring to prevent recurrence and to continue monitoring the resident "since resident is not safe for other residents."
During interviews with the licensed vocation nurse (LVN 12), on 6/16/16 at 3:40 pm, 7/14/16 at 3:20 pm and 7/28/16 at 9:45 am, she stated that Resident 38 was seated at a table near the television set because the resident wanted to watch a show and the resident would calm down (would not get angry) when she was in front of the television set. Resident 38 was sitting to the right side of Resident 37. LVN 12 stated that she went to the back of the dining area to give a medication to a resident and on her way out of the dining room, she observed Resident 38 with a metal spoon "patting hard" on Resident 37's right forearm. LVN 12 stated she saw blanching and bruising to Resident 37's right forearm and Resident 37's left forearm was extended, resting on the table with "six slits, and bleeding. LVN 12 stated there was no CNA supervising Resident 37 and 38 at their table when she (LVN 12) walked into the dining room and on her way out of the dining room. LVN 12 stated that it was hard to supervise and pass medications at the same time.
On 6/16/16 at 1:10 pm., during an interview, Registered Nurse (RN) 6 stated that dinner started at 5 pm on 1/25/16 and at least one or two CNAs or the charge nurse were to remain in the dining room area to make sure the residents, who were waiting to be taken to their respective rooms, were safe.
On 6/16/16 at 3:09 pm, during an interview, CNA 2 stated that she was in the dining room when the incident happened between Resident 37 and 38 on 1/25/16. CNA 2 stated she was at the back part of the dining room assisting two residents to eat. CNA 2 stated that she did not witness the incident. CNA 2 stated that if the CNAs started returning the residents to their respective rooms after dinner, one (1) CNA should be left behind in the dining room to supervise the residents, who were waiting to be returned to their rooms.
On 6/16/16 at 3:37 pm, during an interview, RN 6 stated there was no specific assignment for the CNAs during dinner. RN 6 stated, "We just have a general guideline on meal time." RN 6 stated there were 50 residents who either ate independently and who needed total assistance from staff to eat with four CNAs in the dining room on 1/25/16 during dinner.
On 6/16/16 at 5:01 pm, during an interview, the director of staff development (DSD) stated that nobody witnessed the incident between Resident 37 and 38. The DSD stated that after dinner, when residents were ready to go back to their respective rooms, nobody was assigned to them anymore.
On 7/14/16 at 2:45 pm, during an observation and interview, RN 6 held a metal teaspoon and described the edges of the teaspoon as "hard, not smooth but not too sharp." RN 6 stated plastic utensils were given to Resident 38 for a period of time as prevention "so not to hurt other residents." RN 6 stated Resident 38 was not physically aggressive. RN 6 stated, "She (Resident 38) usually becomes loud and agitated when she doesn't agree with the nurses."
A review of Resident 37's admission record (Face Sheet) indicated the resident was admitted to the facility on XXXXXXX13. The resident's admission diagnoses included dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior), hypertension (a medical condition in which the blood pressure in the arteries is persistently elevated), cerebrovascular accident (CVA, a condition when poor blood flow to the brain results in cell death) with weakness and paralysis of the left side of the body, and cataract (a clouding of the lens in the eye leading to a decrease in vision).
A review of Resident 37's Minimum Data Set (MDS), dated 3/11/16, indicated the resident was severely impaired in cognition. The MDS indicated that the resident had minimal difficulty hearing, impaired vision, usually understood verbal content of others, and required corrective lenses. The MDS indicated that Resident 37 required extensive assistance (resident involved in activity staff provide with bearing support) from staff for transfers, eating, and personal hygiene.
A review of Resident 37's care plan titled, "Fragile Skin," dated 6/15/15, indicated the resident was at risk for skin tears and bruising related to history of skin tears, bruising, poor safety awareness, and use of Aspirin (a medication used to prevent blood clot formation, but it may increase risk of bleeding). The interventions included encouraging the resident to wear long sleeves or protective arm and leg covering, providing safety cueing and oversight, and handling with care to avoid skin tears and scraping of skin.
A review of the Nurses Progress Notes, dated 1/25/16, indicated Resident 37 sustained the following:
a. Seven skin tears on the left forearm measuring from 0.7 centimeter (cm) to 1.2 cm.
b. Skin discoloration on the right forearm measuring 14 cm in length by 8 cm in width.
c. Two "L-shaped" skin tears on the right forearm, sizes 0.7cm in length 0.5 cm in width and 1.2 cm in length 0.9 cm in width.
d. One skin tear on the right forearm measuring 0.7 cm with mild to moderate bleeding.
According to the physician's order, dated 1/25/16, Resident 37 was to receive treatment to multiple skin tears on the right and left forearms. The treatment order was to cleanse the skin tears with normal saline (salt) solution, apply triple antibiotics, cover the skin tears with a dry dressing and wrap with a roller gauze dressing daily for two (2) weeks. The physician also ordered to apply geri sleeves (a reusable, breathable cotton-blend fabric that protects against skin tears) to Resident 37's forearms.
A review of the facility's undated policy and procedure titled, "Guidelines for Dining Room Service," indicated that all staff will tend to the needs of residents during mealtime, and residents will also be supervised per Resident Supervision policy and procedure.
A review of the facility's policy and procedure titled, "Resident Supervision," dated on 6/10/16, indicated that in order to ensure the residents are provided supervision before, during, and after meals, staff will rotate in 15 minute intervals to supervise the residents in either the day room or near the nurses' station according to the needs of the nursing unit.ÿ
The facility failed to provide adequate supervision to residents in the dining room to keep residents safe while staff members were taking other residents to their respective rooms after dinner. Consequently, Resident 38 hit Resident 37's forearms with a metal spoon after dinner on 1/25/16 resulting in seven skin tears to her left forearm and three skin tears with bruises on her right forearm, with moderate bleeding. Resident 37, who had left-sided paralysis, had to undergo skin treatment for two weeks and was given Tylenol (a medication used to treat mild to moderate pain) 650 milligrams (mg) for complaints of mild pain.
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. |
| 950000256 |
KINDRED TRANSITIONAL CARE AND REHABILITATION-FOOTHILL |
950009436 |
A |
10-Aug-12 |
3N6I11 |
8822 |
F323 The facility must ensure that each resident receives assistive devices to prevent accidents. On November 10, 2009, at 1:45 p.m. an unannounced visit was made to the facility to investigate a facility self-reported event whereby, Resident 1 re-injured her left ankle during a transfer from a shower chair to a wheelchair.Based on interview and record review, the facility failed to prevent a resident who had a recent surgical repair of a left ankle fracture from re-injuring her left ankle by failing to: Apply a moon-boot [a device used to manage lower leg fractures specifically for the stability (maintaining the position) of ankle injuries] at all times to Resident 1?s left ankle in accordance with the physician order and care plan.As a result, during a transfer of the resident from a shower chair to a wheelchair without the application of the moon boot in place, the resident?s left ankle turned inward, and caused a re-injury of the left ankle. Subsequently, the resident required a second acute care hospital emergency room treatment and surgical revision of an open reduction internal fixation [(ORIF), a method of surgically repairing a fractured bone), of the left ankle.Review of the acute hospital admission record dated October 15, 2009, at 6:15 a.m., revealed that Resident 1 was admitted to the acute facility from home for a trimalleolar (ankle) fracture. A left ankle x-ray report dated October 15, 2009, at 10:13 p.m. revealed the following: There has been an ORIF of the medial (lying toward the middle of the body) and lateral (pertaining to the side) malleoli (the bony protuberance on either side of the ankle), two orthopedic pins and cerclage wire (hardware needed to repair the fracture) are noted on the medial malleolus and there is a plate (hardware needed to repair the fracture) screwed to the lateral malleolus, the ankle joint is now well aligned (in proper position). The acute hospital history and physical examination dated October 15, 2009, indicated that the resident was to be under the care of an orthopedic doctor. The acute facility undated physician order sheet indicated to transfer the resident to the skilled nursing facility(SNF) for rehabilitation on an unspecified date with diagnoses of left ankle fracture, status post ORIF on October 15, 2009, and to have a rehabilitation/physical therapy evaluation.Review of the SNF Record of Admission Tool, indicated Resident 1 was originally admitted to the SNF on October 18, 2009. A review of the SNF history and physical examination dated October 19, 2009, indicated that the resident had additional diagnoses including osteoporosis and degenerative joint disease.The Minimum Data Set (MDS) an assessment and care planning tool, dated October 25, 2009, indicated that the resident had modified independence with some difficulty in new situations for decision making only, and required help with weight-bearing support with full staff performance with one person physically assisting the resident for transfers.A plan of care dated October 19, 2009, was developed for Impaired Physical Mobility, left ankle fracture and required the use of the moon boot at all times. The care plan approaches dated October 20, 2009, for Impaired Physical Mobility, left sided trimalleolar fracture indicated: 1. Use proper positioning devices. 2. Assist the resident with all transfers as needed. A review of the physician orders dated October 19, 2009, indicated that the resident was ordered partial weight bearing 50% on the left lower extremity with moon boot at all times. On October 20, 2009, Physician 2 (an orthopedic physician) ordered touch down weight bearing (50%) on the left leg (with boot on).A review of the Resident Progress Notes dated October 27, 2009, at 4:15 p.m., revealed as documented by PTA 1, (Physical Therapy Assistant-1) that an incident happened at 10:30 a.m. PTA 1 was in the resident's room and transferred the resident from the shower chair to the wheelchair without the moon boot. The resident became more anxious and during the transfer, the resident?s left ankle averted (turned inward) exposing two to four inches of hardware (orthopedic surgical repair material) out of the skin. The certified nursing assistant, (CNA 1) noticed the exposure of the hardware as the resident was placed in the wheelchair. The CNA informed the wound care nurse, a licensed vocational nurse (LVN 1), who applied pressure and wrapped the wound exposure.A review of the Resident Assessment form dated October 27, 2009, at 10:30 a.m. revealed that Resident 1 had a displacement of a rod injury, with contributing factors as follows: ?slipped, wet floor, did not apply boot prior to transfer.? The assessment further indicated that the resident had frequent significant pain at rest, severe pain with movement, had pain with a verbal pain level scale of 7-8 out of 10, 10 being the most possible pain on a pain scale of 1 to 10.A physician?s telephone order dated October 27, 2009, at 4:30 p.m. indicated that the resident was transferred to an acute care hospital by 911, at an unspecified time.The acute hospital Emergency Room Admission document indicated that Resident 1 was admitted on October 27, 2009, at 11:03 a.m., with complaint of left ankle pain. An x-ray of the left ankle done on October 27, 2009, at 11:15 a.m., revealed that the resident had a recent fracture of the left ankle.The procedure report written by Physician 2, on October 28, 2009, indicated that Resident 1 required irrigation and debridement, and revision of open reduction internal fixation?left ankle fracture. The findings included: ??the resident underwent ORIF of the left ankle on October 15, 2009, ? was therefore placed into a short leg walking boot?with orders for no transfers without the boot in place, for protection of the left ankle? nursing personnel had removed her brace prior to transferring her, she (the resident) slipped ? and sustained an open refracture dislocation with all loss of fixation and the lateral hardware being exposed through the skin and the talus? (the bone in the ankle that connects with the lower leg bones to form the ankle joint) ?again, medial and posterior?.On January 5, 2010, at 2:15 p.m., Evaluator 1 interviewed Physical Therapy Assistant (PTA) 1 who stated that, during transfer (from the shower chair into the wheelchair) the Resident's ankle dislocated exposing the metal rod.On January 6, 2010, at 1:35 p.m., during an interview, CNA 1 stated that while the resident was wearing the boot on her left leg, she and PTA 1 transferred the resident to the shower chair. After the resident sat down, PTA 1 removed the boot. After the shower, she and the resident went back to the room. The resident sat in the shower chair but would not stand up, to be transferred to the wheelchair. So the PTA helped the resident to stand up. Suddenly she heard the resident scream and saw a piece of iron that came out from the resident?s left ankle. On March 12, 2012, at 4 p.m. in an interview with the director of nurses, she stated PTA 1 told her that he forgot to apply the boot on the resident?s left leg and that during the transfer of Resident 1 from the shower chair to the wheelchair on October 27, 2009, at 10:30 a.m., the resident was about to lose her balance and then, put weight on her left leg that caused the resident?s leg to avert (turn inward) and the surgical wound dehisced (opened).On April 23, 2012, at 10:11 a.m. in an interview with Physician 2, he stated that if the resident had been wearing the (moon) boot at the time of the transfer (into the wheelchair), it was unlikely that the fracture (of October 27, 2009), would have happened. Physician 2, further stated that wearing the moon boot during the transfer would have protected the ankle from rolling inward, (averting), and the ankle rolling inward was the cause of the resident?s fracture.The facility failed to prevent Resident 1 who had a recent surgical repair of an ankle fracture from re-injuring her left ankle by failing to: Apply a moon boot at all times to Resident 1?s left lower ankle in accordance with the physician order and the resident?s care plan.The facility?s failure to apply Resident 1?s moon boot during a transfer, as the physician ordered and in accordance with her are plan resulted in a re-injury of the left ankle. Subsequently, the resident required acute care hospital emergency room treatment and surgical revision of an open reduction internal fixation [(ORIF), a method of surgically repairing a fractured bone), of the left ankle on October 28, 2009.The above either violation jointly, separately or in any combination presented a substantial probability that serious physical harm would result. |
| 950000256 |
KINDRED TRANSITIONAL CARE AND REHABILITATION-FOOTHILL |
950009714 |
B |
24-Jan-13 |
8NHZ11 |
10032 |
F327 483.25 (j) The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The facility failed to ensure that Resident 1 had sufficient fluid intake to prevent dehydration (excessive loss of body water) by failing to: 1) Develop a preventive plan of care to prevent dehydration for Resident 1, who was assessed with a poor appetite.2) Follow the physician?s orders to monitor Resident 1?s poor appetite and record her intake.3) Notify and consult with Resident 1?s physician regarding her poor intake as indicated in the facility?s policy. On February 15, 2011, an unannounced visit was made to the facility to investigate allegations that a resident was transferred to the acute hospital emergency room due to being severely dehydrated. A review of the admission face sheet revealed that Resident 1 was a 78 year old female who was readmitted from the acute hospital to the facility on 8/16/10, with the diagnoses of, diarrhea, urinary tract infection, anxiety and Myasthenia gravis (a defect in the transmission of nerve impulses to muscles. The muscle that controls swallowing is frequently affected. The Minimum Data Set (MDS) a standardized assessment and care planning tool dated 8/21/10, indicated that Resident 1 had modified independence in cognitive skills, along with a short term memory recall and a chewing problem. The assessment further indicated that Resident 1 required supervision and set-up help in eating and had a urinary tract infection.The review of the MDS Resident Assessment Protocol Summary (RAPS) for Resident 1 dated 8/31/10, revealed that the nutritional status and the area of dehydration and fluid maintenance was triggered for care planning and a decision was made to proceed with a care plan in both areas. However, a review of the medical record did not contain a plan of care to address both dehydration and fluid maintenance. The registered dietician?s assessment of Resident 1?s estimated daily fluid needs as indicated on 9/1/10 was 1,500 cc of fluid per day.According to the laboratory report dated October 29, 2010, Resident 1?s blood urea nitrogen (BUN) was 18 mg/dl which was within the normal range (10-20 mg/dl). Blood Urea nitrogen measures the amount of urea nitrogen in the blood. BUN levels may vary according to the status of hydration with increased levels seen in dehydration (Mosby?s Diagnostic and Laboratory Test Reference. Ninth Edition). On 12/8/10, the physician ordered to administer Mirtazapine 15 milligram (an antidepressant drug) to Resident 1 at bedtime, due to depression as manifested bypoor appetite, and monitor the resident?s poor appetite and to record the percentage of food consumed at each meal.Resident 1?s Meal Intake Record for the month of January 2011 (between 1/1/2011 and 1/27/11) were as follows:1) 60 percent (%) for 14 meals2) 50 % for 28 meals3) 40 % for 22 meals4) 30 % for 12 meals.Resident 1?s Meal Intake Record for 1/27/2011 revealed that the resident meal intake for dinner had dropped to 20 %. On 1/28/11, Resident 1 consumed 20% of her breakfast, lunch and dinner meals. On 1/29/11, Resident 1 consumed 20% of her breakfast meal and there was no documented record of food intake for her breakfast meal on 1/30/11.There was no documentation in the licensed nurse?s progress notes that the attending physician was notified that Resident 1?s food consumption percentage had dropped to 20% on 1/2711, 1/28/11 or 1/29/11. There was no documented evidence that alternative measures were implemented to ensure that Resident 1 received the required 1500 ccs of fluid as noted by the registered dietitian to prevent dehydration. Also, there was no documented evidence that the licensed nurse monitored the fluid intake of the resident.Additionally, the medical record did not contain any update to the plan of care to address how the facility would ensure that the resident had sufficient fluids to prevent dehydration while the resident?s intake had decreased to 20 % on 1/2711, 1/28/11 and 1/29/11.A review of the physician?s progress notes dated January 30, 2011, at 11 a.m., contained a notation by Employee 1, indicating that Resident 1 had an altered level of consciousness (ALOL) a blood pressure of 90/50, a pulse rate of 77, and a respiratory rate of 16. The registered nurse practitioner was notified and gave orders to perform stat labs and a chest x-ray. It was also noted that at 11:50 p.m., 50 minutes later, the resident?s daughter called the facility stating that she wanted the patient transferred to the emergency room (ER) and a new telephone order was received to transfer the resident to the ER.However, a review of the physician?s orders indicated that the telephone order to transfer the resident to the ER was not actually written on the same date that Employee 1 had received the order, but was written two weeks after she had received the order on 2/15/11, as a late entry (an entry entered that is documented in the medical record after the date and time of the actual order or event) for 1/30/11.At 11:50 a.m., the resident?s blood pressure had dropped to 86/50. The licensed nurse notes further indicated at 12:35 p.m., that the Medic 1 ambulance employee arrived at the facility (Transportation arranged by the daughter) and stated ?We will call 911 because her blood pressure dropped to 74/50. We will take her downstairs and meet 911 there.? At 12:45 p.m. Resident 1 was transferred to the ER for evaluation. A review of the acute hospital Emergency Room record dated 1/30/11, indicated that when the resident was admitted to the emergency room she was alert, confused, had dry mucous membranes and appeared to be dehydrated. The noted clinical impression included dehydration, muscle wasting, pneumonia and urinary tract infection. Additionally, the laboratory results from the acute hospital dated 1/30/11, indicated that Resident 1 had a moderate amount of bacteria in her urine and the blood urea nitrogen was 28 mg/dl which is above the normal range (7-18 mg/dl). Consequently, Resident 1 was administered one liter of 0.9 percent normal saline intravenously for hydration. Resident 1 was also administered Levaquin (an antibiotic) 750 milligram intravenously for a urinary tract infection. Resident 1 stayed at the acute hospital on 1/30/11, for seven hours and was transferred to another acute hospital on 1/30/11, at 8:16 p.m. On 12/7/11, at 4:20 p.m., the medical record of Resident 1 was reviewed with Staff 2 and Staff 3. They both disclosed and confirmed that there was no written plan of care developed to address Resident 1?s nutritional problem since the MDS assessment protocol dated 8/31/10, was completed. They also confirmed that there was no documented evidence that the physician was notified of the resident?s reduced intake for three consecutive days (on 1/27/11, 1/28/11 or 1/29/11) even though, Staff 4 and Staff 5 had signed the medication administration record that the meal percentage intake of Resident 1 was being monitored.During an interview on 12/21/11, at 3:15 p.m., Staff 4 revealed that she did not ask Staff 6 about Resident 1?s meal percentage for breakfast and lunch on 1/28/11. She further stated that she signed the Medication Administration Record (MAR) on 1/28/11, without reviewing Resident 1?s meal record. Staff 4 stated and acknowledged that the resident?s decreased consumption in food and fluid intake might have resulted in the resident?s dehydration. Staff 4 also stated that the physician was not made aware of Resident 1?s 20 percent meal intake for breakfast, lunch and dinner on 1/28/11, because she did not remember if Staff 6 had reported it to her.During an interview on 12/23/11, at 2:15 p.m., Staff 6 disclosed that she provided care to Resident 1 on 1/28/11, and 1/29/11, and that she was worried that Resident 1 was sick due to eating only 20 percent of her meal on 1/28/11 and 1/29/11. Staff 6 stated that on 1/29/11, she reported to Staff 5 that Resident 1 had been ?eating less? for two days. Staff 6 disclosed she did not document in the patient?s record that Staff 5 was made aware that Resident 1 had been eating less for two days.During an interview on 12/23/11, at 2:30 p.m., Staff 5 stated she was aware that Resident 1 was ?eating poorly? and did not remember if Staff 6 had reported that Resident 1?s meal intake was 20 percent for breakfast on 1/29/11. She further stated that she did not notify the physician that Resident 1?s meal intake was 20 percent on 1/27/11, 1/28/11 and 1/29/11, because she signed the MAR without reviewing the meal record or asking Staff 6. A review of the facility?s policy and procedure regarding patient meal intake disclosed that intake of food and fluid at meals and snacks is to be monitored to determine the adequacy of nutrient intake. The policy stipulates that the licensed staffs are to monitor the percentage of meal taken, notify nutrition services if intake has declined for the past three consecutive days and to notify the physician. However, the above policy and procedure was not followed.The facility failed to ensure that Resident 1 had sufficient fluid intake to prevent dehydration (excessive loss of body water) by failing to: 1) Develop a preventive plan of care to prevent dehydration for Resident 1, who was assessed with a poor appetite. 2) Follow the physician?s orders to monitor Resident 1?s poor appetite and record her intake.3) Notify and consult with Resident 1?s physician regarding her poor intake as indicated in the facility?s policy. As a result, Resident 1 became severely dehydrated and was consequently transferred to the acute hospital emergency room where she received Intravenous hydration due to dehydration and antibiotics for a urinary tract infection.The above violations had a direct relationship to the health, safety and security of Resident 1. |
| 950000256 |
KINDRED TRANSITIONAL CARE AND REHABILITATION-FOOTHILL |
950010661 |
B |
24-Apr-14 |
None |
2965 |
1418.21. (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements:(1) The information shall be posted in at least the following locations in the facility: (A) An area accessible and visible to members of the public.(B) An area accessible for employee breaks (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. The Department received an entity reported incident. On March 24, 2014, at 7:38 a.m., an unannounced visit was made to the facility to investigate the allegation.Based on observation, interviews, and record reviews, the facility failed to: Follow its policy and procedure, which stipulates the facility?s STAR system overall rating are to be posted in the following three areas:a. Accessible and visible to the public b. Used for employee breaks c. Used by patients for communal activities including a dining area or activities room On March 24, 2014 at 8:15 a.m., during an observation of the facility?s front lobby, there were five clear plastic holders on the wall, four were empty and one contained the facility?s advertisement. While touring the facility, accompanied by the Minimum Data Set (MDS) nurse, the facility?s STAR rating sign was not visible and the MDS nurse could not convey the location of the sign. At 8:20 a.m., Employee 1 stated, ?It was posted in the front lobby before.?On March 24, 2014, at 8:30 a.m., the registered nurse supervisor (RN 1) stated, ?I thought the star system was supposed to be in the nurses? lounge.? During an observation, accompanied by a Registered Nurse (RN 1) and the Minimum Data Set (MDS) nurse, there was no sign posted in the nurses? lounge. At 8:35 a.m., the MDS nurse handed a printed copy of the facility?s star system to the survey team that indicated an overall rating was ?1? star (out of five).On March 24, 2014, at 8:40 a.m., Employee 1 posted the facility?s overall STAR rating in one of the clear plastic holders, on the wall, at the front door entrance.On March 24, 2014, at 8:45 a.m., during an interview, the administrator stated the sign was down while the facility underwent six months of construction. On Friday, March 21, 2014, the construction was completed. However, Employee 1 posted the facility?s overall STAR rating after the survey team arrived on March 24, 2014.A review of the facility?s policy and procedure, dated January 1, 2011, titled ?Five-Star Quality Rating Posting,? indicated the facility will follow Federal CMS requirements to post the overall rating information in three areas that are: ?Accessible and visible to the public, used for employee breaks, and used by patients for communal activities including a dining area or activities? room.? |
| 950000256 |
KINDRED TRANSITIONAL CARE AND REHABILITATION-FOOTHILL |
950012924 |
A |
15-Feb-17 |
F7AG11 |
12047 |
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 9/30/15 at 1:57 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s multiple falls which resulted in left shoulder and hip fractures.
Based on record review and interview, the facility failed to provide adequate supervision and assistive devices to prevent Resident 1, who had fallen three times, from further falls by failing to:
1. Provide a bed and wheelchair alarm (sensor pad connected to an alarm box that can be placed on a mattress while a resident is lying down, or on a wheelchair seat while a resident is sitting. The alarm is triggered and signals the staff that the resident is attempting to get out of bed or the wheelchair) as ordered by the physician to notified staff that Resident 1 was attempting to stand and for the staff to assist the resident and prevent the resident from falling.
2. Obtain a sitter (person assigned to specifically supervise the resident) in accordance with Resident 1's physician's order to assist the resident and prevent the resident from falling.
These deficient practices led to a fourth fall in which Resident 1 sustained left hip and shoulder fractures. Resident 1 required surgery to repair the left hip fracture.
A review of Resident 1?s ?Record of Admission? indicated that she was admitted to the facility on XXXXXXX15. Her diagnoses included status post fall with a compression fracture of the lower spine [cracks in the bones of the spine due to osteoporosis (weakening of the bone)], high blood pressure, and dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
A review of Resident 1's "Patient Nursing Evaluation Part 2," dated 9/6/15, indicated that Resident 1 was assessed to have a fall risk score of 40. According to the Morse Fall Risk Scale (assesses the risk of a resident falling based on a number of safety factors), a score of 40 indicated a medium fall risk. Resident 1 had a history of falls (25 points) and had two or more medical diagnoses (15 points). Resident 1 was assessed as not needing any ambulation aide, gait was normal, was oriented to her own ability. Resident 1 was assessed as being able to move about the bed without assistance and was aware of her position in bed in proximity to the edge of the bed. No documentation of any fall risk precautions were indicated for Resident 1 on admission.
A review of the clinical record indicated Resident 1 had the following falls:
Fall #1: A review of Resident 1's Post Fall Investigation dated 9/6/15 at 2 p.m., indicated Resident 1 was observed to have slipped out of her wheelchair in her room onto the floor. No injury was noted. Immediate interventions taken to protect the resident: Wheelchair alarm. The resident's physician and family member were notified.
A review of Resident 1's Progress Notes dated 9/6/15 at 2 p.m., indicated Resident 1 was in her room and slid out of her wheelchair onto the floor. Resident 1 was assessed and assisted back into her bed. "Bed alarm (was) placed to wheelchair."
Fall #2: A review of Resident 1's Post Fall Investigation dated 9/6/15 at 2:30 p.m., indicated Resident 1 had an unwitnessed fall and was found kneeling on the floor at the edge of her bed. Resident 1 stated she had slipped off the edge of her bed. No injury was noted. The resident's physician and family member were notified.
A review of Resident 1's Progress Notes dated 9/6/15, at 2:30 p.m., indicated Resident 1 was found kneeling on the floor on the edge of her bed. Resident 1 was assessed and placed back in bed. Resident 1's bed was in lowest position and call light within reach, no other fall precaution interventions were implemented.
Fall #3: A review of Resident 1's Post Fall Investigation dated 9/6/15, at 7:55 p.m. (third fall) indicated Resident 1 was found on the floor of her room lying on her right side next to her bed. Resident 1 stated she got up from her bed and tried to walk to the bathroom and slipped on the floor. Resident 1 complained of pain, level 7 on a pain scale of 0-10 (0-no pain, 10-severe pain) to the left side of her head, left side of her ribs, and left hip. Resident 1's physician was notified and ordered chest and pelvic X-rays. Resident 1 was assessed as noncompliant with call light use and was reoriented to call light use. No other fall precaution interventions were implemented. The resident's family member was also notified.
A review of Resident 1's Progress Notes dated 9/6/15 at 9:27 p.m. indicated that Resident 1 was placed back to bed and neurological checks (assessment to determine if there was a change in a person's mental status) were initiated.
A review of Resident 1's physicians' orders dated 9/6/15 indicated Resident 1 to receive a chest X-ray, pelvic X-ray stat (immediately), monitor mental status, and send to ER (emergency room) if resident had change of mental status. Physicians' orders also indicate that Resident 1 "had an unwitnessed fall" complaining of pain on head, left rib, and left hip.
A review of Resident 1's X-ray results, dated 9/6/15, indicated that Resident 1 had modest osteoarthritis (degeneration of joint cartilage and bone causing pain and stiffness) but no pelvic or hip fracture.
A review of Resident 1's Progress Notes dated 9/7/15, at 7:46 a.m., indicated Resident 1 was responsive with confusion, trying to get out of bed, and agitated. Fall precautions were observed. Bed placed in low position, and bed alarm was in place. Frequent visual checks were done.
A review of Resident 1's Progress Notes dated 9/7/15, at 2:53 p.m., indicated Resident 1 was moved to a room closer to the nurses' station to be closely monitored.
A review of Resident 1's physician's orders dated 9/8/15 included: "OK to have sitter at nighttime. Fall precautions-floor mat, lower bed, bed alarm, chair alarm."
Fall #4: A review of Resident 1's Post Fall Investigation dated 9/10/15, at 9:15 p.m., indicated Resident 1 was found lying on her left side on the floor of her restroom, beside her wheelchair and the toilet. Resident 1 was alone, and no sitter was present at the time. There was no documentation that a sitter had been monitoring Resident 1, that a bed alarm or wheelchair alarm had been in place, or that any alarm had been triggered.
A review of Resident 1's Progress Notes dated 9/10/15 at 9:15 p.m. indicated Resident 1 complained of pain to her left arm, shoulder, and hip. Resident 1 stated it hurt too much to raise her arm up. Resident 1's physician was notified and ordered an immediate X-ray of Resident 1's left shoulder, elbow, forearm, and hip. Fall precautions were in place, bed in low position, and call light within reach.
A review of Resident 1's interdisciplinary team (IDT) note dated 9/11/15 indicated Resident 1 had sustained multiple falls from 9/5/15 to 9/10/15. According to the IDT notes, "Each incident resulted in no injury and patient did not complain of pain. Resident 1 had history of confusion and non-compliance with safety measures often getting up or transferring without assistance. Patient had poor safety awareness due to confusion. Interventions included bed in low position; call light within reach, landing mat beside bed, pressure alarm on wheelchair and mattress, and finally a sitter."
Resident 1's Progress Notes from 9/8/15 to 9/10/15 contained no documentation indicating Resident 1 had a sitter, bed alarm, or wheelchair alarm.
A review of Resident 1's Progress Notes from 9/11/15 to 9/14/15 indicated the following:
1. On 9/11/15, at 4:07 a.m., Resident 1 complained of left shoulder and left hip discomfort. X-ray results for the left shoulder and left hip indicated no fracture.
2. On 9/11/15 at 2:10 p.m., Resident 1 complained pain to the left arm and shoulder. Right shoulder area noted to be very swollen and tender to touch.
3. On 9/11/15 at 10:24 p.m. Resident 1 continued to complain of pain to her left arm and hip.
4. On 9/12/15 at 10:30 p.m., Resident 1 complained of severe pain to her left arm and hip.
5. On 9/13/15 at 4:21 a.m., Resident 1 complained of 7 out of 10 pain to her left arm.
6. On 9/13/15, at 9:31 p.m., another X-ray was taken of Resident 1?s left hip.
7. On 9/13/15, at 11:32 p.m., the X-ray results were positive for a fracture.
8. On 9/14/15, at 12:41 p.m., Resident 1 was transported to a general acute care hospital (GACH) emergency room.
A review of the GACH emergency admission note dated 9/14/15 indicated Resident 1 had a left hip and a left shoulder fracture.
A review of the GACH Discharge Summary indicated Resident 1 was admitted on XXXXXXX16 and discharged on XXXXXXX16. Resident 1 diagnoses included a left hip fracture which required an open reduction and internal fixation surgery (surgery in which the bone is exposed and metal screws or plate are inserted to repair the fractured bones) and a left shoulder fracture.
During an interview with the DON on 6/21/16 at 3:05 p.m., DON stated that the bed alarm was implemented for Resident 1 after the first fall on 9/6/15 at 2 p.m. according to the nurse's progress notes. The DON was not able to show evidence that a bed alarm was in use after 9/7/15.
During an interview with the Assistant Director of Nursing (ADON) on 10/27/16 at 9:00 a.m., the ADON stated that he received the verbal order from the physician on 9/8/15 to obtain a sitter for Resident 1. After receiving the order, the ADON failed to inform Resident 1's case manager to get a sitter for the resident during the night.
In an interview with the case manager (CM 1) on 10/28/16 at 1:05 p.m., CM 1 stated that she coordinated authorizations and discharge planning with Resident 1's health insurance plan. CM 1 stated that if there was an order for a sitter, then CM 1 would initially speak with the resident's family to see if they could come and supervise the resident. If the family could not or if the family could not afford a caregiver, then CM 1 would work with the health insurance plan to obtain a sitter. CM 1 stated she was unaware of Resident 1's physician's order on 9/8/15 for a sitter. CM 1 stated if she was informed of the order, she would have followed up and arranged for a sitter.
In a follow-up interview with ADON on October 28, 2016 at 3:30 p.m., ADON stated that there was no documentation that he spoke with CM 1 regarding the physician's order to obtain a sitter for Resident 1.
The facility failed to provide adequate supervision and assistive devices to prevent Resident 1, who had fallen three times, from further falls by failing to:
1. Provide a bed and wheelchair alarm (sensor pad connected to an alarm box that can be placed on a mattress while a resident is lying down, or on a wheelchair seat while a resident is sitting. The alarm is triggered and signals the staff that the resident is attempting to get out of bed or the wheelchair) as ordered by the physician to notified staff that Resident 1 was attempting to stand and for the staff to assist the resident and prevent the resident from falling.
2. Obtain a sitter (person assigned to specifically supervise the resident) in accordance with Resident 1's physician's order to assist the resident and prevent the resident from falling.
These deficient practices led to a fourth fall in which Resident 1 sustained left hip and shoulder fractures. Resident 1 required surgery to repair the left hip fracture.
The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical hard would result or a substantial probability that death or serious physical harm would result. |
| 120000377 |
Kingston Healthcare Center, LLC |
120013657 |
B |
5-Dec-17 |
M2R511 |
13603 |
F224
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 must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.
On 9/19/17 at 8:25 AM, an unannounced visit was conducted at the facility to investigate allegations of resident's financial abuse.
Resident 1 was 91 year old female with a history of schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality), dementia with behavioral disturbance (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning). Resident 1's cognition status was assessed by the facility staff on 5/31/17. This assessment indicated Resident 1 was cognitively severely impaired (a collection of symptoms that result in the loss of intellectual function).
Resident 2 was 51 year old female who was developmentally disabled (a diverse group of chronic conditions that are due to mental or physical impairments). Resident 2's cognition status was assessed by the facility staff on 9/25/17. This assessment indicated Resident 2 was cognitively severely impaired.
Resident 3 was 86 year old female with a history of Alzheimer's disease (a progressive mental deterioration due to generalized degeneration of the brain), stroke (bleeding in the brain), Parkinson's disease (a progressive disorder of the nervous system that affects movement). Resident 3's cognition status was assessed by the facility staff on 9/5/17. This assessment indicated Resident 3 was cognitively severely impaired.
For Resident 1 and 3 personal funds were used by the facility to purchase items that were not authorized by the residents' or residents' responsible party. For Resident 2, the facility planned to use her personal funds without authorization from the resident or the resident's responsible party.
The Department determined that the facility failed to:
1. Prevent misappropriation of property for two of six sampled residents (1 and 3) when the facility purchased items from Residents 1, and 3's personal funds to "spend down" (to spend residents' funds not to go over $2000 to keep eligibility for Medi-Cal insurance-type of insurance coverage that pays for medical and surgical expenses provided by the government) their trust accounts.
2. Follow the facility's policy and procedure for one out of six sampled residents (2) when the facility had planned to spend down Resident 2's trust account without authorization from Resident 2 or Resident 2's responsible party (RP-a person other than the resident who makes decisions for the resident when the resident is incapable of doing so for themselves).
These failures resulted in financial abuse and the facility using Resident 1, and 3's funds without permission from the residents or the residents' RP and the potential for abuse of Resident 2's funds when the facility planned to use her funds without the permission of the RP.
1. During a review of the "Trust Check Request- Non Petty Cash" form for Resident 1 dated 6/15/17, the report indicated an amount of $1,164.00 was requested and received by the Activity Supervisor (AS). A note was written on the report indicating "Resident [Resident 1] needed to spend down, so Social Services ordered items for Resident [Resident 1]." The AS, the Business Office Assistant (BOA), and the Administrator signed the form. The signatures from Resident 1 or Resident 1's RP were missing from the form. There was no indication Resident 1's RP (RP 1) approved the removal of funds from Resident 1's trust account for the purchases.
The Customer Invoice (Receipt), dated 6/14/17, indicated the following purchases were made:
Striped Keyhole Neck Outfit - $45.00
Denim Capri Set - $47.00
Twiddle Cat - $65.00
Dazzle Tulips - $150.00
Flower Show Lightweight throw - $60.00
Wild Flower Framed Art - $195.00
CD Player with AM/FM Radio - $75.00
Flower Show Lightweight Throw - $60.00
Peace in the Valley: Elvis Presley Complete - $60.00
Hitsville: Motown Collection - $90.00
Smooth Jazz Hits - $25.00
America The Beautiful - $195.00
Fleece Placket Set - $47.00
Shipping and Handling - $50.00
Total of $1164.00
During a review of Resident Trust Fund Statement, dated 7/19/17, a withdrawal of $104.00 was noted. The Customer Invoice (Receipt), dated 4/20/2017, indicated the following purchases were made: Wireless Headphones $95.00 with a total of $104.00.
During a review of the clinical record for Resident 1, the Minimum Data Set (comprehensive assessment tool), dated 5/31/17, indicated Resident 1 had a BIMS score (brief interview for mental status) of 3 (score of 0-7 indicates severe cognitive impairment). The Face Sheet, dated 7/12/17, indicated RP 1 was Resident 1's responsible party. The History and Physical Examination, dated 8/29/16, indicated Resident 1 had no capacity to understand and make medical decisions.
During an interview with Licensed Vocational Nurse (LVN) 1, on 9/19/17, at 8:52 AM, LVN 1 stated Resident 1 was very confused. She stated Resident 1's daughter (RP 1) was Resident 1's responsible party.
During a concurrent observation and interview with Resident 1, on 9/19/17, at 8:55 AM, in Resident 1's room, Resident 1 was alert, confused and unable to be interviewed.
During an interview with the AS and review of Resident 1's clinical record on, 9/19/17, at 10:07 AM, the AS stated she worked as the Social Service Assistant prior to transferring to the Activities Department. The AS stated she helped Resident 1 in ordering and purchasing items from an outside vendor by showing pictures from a catalogue. Resident 1 pointed to the items she liked, and the AS then called the company and placed the orders. Upon receipt of the items from the vendor, the items were given to a CNA (certified nursing assistant) to put away in Resident 1's room. The AS reviewed the Customer Invoice (receipt), dated 6/15/17, and stated not all items on the list were in Resident 1's room. The AS stated she did not label the items with Resident 1's name or add the items to her "Inventory of Personal Effects" form in her clinical record. The AS stated she did not ask RP 1's permission to purchase the above items. The AS stated she was aware Resident 1 was confused. The "Inventory of Personal Effects " form for Resident 1 dated 6/5/13, indicated no entries for the items purchased for Resident 1 from the above list of items on the "Customer Invoice" receipt. The AS verified the finding.
During an interview with the Director of Nursing (DON), on 9/19/17 at 11:06 AM, the DON stated there was no policy for Social Services for ordering items for resident. The DON stated it was Social Service's responsibility to call the RP before purchasing items for residents. The DON stated it was the nursing department's responsibility to label and add items to the "Inventory of Personal Effects".
During a concurrent interview and observation with the AS on 9/19/17, at 11:10 AM, the AS was observed in Resident 1's room holding onto compact discs which the AS stated were those on The Customer Invoice (receipt), dated 6/14/17. The AS stated other items on "The Customer Invoice" for Resident 1 were located in other offices in the facility and located in the maintenance office were the two framed pictures leaning against a wall.
During a review "The Customer Invoice" (receipt), dated 4/20/17, with the AS on 9/19/17, at 11:15, the AS was asked to locate the wireless headphones. The AS went into another office where she located the headphones. The AS stated she knew they were Resident 1's headphones and with a permanent marker wrote Resident 1's name on the headphones.
During an interview with RP 1, on 9/20/17, at 11 AM, RP 1 stated she was not contacted by the facility before the purchase of the above items. RP 1 stated, "They shouldn't be purchasing items aside from candies and treats. They bought her a television which she did not need." She stated Resident 1 did not need all those extra items and there was no reason for spending the money for Resident 1.
During a concurrent interview with the Business Office Manager (BOM) and review of Resident 1's "Trust Check Request- Non Petty Cash" form, Customer Invoice (Receipt), and Resident Trust Fund Statement, on 10/18/17, at 2:15 PM, she verified the above findings. The BOM stated, "We have to spend down [Residents' money from their Trust Funds] so they don't lose their Medi-Cal benefits. If they have more than $2,000 in their trust account, they will lose their Medi-Cal insurance so we have to spend down." The BOM verified RP 1 was not notified of the removal of funds from Resident 1's trust account.
1a. Resident 3's Trust Fund Statements were reviewed with the BOM on 10/18/17, at 2:15 PM. Resident 3's Trust Fund Statement, dated 2/22/17, indicated a withdrawal of $2,152.51 for personal need items. The "Resident Trust Check Request - Non Petty Cash", dated 2/21/17, indicated an amount of $2,152.51 requested and received by the AS. The "Resident Trust Check Request-Non Petty Cash", processed by the Business Office Assistant (BOA) indicated a notation of "Resident [Resident 1] spend down for custom wheelchair. The AS, BOS, and the Administrator signed the request. The request did not include a signature from Resident 3 or Resident 3's RP. The Invoice, dated, 2/6/17, indicated a purchase of a wheelchair amounting to $2,152.51. There was no indication Resident 3's RP had authorized the wheelchair purchase. The BOM verified the findings.
During an observation on 10/18/17, at 2 PM, in the hallway, Resident 3 was sitting in a Geri-chair (large padded chair with wheeled bases). Resident 3 was confused and unable to be interviewed. Resident 3 was not using the purchased wheelchair. LVN 1 verified the finding.
During a review of the clinical record for Resident 3, the Minimum Data Set, dated 9/5/17, indicated a BIMS of 99 (score of 99 indicates resident was unable to complete the interview). The staff assessment for mental status indicated memory problems with short-term and long-term memory.
During an interview with the Administrator, on 10/18/17, at 2:30 PM, he stated the facility did not have a policy and procedure on spending down residents' funds [when the residents' trust funds goes more than $2000]. The Administrator stated they have Resident 3's wheelchair sitting in the storage room.
2. During a review of Resident 2's Trust Account Statement, dated, 10/12/17, indicated Resident 2 had an account balance of $9,333.24.
During an observation and interview with Resident 2, on 10/18/17, at 1:15 PM, in Resident 2's room, Resident 2 was totally dependent from staff with activities of daily living (the things we normally do in daily living including any daily activity we perform for self-care such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure). Resident 2 was unable to interview due to severe confusion.
During a review of the clinical record for Resident 2, the Minimum Data Set, dated, 9/25/17, indicated Resident 2 had a BIMS of 0 (score of 0-7 indicates severe cognitive impairment). The Functional Status, dated 9/25/17, indicated Resident 2 required total assistance with one to two person physical assistance with activities of daily living.
During an interview with the BOM on 10/18/17, 2:15 PM, the BOM verified the above findings concerning Resident 2's Trust Account Statement. The BOM stated, "I worked hard to get her [Resident 2] Medi-Cal insurance, if she will lose her Medi-Cal insurance she will pay private." The BOM stated when the trust account is over $2000 the resident loses their Medi-Cal insurance coverage. The BOM stated, "We are planning to spend down her money by getting her a funeral insurance." The BOM stated Resident 2's RP had not been contacted about the above plan.
The facility policy and procedure titled, "Resident Trust Fund Policy", dated 1/1/10, indicated, "No employee, owner or their immediate relative or representative of the aforementioned may act as an authorized representative of resident's money unless the resident is a relative. Trust Fund Withdrawals: The facility should maintain the Resident Trust Withdrawal Form that is signed by the resident or responsible party."
The facility policy and procedure titled, "Abuse Prevention Program", dated 8/06, indicated, "Our residents have the rights to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual."
These failures had direct or immediate relationship to the health, safety, or security of residents. |
| 100000773 |
Kindred Transitional Care & Rehabilitation - Valley Gardens |
030013526 |
B |
5-Oct-17 |
CFXI11 |
3881 |
F206 483.15 Policy to Permit Readmission Beyond Bed-Hold
(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
The following citation was written as a result of complaint #CA00548020
An unannounced visit was made to the facility on 8/24/17 to investigate an allegation of refusal to readmit.
The Department determined the facility failed to:
Readmit Resident 1 after a brief hospitalization at the General Acute Care Hospital (GACH).
This failure had the potential to cause emotional distress and/or harm to Resident 1, who was a long term resident of the facility.
Resident 1's clinical record indicated he had been a resident at the facility since mid-2016, and was sent to the hospital on 7/14/17, for evaluation and treatment. The resident's health condition required him to be admitted to the general acute care hospital (GACH) for treatment on 7/15/17 and he remained there until 7/25/17.
Review of Resident 1's GACH records included:
1) Resident 1's admission record indicated he was admitted on 7/15/17 and discharged on 8/11/17.
2) Case Management Assessment/Discharge Planning Notes dated 7/24/17 indicated the hospital Social Worker called the facility to have the resident re-admitted on 7/25/17. A subsequent Case Management Note dated 7/25/17 indicated the facility would not take Resident 1 back.
3) Discharge Summary dated 8/11/17 indicated Resident 1 had been stable for discharge for "quite some time."
According to the facility's Room Assignment sheets, covering the period from 7/25 to 8/11/17, a total of 17 days, the facility had 7 to 12 available male beds on each of those days.
In an interview with the facility's Administrator and Director of Nurses (DON) on 8/24/17 at 9:30 a.m., they were asked why Resident 1 was not allowed to return to the facility. They both answered that the facility did not need to accept Resident 1 back because he had expired his 7-day bed-hold.
Review of the facility's policy titled, "NCD [Nursing Center Division] Bed Hold & Readmission," release date 9/20/16, indicated that, "Should a patient elect not to pay for the bed-hold beyond the allowed duration, then the patient will be readmitted to the first available bed..."
Therefore, the Department determined the facility failed to:
Readmit Resident 1 after a brief hospitalization at the General Acute Care Hospital (GACH).
This violation had a direct or immediate relationship to the health, safety or security of Long Term Care patients or residents. |
| 070000066 |
KATHERINE HEALTHCARE |
070013585 |
B |
8-Nov-17 |
6PIZ11 |
5793 |
F226, 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES
483.12
b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to implement their abuse policy and procedures when abuse allegations for Residents 1 and 3 were not reported to the California Department of Public Health (CDPH) within 24 hours and no investigation reports submitted within five working days of the incidents. These failures had the potential to delay the identification and implementation of appropriate corrective actions to prevent future occurrences.
1. Review of the State of California 341 form (SOC, a form used to report alleged abuse) received by the California Department of Public Health (CDPH) on 10/13/17 at 3:02 p.m., indicated an alleged abuse incident occurred on 7/18/17 when Resident 2 called Resident 1 "bitch and would cut her throat".
Review of the social service notes (SSN) dated 7/18/17 indicated Resident 1 was moved to another room and monitored for 72 hours due to an alleged abuse incident between Resident 1 and Resident 2. The incident was reported to the local ombudsman.
Review of the interdisciplinary team (IDT, group of people that meet to improve resident outcomes through a coordinated system of care delivery) notes dated 7/18/17, indicated Resident 2 called Resident 1 "bitch and would cut her throat."
Review of the verbal threat care plan dated 7/18/17, indicated notification to the local ombudsman and the physician was done.
Review of the administrator's (ADM) verbal threat late report dated 10/17/17, indicated the alleged abuse happened on 7/18/17. The report indicated the incident was care planned, sharp objects removed from Resident 2's room and the local ombudsman notified.
There was no evidence the abuse allegation was reported to the CDPH within 24 hours or an investigation report was submitted within five working days of the incident.
During an interview on 10/17/17 at 10:55, Resident 1 stated the incident between her and Resident 2 was resolved and she felt safe and comfortable sharing a room with Resident 2.
During an interview on 10/17/17 at 11:10 a.m., Resident 2 stated she and Resident 1 had issues before and had no issues now.
During an interview on 10/17/17 at 1:25 p.m., the ADM acknowledged there was no abuse allegation reported to the Department within 24 hours and no investigation report submitted within five working days.
2. Review of an SOC 341 received by CDPH on 10/13/17 at 3:16 p.m., indicated an alleged abuse happened on 7/1/17 when a staff member reported Resident 3's family member (FM) had complained that during repositioning of Resident 3, certified nurse assistant (CNA) A handled her rough.
Review of the grievance form dated 7/6/17 indicated a staff member reported Resident 3's family member had complained CNA A roughly handled Resident 3 during repositioning.
Review of the social service progress notes dated 10/10/17, indicated the alleged abuse incident happened on 7/1/17.
There was no evidence the abuse allegation was reported to the Department within 24 hours or an investigation report was submitted within five working days of the incident.
During an interview on 10/17/17 at 10:45 a.m., CNA A stated she was not the regular CNA for Resident 3. She stated Resident 3 needed a two-person assist. She stated she assisted when called for help.
During an interview on 10/17/17 at 1:40 p.m., the ADM acknowledged there was no abuse allegation reported to the Department within 24 hours and no investigation report submitted within five working days of the incident.
Review of the facility's 10/2017 policy "Abuse Reporting and Response" indicated the Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. The Executive Director (ED) or designee reports alleged violations to the state survey agency and other officials in accordance with state law. The Center reports the results of all investigations to the Executive Director and to other officials in accordance with State law including to the State Survey Agency within five working days of the incident.
Review of the facility's 11/2016 policy "Grievance Procedure" indicated if the grievance involves abuse, neglect, exploitation, or misappropriation of resident property, the ED is notified immediately and an investigation begins and notify state agencies where applicable.
The facility failed to implement their abuse policy and procedure to report to the Department within 24 hours for allegation of abuse and to submit investigation report within five working days of the incident.
The above violation could have potential or immediate relationship to the health, safety, or security of the residents. |
| 240000365 |
Knolls West Post Acute LLC |
240013646 |
A |
22-Nov-17 |
LJ4R11 |
13055 |
REGULATION VIOLATION:
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.
42 Code of Federal Regulations Section 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.
Based on interview and record review, the facility failed to ensure one of three sampled patients (Patient A) was provided necessary care and psychosocial support. This failure negatively affected the mental health and well-being of Patient A, which had the potential to result in Patient A's death.
The facility failed to notify the Physician of Patient A's Neuropsychological examination findings on exam, failed to provide for the continuing assessment of the Patient A's care needs with input, as necessary, from health professionals involved in the care of the patient, and failed to provide psychosocial support when Patient A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure had the potential to result in Patient A's death.
An unannounced visit was made to the facility on October 2, 2017 at 1:45 PM, to investigate an entity reported incident (ERI) regarding the death of Patient A, on September 29, 2017.
A review of Patient A's clinical record indicated Patient A was admitted to the skilled nursing facility (Facility) on July 9, 2017, with the following diagnoses: chronic obstructive pulmonary disease (a disease of the lungs), hypertension (high blood pressure), and depression (a mental disease that causes the person to feel sad and hopeless). Patient A had received inpatient treatment from a general acute care hospital from July 5, 2017 until he was transferred to the skilled nursing facility on July 9, 2017. A review of Patient A's clinical record from the general acute care hospital (GACH) revealed Patient A was admitted to the GACH on July 5, 2017 with a diagnosis of depression. Patient A had a physician's order for a one to one sitter while at the GACH due to Patient A's suicidal ideation (thoughts of killing or injuring one-self). A physician's order was recommended consultation with a Psychiatrist (a physician specializing in mental illness) due to Patient A's suicidal ideation.
A review of Patient A's ancillary and nursing transfer orders from the GACH, dated July 9, 2017, indicated the following notation: "Patient depressed and does not want to live."
A review of Patient A's care plan at the Facility entitled, "Depression," dated July 10, 2017, indicated Patient A had depression. The interventions listed included: social services to interact as needed, listen attentively and attempt resolve or discuss...upset, and monitor episodes of depression. A review of the physician's admission orders for Patient A, dated July 9, 2017 at 10 PM, indicated Patient A had an order for sertraline (antidepressant) 50 mg by mouth every day.
A review of the 2016 Edition, Nurse's Drug Handbook, indicated the following black box warning for sertraline, "Antidepressants increased the risk of suicidal thinking and behaviors in children, adolescents, and young adults in short term studies of major depressive disorders and other psychiatric disorders. Monitor and observe closely for clinical worsening, suicidality or unusual changes in behavior in patients who are started on an antidepressant therapy."
A review of Patient A's antidepressant medication form, undated and untimed, signed by Patient A's physician indicated that Patient A should be monitored for behaviors to include crying, inability to sleep, and suicidal ideations. A review of Patient A's antidepressant medication form clarification, dated July 10, 2017 at 9 AM signed by the physician, indicated Patient A should be monitored for behaviors of withdrawal and verbalization of depression. The monitoring for behaviors of crying, inability to sleep, and suicidal ideation, however, were discontinued.
A review of the licensed nurses' progress notes dated July 10, 2017 at 9 AM, revealed no documentation for the discontinuation of monitoring Patient A for crying, inability to sleep and suicidal ideation.
During an interview with the Director of Nursing (DON) on October 6, 2017 at 2:10 PM, the DON reviewed the licensed nurses' progress notes dated July 10, 2017 at 9 AM, and the DON confirmed there was no documented evidence to show the reason for discontinuation of monitoring Patient A's behaviors of crying, inability to sleep, and suicidal ideation. The DON stated, "The nurse should have documented why those behavior monitoring were discontinued."
A review of Patient A's care plan titled, "Psychosocial" dated July 10, 2017, indicated Patient A had depression and anxiety. The interventions listed included: Explain all care, validate feelings and demonstrate empathy (the ability to understand other's feelings).
A review of Patient A's physician's order dated August 15, 2017 at 2 PM, indicated Patient A had an order for a neuropsychological evaluation (an examination provided by a mental health professional to determine the emotional status of a resident).
The order for neuropsychological evaluation was obtained 37 days after Patient A was admitted to the facility.
However, during a telephone interview conducted on November 17, 2017 at 2:45 PM, with the Administrator, she stated that she reviewed Patient A's medical record and that, "There was no physicians order for the neuro psych consult." She stated the facility had a protocol in that a neuro psych group comes into the facility and speaks with the Social Worker regarding new patients or patients that were in need of a consult. The Social Worker would provide a list of residents. She said that is how this patient received a neuro psych consult.
During an interview with the DON on October 6, 2017 at 3:10 PM, the DON reviewed the licensed nurse's progress notes from August 25, 2017 through September 29, 2017 and the Nurse Practitioner notes dated September 9, 2017 and September 16, 2017. The DON confirmed there was no documented evidence to show Patient A's Physician or Nurse Practitioner were notified about the results of the neuropsychological consultation executive summary which indicated, Patient A was feeling depressed, hopeless, and helpless. The DON stated, "The consultation reports are put in the medical record chart under the consultation tab. When the doctor comes in, it is up to the doctor to look at the consultation report." The DON further stated, "The Doctor or the Nurse Practitioner should have been notified about the results and documented."
During a telephone interview with Patient A's physician conducted on November 21, 2017 at 2:20 PM, the physician confirmed he did not write any order for the neuropsychological consultation and he did not know that a neuropsychological consult had been done until after the patient's suicide.
A review of the IDT (Interdisciplinary Team- a team meeting of staff members that discuss patient care) conference review, dated August 22, 2017, noted that a care coordinator, social services worker, physical therapy assistant and Patient A's family members were in attendance. Further review of the IDT conference review indicated the family did not want Patient A to be discharged to home. The family wanted Patient A to be discharged to an assisted living facility.
A review of the written statement by the Physical Therapy Assistant (PTA) who attended the IDT conference and interpreted for Patient A and Patient A's family on August 22, 2017, documented the following notations: "The patient's daughter stated they would like him to go to an assisting living facility since all the daughters work and are unable to help with his care. The patient expressed not being satisfied with this decision multiple times, and he stated he preferred to go home with a caregiver during the day...The patient continued to express not wanting to discharge anywhere else but home."
A review of Patient A's neuropsychological consultation executive summary, dated August 25, 2017, indicated Patient A felt depressed, hopeless, and helpless. It indicated Patient A's family and his returning to house motivated him to rehabilitate. Further review of Patient A's neuropsychological consultation executive summary indicated Patient A was reporting significant depressive and anxiety symptoms. The recommendation listed included anticipate and prevent fear producing stimuli (an event that triggers behaviors).
A review of the licensed nurses' progress notes from August 25, 2017 through September 29, 2017, revealed no documentation that Patient A's physician was notified that Patient A was feeling depressed, hopeless, and helpless, nor that the Patient had reported significant depressive and anxiety symptoms on the neuropsychological consultation executive summary findings.
A review of social services notes dated September 28, 2017 indicated the following notation: "Social Services returned call from daughter {name of daughter} regarding anticipated discharge date...stated father could not come home due to being unable to take care of him. Requested assisted living placement." Further review of the Social Services notes, contained no documentation to show any interventions were done for Patient A's expressed feelings of dissatisfaction with the family decision of being discharged to an assisted living facility.
The social worker was not available for interview.
During an interview with the DON on October 6, 2017 at 3:10 PM, the DON reviewed the licensed nurse's progress notes from August 25, 2017 through September 29, 2017 and the Nurse Practitioner notes dated September 9, 2017 and September 16, 2017. The DON confirmed there was no documentation that Patient A's Physician was notified about the results of the neuropsychological consultation executive summary and examination findings. The DON stated, "The Doctor should have been notified about the results and documented."
During an interview with the DON on October 6, 2017 at 5 PM, the DON reviewed the Social Services notes for the months of August 2017 and September 2017, and confirmed there was no interventions for Patient A's expressed feelings of dissatisfaction with the family decision of being discharged to an assisted living facility. The DON stated, "The Social Worker should have been working with the resident to cope with his feelings of not wanting to go to an assisted living facility." The DON further stated, "It is about what the resident wants. There should have been interventions."
A review of the Facility policy and procedure titled, "Social Services Responsibilities," dated November 2008, set forth the following: "psychotropic/behavior management: lead the IDT to identify possible medical, environmental, and psychosocial causal factors of behaviors."
During a review of the clinical record for Patient A, the licensed nurses' progress notes dated September 29, 2017 at 4:10 AM, indicated the Licensed Vocational Nurse (LVN 1) documented, "Called to room by CNA, patient found on the floor with call light tied around his neck with a knot, patient facing the floor unresponsive, unplugged call light right away to be able to remove call light quickly from his neck, unable to feel pulse per forearm, CPR code blue paged to the building, called paramedics for help, and further evaluation while performing CPR with RN (registered nurse)."
A review of the licensed nurses' progress notes dated September 29, 2017 at 4:25 AM, revealed Patient A was transported out of the facility via 911 (ambulance).
During a telephone interview with the LVN 1 on October 11, 2017 at 1:27 PM, the LVN 1 stated, "The patient tied the call light around his neck. We started CPR immediately and called 911. He was still very warm but no pulse."
The facility failed to notify the Physician of the Neuropsychologists findings on exam and did not provide Patient A with any psychosocial support when Patient A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure resulted in Patient A's death. This failure negatively affected the mental health and well-being of Patient A, which resulted in Patient A's death. |
| 020000079 |
Kindred Nursing and Rehabilitation - Medical Hill |
020013549 |
B |
18-Oct-17 |
BH9411 |
5725 |
483.25(d)(1)(2) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility violated the aforementioned regulation by failing to provide adequate supervision and assistive devices to prevent an accident when Certified Nurse Assistant (CNA) 1 and CNA 2 transferred one of five sampled residents (Resident 1) without using an E-Z stand lift or a Hoyer lift (mechanical devices used to lift people) per Resident 1's care plan. Resident 1 sustained a painful fractured (broken bone) right tibia (anklebone), a fractured right fibula (anklebone).
Review of the Resident Face Sheet, dated 8/30/17, indicated Resident 1 was initially admitted to the facility on 6/2/11.
Review of the annual Minimum Data Set (MDS - an assessment tool used to guide care), dated 4/24/17, indicated Resident 1's decision making ability was severely impaired. The MDS also indicated Resident 1 required extensive assistance of two plus persons when transferring to and from bed to wheelchair. Further review of the MDS indicated Resident 1's active diagnoses included Osteoporosis (a condition in which bones lose density and become very fragile) and Arthritis (stiff joints).
During an interview with CNA 1 on 8/30/17 at 12:22 p.m., CNA 1 stated she and CNA 2 transferred Resident 1 from the wheelchair to the bed on 8/20/17 manually (without a mechanical lift). CNA 1 stated she was on the left side of Resident 1 and CNA 2 was on the right side of Resident 1. CNA 1 stated she and CNA 2 each placed one hand under the armpits of Resident 1, placed their other hands on the back of Resident 1's pants and lifted her from the wheelchair to a standing position. CNA 1 stated she and CNA 2 then guided Resident 1 to the bed. CNA 1 stated after Resident 1 was in bed, CNA 1 removed Resident 1's pants, changed her wet undergarment, and then Resident 1 stated "cut my leg off, it hurts." CNA 1 stated she received training on how to use the lifts before the incident, and she was aware Resident 1 required a mechanical lift for transferring.
During an interview with CNA 2 on 8/30/17, at 12:44 p.m., CNA 2 stated on 8/20/17 CNA 1 asked her to assist with transferring Resident 1 from wheelchair to bed. CNA 2 stated she and CNA 1 did not use a Hoyer lift or an E-Z stand lift to transfer Resident 1. CNA 2 stated she and CNA 1 put their hands under Resident 1's armpits, their other hands held the back of Resident 1's pants and lifted her from the wheelchair to a standing position. CNA 2 stated she kicked Resident 1's wheelchair out of the way and she and CNA 1 turned Resident 1 until the back of her legs touched the bed. CNA 2 stated she and CNA 1 assisted Resident 1 to a sitting position. CNA 2 stated she was not sure if Resident 1's feet moved when she was turned. CNA 2 stated Resident 1 complained of leg pain after she sat on the bed.
Review of Resident 1's care plan "Risk for falls," initiated on 1/5/15 and revised on 7/20/17, indicated Resident 1 was "Only transfer(ed) with a Hoyer or EZ lift."
Review of the facility's "Transfer Levels For All Residents" document, dated 8/14/17, indicated Resident 1's "Level of assistance/mode of transfer" was "Hoyer, EZ stand."
Review of the facility's investigation summary, dated 8/24/17, indicated CNA 1 and CNA 2 did not use an E-Z stand lift to transfer Resident 1, and this resulted in Resident 1 receiving a fracture on her ankle.
During an interview with Registered Nurse (RN) 1 on 8/30/17, at 2:09 p.m., RN 1 stated on 8/20/17, stated CNA 1 informed her Resident 1 was yelling "cut off my legs." RN 1 stated Resident 1 was grabbing her legs and complaining of pain when she entered the room. RN 1 stated she assessed Resident 1's feet and legs. RN 1 stated she noticed Resident 1 had a skin tear on her right shin (front part of lower leg). RN 1 also stated Resident 1 complained of pain when RN 1 touched Resident 1's right ankle. RN 1 further stated she notified the physician.
Review of Resident 1's Progress Notes (Notes), dated 8/21/17, at 7:37 a.m., indicated Resident 1's right foot was twisted to an outward position from the ankle. The notes also indicated Resident 1 had swelling at the ankle and foot. The Notes further indicated Resident 1 was transferred to the acute care hospital for the evaluation and treatment of her right ankle.
Review of the acute care hospital X-Ray report, dated 8/21/17, indicated Resident 1 sustained a fracture of her right tibia and fibula bones.
Review of the facility's policy and procedure titled "Full Body Transfer," dated 8/3/11, indicated "...The full body transfer is a multi-person procedure usually used in emergencies under the supervision of a licensed nurse. (The facility) discourages the practice of manual body lifts for the safety of the staff and patients and only should be done in extreme circumstances. Use of mechanically lifts are preferred...."
Therefore, the facility violated the aforementioned regulation by failing to provide adequate supervision and assistive devices to prevent an accident when Certified Nurse Assistant (CNA) 1 and CNA 2 transferred one of five sampled residents (Resident 1) without using an E-Z stand lift or a Hoyer lift (mechanical devices used to lift people) per Resident 1's care plan. Resident 1 sustained a painful fractured (broken bone) right tibia (anklebone), a fractured right fibula (anklebone).
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 010001037 |
Kindred Transitional Care & Rehab - Smith Ranch |
110013047 |
B |
27-Dec-17 |
6DUC11 |
2310 |
A 065 1418.91(b) Health & Safety Code1418
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The facility failed to report an allegation of resident abuse to the California Department of Public Health (the Department) within 24 hours of the alleged incident.
Resident 1 was 99 years old. She was admitted to the facility on 6/7/16, with an admitting diagnosis of acute cerebro-vascular accident. On 6/21/16, a standardized assessment was completed to determine Resident 1's attention, orientation, and ability to register and recall new information. This evaluation recorded a score of 13 corresponding to, "cognitively intact."
On 7/14/16, the Department received, via facsimile from the facility, a report informing that on 6/30/16, Resident 1 had made an allegation of abuse against a facility staff member, Unlicensed Staff A. The report was dated 7/14/16, and signed by the facility's Administrator.
During an interview at the facility on 9/6/16 at 11:30 a.m., the Administrator provided copies of the facility's investigation report and related documents concerning the abuse allegation made by Resident 1.
A review of the records revealed a resident, "Complaints/Grievances" form, dated 6/30/16, and authored by facility staff, which stated that on 6/30/16, Resident 1 reported an allegation of abuse against a staff member later identified as Unlicensed Staff A.
During an interview on 9/6/16 at 3:20 p.m., the Administrator was asked about the delay of reporting to the Department an allegation of abuse made by a resident to the facility on 6/30/16. He stated that he started working as the facility's Administrator on 8/15/16, after the events had taken place and had no explanation for the delay in reporting the incident.
A review of the facility's policy and procedure, "Responding to and Investigating an Abuse Allegation," dated 5/22/13, indicated, "For All Abuse Allegations: If no serious bodily injury - submit a written report (SOC 341) within 24 hours to LTC ombudsman, law enforcement and licensing agency."
The facility failed to report an allegation of resident abuse to the Department within 24 hours. This failure delayed the Department's investigation of the incident and placed residents at risk for abuse. |
| 120000695 |
KERN VALLEY HEALTHCARE DISTRICT D/P SNF |
120013637 |
B |
29-Nov-17 |
C4GH11 |
17011 |
CFR 483.12 (a) (1) F223 - The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
The facility failed to protect two of three sampled patients (1 and 2) from verbal abuse from a physician (Physician 1). This occurred when Physician 1 entered both of their rooms and verbally abused them both by reprimand and intimidation. This failure resulted in Patient 1, who was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), becoming anxious, upset, distraught, tearful, and required an anti-anxiety medication to calm down; and resulted in Patient 2 becoming upset, agitated, distraught, short of breath, and feeling "beaten up emotionally" after the incident.
Patient 1 (also referred to in facility documentation as a "Resident," the two terms can be used interchangeably) is a 73-year-old female admitted to the facility on 7/1/17, with diagnoses that included breathing problems which required supplemental oxygen via a tube, high blood pressure within the lungs, and bipolar, a brain disorder that affects mood, energy, activity levels, and the ability to carry out day-to-day tasks.
Patient 2 (also referred to in facility documentation as a "Resident," the two terms can be used interchangeably) is a 65-year-old female admitted to the facility on 5/4/16, with diagnoses that included high blood pressure, depression, breathing problems, chronic pain, and high blood sugar.
During a review of the clinical record for Patient 2, the "Patient Progress Notes," dated 8/30/17, at 5:33 PM, indicated under Social Service Notes, "Met with [Patient 2] to discuss incident that happened this past weekend. [Patient 2] reported she had referred to a [Certified Nursing Assistant or CNA] to another CNA as "the new colored CNA" and that was told to the CNA who became upset. [Patient 2] reported that CNA told the Emergency Room doctor [Physician 1] and emergency room doctor came and confronted [Patient 2] in her room [located in the Skilled Nursing Facility, or SNF, which is a distinct part of the same facility that also contains an Emergency Room, or ER]. [Patient 2] reported she did not know doctor and was upset that doctor came in her room to confront her about incident without knowing the details and accused her of being racist. [Patient 2] reported that snf nurses heard incident and came to room to assist [Patient 2]."
The "Daily Progress Nurse's Notes," dated 8/26/17, at 11:30 PM, written by Licensed Vocational Nurse, (LVN) 2, indicated, "At approximately 8:10 PM, Registry CNA [RCNA, a CNA from an outside agency hired by the facility to help with staffing] was wheeled in a wheelchair by our ER RN [Emergency Room Registered Nurse, or RN 1], and accompanied by [Physician 1] from our ER. They headed to [Patient 2's room]. At the moment, [Treatment Nurse, TN], stated, "Where are they going?" headed to [Patient 2's room]. Before the [LVN 1] was able to go down to the room, they all three were heading back out of room. When [Physician 1] came, asked if there was a problem and she stated, "No." Both [TN] and [LVN 1] went to the patient's room to speak to the patient [2] involved. Patient [2] told us that the reason they came down to tell something about a conversation said a day ago. It was about what the patient said to the [RCNA]. The patient had also stated that she wanted to just let it go and not talk about it."
During a review of the clinical record for Patient 1, the document titled "Daily Progress Nurse's Notes," dated 8/26/17, at 8:05 PM, written by LVN 3, indicated "[Physician 1, RN 1] wheeled [RCNA] being seen in ER to SNF entering [Patient 1]s room to talk with patient. [Patient 1] sat on [her roommate's bed] while being talked with about how she was talking with [RCNA]. After conversation patient came to nurses station with increased anxiety and stated that "grandma" [how Patient 1 refers to her roommate in the next bed] is upset because she had to hear the conversation that took place in the room. Resident stated "I'm not crazy", staff members around resident talked with residents about her feelings decreasing the anxiety a little. This nurse took resident back to her room to give Ativan . . . [a controlled anti-anxiety medication] to help with the anxiety that she was having prior to the conversation that is now increased. Resident states that she was told that she was being aggressive. Resident . . . placed on alert charting to monitor emotional concerns and anxiety."
During an interview with RN 1, on 9/12/17, at 10:01 AM, she stated Physician 1, who she had been working with in the ER on 8/26/17, told her to wheel the [RCNA] to the Skilled Nursing Facility "to educate people." RN 1 stated, "I did not know the doctor [Physician 1] wanted to 'educate' the patients in the SNF. [Physician 1] told the patient [1] not to discriminate and not to call people 'colored' or 'redneck,' but the first patient [1] was confused, but apologized." RN 1 stated, "The [RCNA] said there was another patient [2] who discriminated against her, so [Physician 1] said to go check this second patient [2] and we went to the patient's [2] room." RN 1 stated, "[Physician 1] told her the same thing, not to discriminate. [Patient 2] got upset and [Physician 1] tried to calm her down." RN 1 stated, "I was scared . . . I just followed what she asked me to do. I knew it was wrong to go to the SNF to educate patients. I am uncomfortable working with [Physician 1]."
During an interview with the Director of Nursing (DON), on 9/12/17, at 10:20 AM, she stated Physician 1 was not suspended from employment at the facility after the incident. The DON stated, "I talked to the [Administrator] and CNO [Chief Nursing Officer] and it's in their hands. The way [Physician 1] handled the situation was wrong."
During an interview with the CNO, on 9/12/17, at 10:47 AM, he stated Physician 1 was not suspended, but was informed not to enter the SNF anymore unless invited. The CNO stated, "She had no right to go there [to the SNF]. If she's on duty [in the ER] and when a patient is sent to the ER, we might have a separate ER for them." The CNO did not indicate how a patient sent to "a separate ER" while Physician 1 is on duty, would not still be seen and treated by Physician 1, thereby potentially exposing patients to verbal abuse from her.
During an interview with Physician 1, on 9/13/17, at 12:53 PM, she stated, "First of all, I have a degree in law and currently a physician." Physician 1 stated discrimination and profiling is illegal, and her patient [the RCNA] had told her in the ER that she was called a 'colored girl' by Patients 1 and 2 while she was on duty in the SNF. Physician 1 stated, "So we wheeled the patient [RCNA] over to the unit [SNF] and I talked to [Patient 1] in private. I told [Patient 1] we cannot call people 'colored girl' or 'nigger.'"
Physician 1 stated that she also "told [Patient 2] that she cannot call people a 'colored girl.' She got a little upset. The [Administrator] called me and he was very angry and told me I cannot go to the SNF anymore. This is an eye opening for me. But they [facility] cannot use the State and Federal government money for discrimination. Profiling is illegal. [RCNA] was discriminated and they [facility] did not do anything about it. The SNF was wide open, nobody was there, not a single employee came to us."
During a concurrent observation and review of the clinical record for Patient 1, on 9/12/17, at 9:05 AM, in the hallway of the SNF, Patient 1 was confused and unable to be interviewed. Patient 1 had no recollection of the incident with Physician 1. The "Minimum Data Set" (a standardized, comprehensive assessment tool), dated 9/12/17, indicated she had a Brief Interview of Mental Status score of 3 (score of 0-7 indicated severe cognitive impairment).
During a review of the clinical record for Patient 2, the "Minimum Data Set," dated 8/9/17, indicated she had a Brief Interview of Mental Status score of 15 (score of 13-15 indicated she was cognitively intact).
During an interview with Patient 2, on 9/19/17, at 2:30 PM, she stated she recalled the incident, occurring over three weeks earlier, with Physician 1 and stated she had accused her of "name calling. Something like the [RCNA] was black or colored. I can't get over that, it hurt me. I am very confused who was spreading the rumors. She's [Physician 1] very mean, she came stormed at me and finger point in my face. She's rude, how dare her treat me that way? I feel like I have been beaten up emotionally. I don't understand why that doctor came to me and said she had a degree in law and she is Italian and Spanish. It was a lot to endure, my husband just passed away." Patient 2 stated, "[RCNA] was my CNA that day, she did not say anything to me. I did not call her 'a colored girl.' It was terrible. My nurse was trying to ask the doctor what's going on. She tried to protect me. She's nice. Only that doctor, I carry a grudge."
During an interview with the TN, on 9/21/17, at 12:31 PM, she stated she saw Physician 1 with the RCNA in a wheelchair being pushed by RN 1 walk into the SNF. The TN stated, "They went to talk to [Patient 1] and then later, [Patient 1] came out of her room upset and very confused. Then, [Physician 1] was looking for the other patient [2]. I saw [LVN 1] asking questions to [Physician 1], but [Physician 1] was not answering her." The TN stated, "[Physician 1, RCNA, and RN 1] all went down the hall together. I alerted [LVN 1] something is going on. By the time we got there, [Patient 2] was disturbed and did not want to talk about what [Physician 1, RCNA, and RN 1] did in her room. I don't think [Physician 1] did the right thing, this is the patients' home and both patients [1 and 2] have mental issues. [Physician 1] did not ask the Staff any questions before going to see the patients. It was totally inappropriate. It was shocking. We were appalled because of her position as a doctor. She should be advocating for the patients but she was advocating for the Registry CNA." The TN was asked if there were SNF staff available for Physician 1 to talk to while she was in the SNF. The TN stated, "Yes, [LVN 1] was at the desk and actually [LVN 1] kept on questioning [Physician 1] what was going on, but [Physician 1] did not give an answer. [Patient 2] later said the doctor told her not to call a colored girl and something against the law and she knew the law because she had a degree in law." The TN stated, "Recently, [Patient 1] is having severe depression, her husband passed away. . . [Patient 1] is the one who can't let go."
During an interview with LVN 1 on 10/16/17, at 9:30 PM, she stated she recalled the incident with Physician on 8/26/17. LVN 1 stated she had never seen Physician 1 prior to that evening, and did not know who she was. LVN 1 stated upon [Physician 1]'s arrival on the SNF, she asked her if she needed assistance with anything, and Physician 1 "Absolutely 100 percent ignored me, and was very rude." LVN 1 stated Physician 1 eventually gave her name, and that she had spoken to the DON. LVN 1 stated after Physician 1's encounter with Patients 1 and 2, that they were both upset and distraught. LVN 1 stated she does not believe anyone should be treated the way Physician 1 treated them. LVN 1 stated, "I felt so bad for [Patient 1]. She has dementia. [Physician 1] should have explained herself. She didn't do that. I called the DON, she was shocked [by Physician 1's behavior]. [Patient 1] was definitely distraught, she was upset after [Physician 1]'s visit.
I also saw [Patient 2] after [Physician 1] spoke with her. [Patient 2] is more alert, and she was absolutely upset and distraught. [Patient 2] was saying she could not believe a doctor would behave this way, could do that. I was upset for both of them [Patients 1 and 2]. Their rights had been violated. I feel they were harassed and bullied, violated by that doctor. I feel like I protect my patients, but I never thought I'd have to protect them from a doctor."
During an interview with the DON on 10/18/17, at 1 PM, she stated Physician 1 had telephoned her at home from the ER during the evening of 8/26/17 about RCNA, but gave no indication she was intending to come to the SNF to "reprimand patients." The DON stated had she known that, she would have come to the SNF immediately to stop her. The DON stated, "How dare she do that. How dare her."
The document titled "Incident Report," written by the DON and addressed to the Department, indicated "On or about August 26, 2017 at approximately 8:11 PM, I received a call from [LVN 1] regarding [Physician 1] walking over to our skilled nursing center with [RN 1], [RCNA].
I arrived at the skilled nursing center approximately 15 minutes later and spoke to [Patient 2]. I asked her "What did the doctor want?" [Patient 2]'s reply "she said I shouldn't say things like 'Colored Girl' because she's involved in a civil case litigation against discrimination and that's against the law, I'm a wop spic are you going to call me that?" I noticed [Patient 2] appeared a little anxious and short of breath so I left the room to let her calm down. I then proceeded to [Patient 1's room], as I knocked and went in I seen that [she] was sleeping on her bed. I asked [LVN 1] is she was ok, [LVN 1] replied, "Yeah she has an Ativan on board that's why she's asleep."
During an interview with LVN 3, on 10/20/17, at 10:20 PM, she stated she was Patient 1's nurse during the evening of 8/26/17. LVN 3 stated after Physician 1 left her room, "[Patient 1] was extremely upset. She was upset this conversation took place in front of her roommate. [Patient 1] was crying, tears coming out of her eyes, nose draining. She was very anxious, this made her existing anxiety worse. It increased her behaviors very much so. [Patient 1] told me, immediately after [Physician 1] left her room, that the Doctor had come to see her and said she had been aggressive. [Patient 1] has no idea what she was talking about. The Doctor had brought a CNA into the room with her to show her. After this, [Patient 1] was clearly in distress, upset. I thought it was inappropriate to enter [Patient 1]'s room like that. She should have grabbed me or another nurse to go in with her. I work with [Patient 1] all the time, she can't remember my name from one night to the next. It was really inappropriate to take another employee and confront her. If I'd have known this was her plan, I wouldn't let it happen. Unfortunately, it happened."
LVN 3 stated, "If a patient had to go to the ER, I'd want a staff person to go with them, one-on-one, if [Physician 1] was on duty. For any patient. As shook up and uncomfortable as [Patient 1] was after this event, I think it was a form of abuse." LVN 3 stated she personally gave Patient 1 the anti-anxiety medication for anxiety.
The facility policy and procedure titled, "Abuse Prevention Program," dated 12/7/16, indicated, "Each patient will be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. Additionally all patients will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated and all patients will be monitored for protection. The facility will strive to educate all participants in techniques to protect all parties.
The facility policy and procedure titled, "Abuse Prevention Program - Definitions and Indicators," dated 12/7/16, indicated, "Abuse means any of the following if done intentionally: Causes or could reasonably be expected to cause mental or emotional damage to the patient, including harm to the patient's psychological or intellectual functioning that is exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior, agitation, or fear of harm or death, or combination of these behaviors. A course of conduct or repeated acts by caregiver which serve no legitimate purpose and which, when done with intent to harass, intimidate, humiliate, threaten or frighten a patient, causes or could reasonably be expected to cause the patient to be harassed, intimidated, humiliated, threatened or frightened. Emotional or Psychological Abuse: The verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering. Demeaning statements, harassment, threats, insults, humiliation, or intimidation.
This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients and therefore constitutes a Class B citation. |